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Thread: Advice?

  1. #11

    Pain vs Function

    Dr. Young:

    I have posted before. I am a C5/C6 incomplete quad post one year. My worst pain occurs the day after strenuous physical therapy. My legs and bottom literally feel like they are encased in ice. Nothing touches the pain or cold. I can wrap up in an electric blanket and still feel frozen. Taking 2 Vicodin and an extra 300mg Neurontine helps a little but only slightly. Usually by the next day my legs feel warm again. However, you were curious how some people would choose pain or movement? I would take 10 times the pain I have now just to be independent again. Even as close as you are to the SCI community you will never understand what it's like being a plegic until you (God forbid) experience it yourself.

    Thanks for all you do for us.

    Deb

  2. #12
    Calico,

    I think that probably everybody has some combination of both noxious and neuropathic pain. From your description, I agree that you very likely have neuropathic pain. However, neuropathic pain coexists with and is aggravated by noxious pain. Also, one type of neuropathic pain is allodynia which is hypersensitivity to touch, where light touch is interpreted by the nervous system painful or uncomfortable.

    I was speculating about pain behavior based on what I have seen in animals and people who have neuropathic pain. I have a friend, a paraplegic, who tells me that he has quite severe neuropathic pain, burning sensation. Yet, he is a cheerful man. He actually smiles at me when he tells me that he has pain. And, I can clap him on the shoulder and give him a hug and he doesn't cringe. If I have severe pain, I would probably be hunched over and guarding myself from touch. I have seen a lot of people who have noxious pain and they behave that way.

    Some rats bite themselves in the flank after spinal cord injury. They sometimes bite themselves so much that they penetrate through muscle and often expose internal organs. They always bite the areas below the injury site, areas that have no sensation. These same rats often show allodynia in the skin above the injury site. Rats squeak when they are uncomfortable or frightened. If you touch these rats lightly on around the back above the injury site or pick them up, they squeak and twist their bodies. Beattie and Bresnahan recently did a study showing that many rats exhibit allodynia above the injury site after spinal cord contusions. So, I think that these rats have neuropathic pain and allodynia.

    We have tried a number of treatments of such neuropathic pain and it is interesting that acetaminophen stops the autophagia and the rats don't squeak when they are picked up. In any case, these rats have neuropathic pain but we don't find them stopping their efforts to walk and their locomotor recovery does not hamper their recovery. In contrast, as I pointed out below, if rats have urinary tract infections, they tend not to walk as well and their walking scores fall.

    Wise.

  3. #13
    Debbie7, exactly. You have expressed what I was trying to describe. Contrast this to people who have severe noxious backpain, arthritis pain, or abdomenal pain. They can't stand the pain. Wise.

  4. #14

    Dr. Wise: Neuropathic vs Noxious Pain & Ultram

    Neuropathic pain certainly comes in many different flavors. Touching my skin does not exacerbate my pain, but movement does.

    Many times I've tried to use my arm weights for exercise just to see if I could. Pre-injury, I would experience the normal soreness in a muscle a person might feel with exercise. Now, it's as if the volume on the normal soreness is turned up full blast, the abnormal burning/tingling is severely exacerbated and my arms feel weaker. It can take 3 - 4 days for the pain/weakness to get back to baseline. Maybe this is what you mean by the noxious/neuropathic pain combo.

    I read recently that with Ultram "the norepinephrine activity makes it an attractive pain medication, especially if there is burning, traveling pain accompanied by tingling and numbness". That sounds like it should be helpful with neuropathic pain. Do you have any opinions/experience with this?

    I tried Tylenol at the beginning of this mess and never noticed that it helped. Glad it helps the rats at least!

    Calico

  5. #15

    My Guess

    Dr. Young,

    I think in a round about way Maslow's(?) hierarchy of need might apply. When you lose the ability to take care of youself you perceive that you will be able to stand anything in order to survive. I relate that if you must rely on someone else for the bottom most basic instinct (food and shelter) the fear of losing the caregiver that provides that instinctual need is enough to override any pain as long as the outcome is that you can again provide for yourself. People with diabilitating pain still have the ability (usually) to at least take care of themselves.

    I'm not saying that this theory applies to anyone else but me but my lack of independence is the worst part of my injury.

    Thanks,

    Deb

  6. #16
    Senior Member alan's Avatar
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    I can't do exercises with my arms. Any movement of them exacerbates the shoulder blade pain, and makes the blades pop. Heck, between that pain and the scoliosis, I can barely type these days.

    Before I got mangled, I also was big on exercising, including running four miles three times a week, and doing 100 pushups and 50 situps daily.

  7. #17
    Calico, neuropathic pain is very likely to be due to a combination of three mechanisms.

    The first is the loss of ability of the spinal cord to inhibit pain messages. The spinal cord possesses remarkable mechanisms for shutting down pain input. These mechanisms of accomodation are the main reason why people can wear uncomfortable shoes, athletes and ballerinas can tolerate noxious pain, and how people can wear corsettes, tight pants, and so on.

    The second mechanism is the circuits that the spinal cord utilizes to distinguish pain from other sensory messages. For a long time, people thought that pain is primarily conducted through specialized axons (called C-fibers) and conducted through specific spinal pathways. These pathways appear to mediate thermal and pressure sensation, as well as pain. However, it appears that noxious signals are also carried in sensory fibers that mediate other kinds of sensations. The spinal cord can, however, distinguish between noxious and non-noxious sensory input, a function that is carried out by neurons in the dorsal horn of the spinal cord. I don't think that we understand how these neurons work but the pain neurons generally fire only when the messages reach a particular threshold or do not make sense. For example, there is a very interesting experiment that I saw recently... if you take a normal person and put his/her hands on parallel pipes of alternating warm and cool temperatures, the person perceives burning pain. Somehow, the spatial input of the conflicting signals may be confusing the spinal neurons and getting them to send off pain signals to the brain.

    The third mechanism is spontaneous firing of the disinhibited pain neurons in the spinal cord. Several recent studies suggest that these neurons posses a special enzyme called phosphokinase C gamma (PKCg). Mice that have had their genes for PKCg knocked out do not develop allodynia or neuropathic pain after peripheral nerve lesions, even though they continue to be able to sense thermal, pinprick, and pressure. The hyperexcitability of such neurons may be the reason why many of the drugs that are used for neuropathic pain are anti-epileptic drugs. They reduce spontaneous excitability of neurons. Carbamapazine (Tegretol), for example, is such a drug. Likewise, Neurotin is an anti-epileptic drug and may work by suppressing spontaneous activity of pain neurons.

    There are of course a number of central brain mechanisms that mediate pain and pain behavior. There are many groups studying brain activity in people with neuropathic pain and the studies uniformly show increases in activity level in certain areas of the thalamus. There is a theory that continued activity in these circuits may promote sprouting and ingrained activity in these centers, leading to continued pain sensations and behaviors.

    Ultram is of interest because it appears to have both opioid activity and anti-depressive activities. As you know, one of the first lines of therapies for neuropathic pain is amitryptaline or Elavil, which blocks an enzyme called monoamine oxidase. This enzyme is responsible for the breakdown of catecholamines in the extracellular space and therefore enhances the activites of these neurotransmitters (including epinephrine and norepinephrine). Ultram appears to activate opioid receptors which modulates the excitability of pain neurons, as well as have antidepressant activities.

    Wise.

  8. #18
    Debbie7,

    I agree with you. For many people with spinal cord injury, dependence on others is the most intolerable aspect of spinal cord injury, more noxious than pain. Your suggestion that this may be a survival mechanism is very innovative and interesting. The need for independence is a strong driver of behavior, particularly in young people. However, this may be a cultural trait as well and may depend on who is providing the care. As babies, we are dependent on our parents and people can slip back into dependent behavior.

    Wise.

  9. #19
    Alan, mechanical allodynia of the type that you describe is common. It is, in my opinion, part of the neuropathic pain syndrome. Wise.

  10. #20

    Thanks, Dr. Wise

    Thanks so much for your learned overview of the mechanisms of neuropathic pain. It's also good to hear about the studies even if they haven't produced any great cures YET. Knowing that there is research underway keeps us going.

    Just as an aside, I can't take Elavil or any tricyclic anti-depressant because, at 42, I had a "minor" heart attack two months after my cervical fusion surgery (angiogram showed no blockages). To borrow a phrase from Queen Elizabeth, "1997 will not be a year upon which I will reflect with undiluted enthusiasm."

    I am on Wellbutrin which does help with mood and dealing with the pain, but I don't think it really helps the pain itself.

    Maybe I'll give Ultram a try.

    Thanks again!

    Calico

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