Pain in the Neuromuscular Disease Rehabilitation Patient




© Springer International Publishing Switzerland 2017
Alexios Carayannopoulos DO, MPH (ed.)Comprehensive Pain Management in the Rehabilitation Patient10.1007/978-3-319-16784-8_14


14. Pain in the Neuromuscular Disease Rehabilitation Patient



David Haustein1, 2   and Steven Papuchis3  


(1)
Physical Medicine and Rehabilitation, Robley Rex VA Medical Center, 800 Zorn Avenue, Louisville, KY 40206, USA

(2)
University of Louisville, 220 Abraham Flexner Way, Louisville, KY 40202, USA

(3)
Physical Medicine and Rehabilitation, University of Louisville, 220 Abraham Flexner Way, Louisville, KY 40202, USA

 



 

David Haustein (Corresponding author)

Email:


 

Steven Papuchis

Email:


Keywords
PainNeuromuscularMotor neuronMotor unitPlexopathyMyopathyNerveNeuropathic painWeakness



Introduction


Neuromuscular diseases refer to a group of disorders affecting one or more of the components of the peripheral nervous system, ranging from the proximal cell body, the nerve root, the peripheral nerve, the neuromuscular junction, and the target muscle. These disorders frequently will result in neuropathic or musculoskeletal pain or both, and proper diagnosis of the pain source will help guide a multidisciplinary treatment plan.


Motor Neuron Diseases





  1. 1.


    Introduction

    Motor neuron disease (MND) is a collection of progressive neurodegenerative diseases that affect nerve cells in the brain and the spinal cord. This section will focus on amyotrophic lateral sclerosis (ALS) , the most common motor neuron disease in adults. Patients with ALS have an average survival of 3–5 years after symptom onset [1–3].

     

  2. 2.


    Pathophysiology

    The pathophysiology underlying ALS and other motor neuron diseases is unknown. The etiology of pain in patients with ALS is frequently multifactorial and progresses along with the disease [1–3].

     

  3. 3.


    Functional limitations

    Patients experience difficulty with mobility and ADLs due to the progressive nature of the disease.

     

  4. 4.


    Symptoms

    Patients can experience a wide variety of pain symptoms . The most common causes of pain are related to cramps, spasticity, and immobility, but muscular atrophy, joint stiffness, and contractures may produce pain as well [1–3].

     

  5. 5.


    Treatment

     

  6. 6.


    Initial



    • Cramps

      Unfortunately, medications for cramps in patients with ALS have limited evidence to support their use. Vitamin E, magnesium, carbamazepine, phenytoin, verapamil, and gabapentin are occasionally trialed; while quinine is used in Europe, it is not FDA-approved for the treatment of cramps [1, 2].


    • Spasticity

      Oral baclofen is the preferred initial agent. Tizanidine, diazepam, and dantrolene are used occasionally, but diazepam is associated with respiratory depression and dantrolene may cause generalized muscle weakness and thus is avoided in MND patients [1, 2].


    • Immobility

      Reduced mobility can result in pain from adhesive capsulitis, mechanical back pain, and pressure areas on the skin. NSAIDs, with or without the addition of acetaminophen, may be appropriate for mild to moderate pain. Opioids may be required for severe or refractory pain. Patient-controlled analgesia (PCA) devices are seldom used due to patient’s difficulty in controlling the device.1, 2,

     

  7. 7.


    Rehabilitation



    • Physical and occupational therapy can assist with stretching activities to preserve joint range of motion and to help manage spasticity, including modalities. PT and OT can also assist with mobility and transfer training, durable medical equipment for eating and bathing, and home safety evaluations.


    • An assistive technology professional (ATP) may assist with optimizing comfort in a wheelchair with adequate support and cushioning.


    • Orthotics such as an ankle foot orthosis (AFO) to treat foot drop may assist with ambulation and transfers early in the disease. A resting hand splint may help preserve range of motion in the hand [1, 2].

     

  8. 8.


    Procedures

    An intrathecal baclofen pump may be helpful in patients with severe spasticity unrelieved with oral medications or in patients who cannot tolerate the side effects of oral anti-spasmodics [1–3].

     

  9. 9.


    Surgeries

    Tendon lengthening procedures are possible for patients with severe spasticity and contractures. However, patients with ALS are very high-risk surgical candidates, especially late in the disease course [4].

     

  10. 10.


    Potential Treatment Complications

    Although higher than manufacturer-recommended doses of oral baclofen have been used, caution should be exercised given the possible side effects of weakness, fatigue, and sedation. Narcotics can cause respiratory depression [1, 2].

     

  11. 11.


    Evidence

    Per a 2013 Cochrane review, there are no randomized controlled trials regarding pain management in ALS; most management techniques come from case series or case reports [3].

     

  12. 12.


    Conclusion

    Pain is a common complaint for patients with ALS and other motor neuron diseases. Focus should be on symptom management, with close follow-up, to reduce pain and to improve quality of life for these patients.

     


Radiculopathies





  1. 1.


    Introduction

    Radiculopathies involve a pathologic process affecting one or more spinal nerve roots leading to both axial and referred pain, often including paresthesias and weakness. The most common cervical level involved is C7, while the most common lumbar level is L5 [1, 2].

     

  2. 2.


    Pathophysiology

    Common etiologies include herniated discs, spondylosis, and facet arthropathy; less frequent causes include tumors and infection. Pressure against a nerve root or inflammation is theorized to lead to a hyperexcitable state, producing pain and radicular features [5].

     

  3. 3.


    Functional Limitations

    Patients can have weakness, impaired sensation, and pain that limits ADLs or mobility.

     

  4. 4.


    Symptoms

    Axial and radicular pain, dermatomal paresthesias and/or sensory disturbances, and muscle weakness in a myotomal pattern can be seen.

     

  5. 5.


    Treatment


    1. (a)


      Initial

      Conservative management consists of oral analgesics such as NSAIDs or acetaminophen and rehabilitation. Adjunctive medications may include anti-spasmodics such as cyclobenzaprine. Tricyclic antidepressants and anti-epileptics like gabapentin may help treat neuropathic pain [6–8].

       

    2. (b)


      Rehabilitation

      Posture and good body mechanics may help to reduce pressure on the nerve root(s); patients are frequently told to avoid repetitive and heavy lifting during the acute phase. Patients with cervical symptoms should avoid neck extension and may consider cervical traction with physical therapy. Heat and cold modalities can help temporarily, as well as use of a TENS unit [1, 2, 9].

       

    3. (c)


      Procedures

      Epidural steroid injections may be helpful for alleviating radicular symptoms. While the transforaminal approach is associated with higher efficacy than the interlaminar or caudal approaches, it also carries an elevated risk of adverse events [10].

       

    4. (d)


      Surgery

      Indications for more invasive surgical procedures such as a discectomy or laminectomy include intractable pain, not responsive to conservative measures, severe and progressive neurologic deficits, or progression to myelopathy [1, 2].

       

     

  6. 6.


    Potential Treatment Complications


    1. (a)


      Symptoms suggestive of cauda equina syndrome require emergent surgical referral.

       

    2. (b)


      Avoid deep heating methods as these can worsen inflammation.

       

    3. (c)


      Transforaminal epidural steroid injections performed with particulate steroids may lead to a CVA or SCI due to infarction [5, 10].

       

     

  7. 7.


    Evidence

    Short-term and intermediate-term use of opioids has been effective in controlling neuropathic pain symptoms. However, there are no long-term randomized controlled trials that look at the long-term efficacy and safety of opioids in treating neuropathic pain [11].

     

  8. 8.


    Conclusion

    Acute radiculopathies are often initially treated conservatively with a combination of NSAIDs, neuropathic pain medication, and physical therapy. Progressing to interventional injections or surgery may be appropriate when conservative measures have failed to produce pain relief.

     


Plexopathies





  1. 1.


    Introduction

    The brachial plexus is a confluence of nerves that begins as the nerve roots exit the middle cervical to upper thoracic spinal canal and combine to produce individual peripheral nerves that innervate the upper limbs. Similarly, the lumbar and lumbosacral plexus exit the lumbar and sacral spine and innervate the lower limbs [1, 2]. Common causes of plexopathies include traumatic injury, compression such as in thoracic outlet syndrome, invasion via cancer, infection, idiopathic or associated with a metabolic syndrome as in diabetic amyotrophy [1, 2]. This chapter will focus on acute brachial neuritis, neurogenic thoracic outlet syndrome and neoplasm, or radiation-induced plexopathy.

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Aug 26, 2017 | Posted by in Uncategorized | Comments Off on Pain in the Neuromuscular Disease Rehabilitation Patient

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