Hypersensitivity due to nerve pain

“Ma’am, your pain is between the ears.” With that remark, people with neuropathic pain, commonly called nerve pain, are sometimes dismissed as posers. Because there is no immediately identifiable cause, they are labeled ‘whiner’. But nerve pain is definitely something to complain about.

Nerve pain patients experience pain much more intensely than others: the pain lasts longer and is more intense. For example, a pinprick, which usually hurts only equally, continues to hurt in people with nerve pain long after the sting. Non-painful stimuli are also experienced as painful; just a movement can trigger or exacerbate the pain. Even a sheet over bare skin can be too much, some patients cannot tolerate socks or shoes on their feet.

Nerve pain is a difficult pain to treat. What makes it even more complicated is that the pain is difficult to recognize, says Marion Giesberts, who worked for years as a pain nurse and now develops online courses in pain management for healthcare institutions. “Both patients and doctors are not always aware that it is nerve pain. Not only GPs, but also other doctors and specialists lack knowledge of nerve pain. In addition, insufficient research has been done into causes, diagnosis and treatment. The result is that the pain is not treated or is treated incorrectly. There are no hard figures, but it is estimated
90 percent of patients do not manage nerve pain properly. For example, GPs would prescribe painkillers such as ibuprofen and naproxen for half of the patients, but these usually do not work for this type of pain. Patients then just accept that they have to learn to live with the pain.”

Ringing phone
Nerve pain is a chronic pain caused by a damaged or malfunctioning nerve. Hence the name nerve pain. This damage causes a disturbance in the conduction of pain signals in the nervous system. Normally, our nerves receive stimuli and pass them on to the brain. They interpret and translate the stimuli for us. In this way we can feel cold and heat, a touch or pain. With nerve pain, something goes wrong somewhere in the nervous system: our ‘power station’ of nerves is, as it were, disrupted. Due to hypersensitive nerves you can have a constant feeling of pain in and around the place where the nerves are damaged or disturbed, or your brain interprets a light touch as pain. Compare it to a wrongly connected telephone wire that causes the telephone to ring constantly.

One million people
The number of people who suffer from nerve pain is large. According to figures from dali (Dutch Alliance for Improvement of Paincare, a collaboration of healthcare experts and an initiative of drug manufacturer Pfizer), it affects one million people and 130,000 new patients are added every year. Nerve pain can arise after surgery, after an injury such as a deep cut and even after a seemingly simple (sports) injury. When not only a muscle, tendon or joint is damaged, but also a nerve is damaged, we speak of ‘post-traumatic dystrophy’. Many people with cancer or a chronic illness can also suffer from nerve pain. It occurs in 50 to 80 percent of MS patients, 40 percent of people with Parkinson’s, 75 percent of people with spinal cord injury, and 16 percent of people with diabetes (both type 1 and 2). The phantom pain after a (breast) amputation also belongs to neuropathic pain; 20 to 30 percent of patients suffer from it. Facial or facial pain is also a form of nerve pain.

Nerve pain is more common in women than in men and age also plays a role. The older a person gets, the more vulnerable the nervous tissue. In the above cases, older people are therefore more likely to develop nerve pain than younger people. Take shingles, for example: 5 to 10 percent of all people with shingles develop nerve pain, but in shingles patients over the age of 70, that percentage goes up to 50 percent.

Treatment methods
Nerve pain is not easy to treat. Regular painkillers such as paracetamol or ibuprofen will not solve the complaints. Even morphine has little to no effect on nerve pain. What can help are drugs that slow down the conduction of nerve impulses. Antidepressants and anticonvulsants are often used for this, not to treat depression or seizures, but purely as a painkiller. These drugs need to be used for about four weeks before it is clear whether they work. Usually several drugs are needed that have to be used for a long time. If the pain disappears, it is sometimes possible to reduce the dose slowly and eventually stop without the pain returning. Unfortunately, it is not always possible to stop all medicines. Moreover, medicines do not always and not everyone completely eliminate the pain. There are people who will always be in pain – it is not yet known how many people are involved.

Another method that influences nerve impulses is tens: Transcutaneous Electrical Neuro Stimulation. The nerves are stimulated via electrodes on the skin with a portable device the size of a Walkman. The electrodes deliver small electrical impulses and thereby stimulate the thick nerve fibres. In this way they drown out the small nerve fibers, which are responsible for transmitting pain. In addition, endorphins (morphine-like substance) are produced in the body. This can provide pain relief, but no figures are available on this either. The advantage of a tens device is that it has no unpleasant side effects (as is often the case with medicines) and that the patient can operate it himself and adjust the intensity, according to what feels comfortable.

A definitive way to combat nerve pain is to apply nerve blocks: the nerve that carries the stimuli is simply interrupted. This method is not suitable for all types of nerve pain. It does lend itself to nerve pain with a small painful area, such as facial pain.

puzzle tour
Figuring out what works and what doesn’t is often quite a puzzle. Pain treatment centers that involve care providers from different disciplines (such as an anesthesiologist, neurologist, physiotherapist and specialized nurse) are the best help with this. Usually a combination of treatment methods works better than one approach. But the original cause of the nerve pain often cannot be removed: an amputation, for example, or a disease such as diabetes is simply irreversible.
Becoming completely pain-free is therefore not always possible, but pain relief is achievable. In addition, people with nerve pain can do things themselves to reduce the effects of the pain or be less bothered by it. Daily relaxation exercises, for example: when the muscles relax, the pain decreases. Yoga is therefore beneficial for people with nerve pain. Music and visualization exercises also have a proven effect on pain. The Van Praag Institute has made a CD especially for this purpose (‘Healthy imagination: guided visualization in pain’). It is also important to prevent stress and to find a good balance between activity and rest.

Nerve pain is a chronic pain with a huge impact on life. Work and partner suffer as a result, it affects social life. As a result, people with nerve pain can become angry or depressed. What makes it extra difficult is that nerve pain is not visible to outsiders. Family, friends and colleagues generally don’t care about someone with nerve pain. They don’t know what such a person is going through. “That is why it is important that people with nerve pain indicate what they can and cannot do, and explain what it is,” says Marion Giesberts. “Nervous pain is indeed between the ears, to be precise: in the brain. That is where we experience pain.”

How do you recognize nerve pain?
Nerve pain can be recognized by one of the signs and symptoms below. Not everyone has them and certainly not all at the same time.

• A constant pain with outliers.
• A burning, aching pain.
• Sensation of pins and needles, stabs, ‘electrical’ pain.
• Deafness, ‘sleeping’ feeling.
• Feeling like walking on cotton wool.
• Itching, feeling as if ants are crawling over or under the skin.
• Hypersensitivity to cold or heat.
• Disproportionate pain after a touch or stimulus, such as being unable to tolerate wind or clothing on the skin.

on www.stopdepijn.nl you can take a test to find out if you may have nerve pain.

Increase your chance of a good treatment
Most patients with nerve pain, an estimated 90 percent, do not receive the right treatment. These tips will help you on your way.

• Check whether your pain is indeed nerve pain (see the symptoms and complaints above).
• If ordinary painkillers (such as paracetamol) and anti-inflammatory painkillers (such as naproxen or diclofenac) do not help, first check whether you are taking the right dose. If so, ask your doctor about other medicines, such as anticonvulsants or antidepressants.
• If your GP is not sure how to deal with your pain, ask him for a referral to a pain centre. It is important that different types of specialists work there. Your GP can also first seek advice by telephone from that team.

More information
• Neuropathy treatment center in Soest:
T 030-691 09 32 or www.neuropathy.nu.
• Dutch Association of Post-Traumatic Dystrophy Patients: T 013-455 49 51 or http://pdver.atcomputing.nl/Gezondheidsbeeld.html.
• www.stopdepijn.nl: All About Nerve Pain, a website from drug manufacturer Pfizer.
• www.Gezondverbeelding.nl: here you can order the CD-ROM ‘Healthy Imagination: guided visualization in pain’ for €19.95 excluding shipping costs.
• www.dalvoorpijn.nl: website that informs about improving care for people with nerve pain.

Mmv Dr Frank Huygen, pain specialist and anesthesiologist at the Erasmus Medical Center Rotterdam.