Treating and managing nerve pain

Thanks for joining us March 23 for a live chat with Dr. Steven Cohen of Johns Hopkins on nerve pain, including neuralgia, nerve damage, sciatica, diabetic neuropathy and other neuropathic pain.

Cohen is an associate professor and researcher with Hopkins School of Medicine and professor of anesthesiology at Uniformed Services University of the Health Sciences and director of Pain Research at Walter Reed Army Medical Center. He answered questions on treatments and managing nerve pain. Read the transcript below.

Note: Comments made here are for informational purposes only and do not represent or substitute as medical advice. Patients are advised to consult their own physician or pharmacist for advice, diagnosis and treatment.

 Health chat: Treating nerve pain(03/23/2011) 
Baltimore Sun Health: 
Hi, Dr. Cohen will be joining us at noon, but feel free to add your questions now.
Wednesday March 23, 2011 11:28 Baltimore Sun Health
Baltimore Sun Health: 
Hi, welcome to our live chat with Dr. Steven Cohen of Johns Hopkins School of Medicine, Walter Reed Army Medical Center and Uniformed Services University of the Health Sciences. We'll try to get to as many questions as we can within the hour. Dr. Cohen will be taking your questions on nerve pain. If we get a lot of questions related to one topic, we may combine them and move on to other ones so we represent the diversity of questions in the queue.
Wednesday March 23, 2011 12:00 Baltimore Sun Health
Steven P. Cohen: 
Good afternoon everyone and thank you for joining us today. I welcome any question you may have about chronic pain.
Wednesday March 23, 2011 12:01 Steven P. Cohen
[Comment From JoanJoan: ] 
Regarding the upcoming live chat on treating and managing nerve pain, March 23rd, I have burning on the balls of my feet and toes. I have been tested for neuropathy and the results were negative. Neurologist gave me a prescription for Gabapentin (100 mg 3 times a day) with no results other than diarreah. I am not diabetic, and have no health issues. Podiatrist is having me try orthotics which have helped some, but if I walk (which I enjoy doing 3 or 4 times a week .. approx. 2-3 miles), or if I am on my feet a lot, they are burning at the end of the day. Is giving up walking my only solution? It keeps me healthy and helps keep weight off. I am 73, active, and in very good health otherwise. I look forward to your advice. I will certainly try to tune into the discussion on the 23rd. Thank you for any suggestions you may offer.
Wednesday March 23, 2011 12:02 Joan
Steven P. Cohen: 
Sometimes, the most common tests to detect neuropathy, electromyography & nerve conduction studies, can miss some cases (i.e. tarsal tunnel syndrome, which can cause burning on the soles of your feet). If your doctor really feels like you have neuropathy, he (or she) can send you for additional tests such as a skin biopsy. It sounds like you may have plantar fasciitis, which is characterized by foot pain with walking- often early in the morning, which you do not have. The podiatrist you are seeing should be able to tell you if this is what you have, and suggest stretching exercises to help. Other treatments to consider for plantar fasciitis include “orthotics” and injections of steroids or other substances into the soles of your feet and (extracorporeal or radial) shock-wave therapy. If you are overweight, weight loss can be helpful.
Wednesday March 23, 2011 12:04 Steven P. Cohen
[Comment From BruceBruce: ] 
I suffer from episodic sciatic back pain aggravated by sitting. Though I participate in back exercises and yoga which both seem to help, I wondered if I would especially benefit from a quality ergonomic chair for computer use or is sitting just bad no matter what? I do watch my posture when seated and try to move around from time to time when using the computer. For painful exacerbations, I reluctantly take ibuprofen but will not consider gabapentin, Lyrica, or other sedative medications because of their unwelcomed side effects. What is new in the treatment of sciatic nerve pain? Thanks.
Wednesday March 23, 2011 12:04 Bruce
Steven P. Cohen: 
Answer: Sitting in particular increases the stress on the intervertebral discs, so if this is the cause of your sciatica it could very well worsen with sitting. An ergonomically designed chair can be beneficial, as many people with sciatica use them. Nonsteroidal anti-inflammatory drugs are generally better for mechanical pain than ¿nerve¿ pain shooting down the leg. Cymbalta was recently approved for back pain. Although less effective than the older tricyclic antidepressant drugs, the side effects tend to be more mild. Unless one tries a medication, it’s not possible to adequately assess the ¿risks and benefits¿.

If you have not tried epidural steroid injections, I think a trial would be worthwhile, as it is ¿minimal risk¿. For one-sided sciatica, transforaminal injections, in which the medication is targeted at the affected nerve root, are probably more beneficial than the traditional ¿interlaminar¿ epidural steroid injections.

One promising avenue is pulsed radiofrequency of the dorsal root ganglia (where the cell bodies for pain-transmitting nerve fibers reside), which has been shown in one controlled study to benefit people with radiculopathy (i.e. sciatica). Percutaneous disc decompression procedures, which aim to remove disc material without a surgical incision, may benefit a small percentage of people with sciatica (i.e. those with very small protrusions), but the evidence is limited by a lack of well-designed studies.
Wednesday March 23, 2011 12:06 Steven P. Cohen
[Comment From JoJo: ] 
I am a 64-yr-old female pianist and piano teacher (and former cellist), accustomed to playing technically demanding, professional-level, pieces. I have been studying piano from 5 years of age. In my 40s I was practicing approximately 4.5 hours per day; in my 50s, 3 hrs per day (a period in which I developed tendonitis mostly in the R [far less so in the L] forearm and elbow, reaching up into the upper arm); in my 60s, 2 hours per day. My current two hours is divided into small increments: for instance, I'll begin with an uninterrupted 40 minutes of work; then proceed with smaller increments of 10 to 20 minutes, in an attempt to forestall repetitive-motion syndrome, whether nerves or tendons. This past summer, 2010, I developed nerve-inflammation in the R hand and, specifically, in the thumb-to-index complex; additionally, it affects the middle finger to a modest degree. Recuperation required approximately 6 weeks, during which time: (a) I transferred "normal" motions to my L hand (e.g., turning on the kitchen water faucet), (b) I did not use my R at piano for an entire 3-4 weeks (mentally painful, but physically necessary). After this initial period, (c) I mentally "edited" the R-hand part of the music scores down to one "voice" (i.e., one finger at a time), thus ensuring that there was only minimal stretching of the fingers-thumb complex. I am now, March 2011, experiencing a reoccurence of this inflammation. However, I became aware of the pain much earlier on
Wednesday March 23, 2011 12:06 Jo
Steven P. Cohen: 
You seem to be suffering from carpal tunnel syndrome, which is very common in your demographic category (i.e. elderly, female, people who work a lot with their wrists). It is due to compression of the median nerve at the wrist, and people generally experience similar symptoms to what you¿re experiencing. Although stretching and strengthening exercises, along with anti-inflammatory drugs and occasional drugs used to treat nerve pain, can sometimes be effective, many people require a very simple ¿decompression¿ operation. Injections of corticosteroids have also been shown to be beneficial, with some (but not all) studies showing they work as well as surgery. The diagnosis can be confirmed with muscle and nerve testing (EMG/ nerve conduction studies).
Wednesday March 23, 2011 12:08 Steven P. Cohen
[Comment From JudithJudith: ] 
I have arachnoiditis and foot drop following lumbar fusion. The pain is unrelenting although it varies in intensity, location and frequency. I take Gabapentin 1100mg/day with minimal relief and find that increasing the dose, no matter how gradually, makes me feel very ¿foggy¿ and I have difficulty with memory and thought. I have done a fair amount of research on arachnoiditis and know that there is not much hope for help, but I am always looking for a new perspective. Can you offer any advice?
Wednesday March 23, 2011 12:09 Judith
Steven P. Cohen: 
Arachnoiditis is a possible cause of pain following spine surgery, especially extensive procedures associated with lots of bleeding of injection of substances into the spinal canal. The treatment for arachnoiditis is similar to that for other forms of neuropathic pain, such as the use of "nerve" medications. Epidural steroid injections can be helpful for pain shooting into the leg, but tend not to be as beneficial as for sciatica from other causes. Spinal cord stimulation has been shown in several well-conducted studies to provide good pain relief for leg pain following spine surgery.
Wednesday March 23, 2011 12:10 Steven P. Cohen
[Comment From ToddTodd: ] 
My Mother had a tooth extraction back in June 6th, 2006 and when it was done they severed a nerve in her face. My Mother has developed a significant parenthesis of the right inferior alveolar nerve which seems to be non-treatable. We have spent years trying to find a solution that would lessen the pain that she suffers daily without a break. She has been on so many different drugs that its very hard to keep up with the different types of medication that has been tried. Currently she is looking into a doctor who is suggesting burring the nerve in her jaw into the bone to lessen the pain. The question is have you heard of this type of procedure and do you think it would work. At this point she is will to try anything, her day-to-day life has been severely impacted. Any suggestion would be greatly appreciate, we look forward to any help. Thanks so much, it¿s great to see research continues in this field where so many people suffer daily.
Wednesday March 23, 2011 12:11 Todd
Steven P. Cohen: 
Answer: I am not familiar with ¿burying¿ (if that is what you intended to write) the nerve into the jaw for this type of pain, but do not believe there is evidence to support this or that it is likely to provide long-term relief. If you meant ¿burning¿ the nerve, this is generally not helpful in the long-term, as nerves regenerate. In some people, after nerve regeneration, the pain may return worse than at baseline. One thing that might be considered if your mother responds to a ¿prognostic/ diagnostic¿ nerve block would be pulsed radiofrequency of the nerve. This is associated with minimal risk of worsening the pain, but there is some evidence that it may provide improvement for several months or longer.

Wednesday March 23, 2011 12:17 Steven P. Cohen
[Comment From BarryBarry: ] 
I have been told that I have spinal stenosis (based on a CT) and that it is the cause of severe pain I experience intermittantly that runs from the left buttock down the thigh, the knee, the leg, and the instep, and that sometimes causes numbing/tingling of the toes. The pain is most severe when I stand still or walk slowly. Least severe when seated. Bothersome when I lay flat in bed. Generally pretty good when walking briskly or climbing up/down steep hills. Both my GP and my orthopedist have said that the only effective treatment and the only cure is surgery. I have tried an epidural (effective for a few days only) and now I'm trying acupuncture - too early to tell. I'm also on Tagin (oxycodone and naloxone prolonged release tablets, low dose) 2x day plus Percoset if/when needed. The meds are not effective (I have not taken the Percoset - I'm afraid of it). Is surgery truly the eventual, unavoidable route? I am 72 1/2, male, healthy, active, non-smoker, no other chronic problems. Answer: There are many different causes for spinal stenosis, but almost all are characterized by pain shooting into the leg(s) that occurs with various activities. Because bending forwards opens up the spinal canal, patients often state that they are able to ride a bicycle or walk up a hill or stairs without difficulty. Surgery is not ¿unavoidable¿, unless your lose control of your bowel or bladder function, develop true neurological weakness that endangers you, or you ha
Wednesday March 23, 2011 12:17 Barry
Steven P. Cohen: 
There are many different causes for spinal stenosis, but almost all are characterized by pain shooting into the leg(s) that occurs with various activities. Because bending forwards opens up the spinal canal, patients often state that they are able to ride a bicycle or walk up a hill or stairs without difficulty.

Surgery is not ¿unavoidable¿, unless your lose control of your bowel or bladder function, develop true neurological weakness that endangers you, or you have incapacitating pain that fails to respond to more conservative treatments. Studies conducted in patients with sciatica have generally shown that surgery is more effective than not having surgery for 6 months, and up to two years in people with spinal stenosis, but then the benefits dissipate. People with spinal stenosis may also report more pain relief than improvement in function. However, some people will get worse with surgery.

Acupuncture appears to be better than ¿no acupuncture¿, although the magnitude of benefit is not that strong. For the nerve pain shooting down your leg, I would try one of the first line medications before considering surgery. These would include the anticonvulsants gabapentin or pregabalin, or antidepressants such as nortriptyline. I would continue to do a regular exercise program. Another option that you might want to look into would be the MILD procedure (minimally invasive lumbar decompression). The data are favorable at this point, but the evidence is purely anecdotal (i.e. no well-designed studies).
Wednesday March 23, 2011 12:18 Steven P. Cohen
Baltimore Sun Health: 
We had a couple of advance questions that we just answered.
Wednesday March 23, 2011 12:19 Baltimore Sun Health
[Comment From BillBill: ] 
I am a 77 year old male. I was an active MD Senior Olympic participant ( track ) I currently try to stay active on a weekly basis. About 10 months ago I started experiencing pain starting from the left hip area including the hamstring and calf. I have had an MRI of the pelvis and leg which indicated nothing out of the ordinary beyond mild stenosis and possibly spondolothesis. Over the months my discomfort has increased in spite of physical therapy, Advil, and Celebrex. Recently, I noted that some range of motion causes pain and the hamstring saeems to ache throughout the day, more so in the evening. - to the point of interrupting my sleep With all due respect to my current physician, I am still confused about how I went from a fairly active lifestyle to one marked with pain. Question: Can I minimize the pain and stiffness and return to a fairly active lifestyle or should I acknowledge the situation as expected changes associated with aging?
Wednesday March 23, 2011 12:19 Bill
Steven P. Cohen: 
I would need to know more about the quality of your pain, and which part of the hip, to know whether it was pain from nerve injury or typical degenerative changes associated with aging. Nerve pain is more likely to be characterized as ¿burning, shooting, sharp¿ etc. than pain from degenerative changes, which are more often described with words such as ¿deep, aching, pressing¿. Nerve pain is also frequently associated with numbness or tingling. Arthritis and bursitis are non-nerve pain syndromes that normally would NOT extend all the way down to the calf. Spinal stenosis could cause pain extending from back down to the calf, and the MRI findings don¿t always correlate well with symptoms. Other possibilities could include pain from the sacroiliac joint, entrapment of the sciatic nerve from a muscle in your buttock region (piriformis syndrome), and possibly a tight iliotibial band (though that pain usually won¿t go to the mid-calf).
Wednesday March 23, 2011 12:20 Steven P. Cohen
[Comment From ErinErin: ] 
I have various types of neuropathic pain in my body, and it seems very hard to treat. Are there new medications or treatments being developed, or soon to be approved that can give patients hope?
Wednesday March 23, 2011 12:21 Erin
Steven P. Cohen: 
Neuropathic pain generally does not involve most of the body, but instead tends to be regional (i.e. diabetic neuropathy that affects the feet and hands in a glove-stocking distribution and sciatica that extends to the leg). Pain that is more ¿diffuse¿ and multifocal tends to be less likely to respond to procedures such as surgery and nerve blocks, but instead is better treated with medications, exercise, and sometimes complementary and alternative medical treatments. For people who have widespread pain complaints, especially middle-aged women, fibromyalgia should be ruled out. Effective treatments for fibromyalgia include antidepressants and anticonvulsants. Perhaps the most beneficial treatment is low-intensity exercise programs that emphasize aerobics. Although some people consider fibromyalgia a type of ¿nerve pain¿, others do not.
Wednesday March 23, 2011 12:22 Steven P. Cohen
[Comment From KEITHKEITH: ] 
Wednesday March 23, 2011 12:23 KEITH
Steven P. Cohen: 
Epidural steroid injections don't work for everyone, and the studies regarding effectiveness are mixed. Perhaps the strongest evidence for back pain in general is for high-intensity exercise programs. Nerve medications can work in some cases, but the magnitude of benefit is generally not great. If there is a clear-cut abnormality on MRI, then surgery can be considered for intractable pain. This is more beneficial than non-surgical treatments for 6 months, and perhaps 2 years in some people, but there is no strong evidence for longer benefit. Surgery (and injections) tend to work better in patients with a herniated disc than spinal stenosis.
Wednesday March 23, 2011 12:25 Steven P. Cohen
[Comment From gretagreta: ] 
I was diagnosed with BFS (benign fasiculation syndrome) last year. The neuros basically shrugged their shoulders and said I should be happy I don't have ALS. I am of course but some days I am in a lot of pain with muscle cramps, terrible exercise fatigue, and lots of strange parathesias. My symptoms fluctuate a lot. I took neurontin but it made the fascis dramatically worse. Are there any other drugs or supplements that could be beneficial?
Wednesday March 23, 2011 12:26 greta
Steven P. Cohen: 
This is an uncommon neurological disorder characterized by fasciculation (involuntary contractions) and pain. Drugs used to treat heart conditions (e.g. Beta blockers) and anticonvulsant drugs are often used, but don't work in everyone. If Neurontin was not effective, I would consider trying other anticonvulsant drugs, which work by stabilizing injured nerves. Some of these include oxcarbazepine, lamotrigine, topirimate and pregabalin (which works on the same receptor as Neurontin). Some people advocate opioid drugs, but it's not clear the risks outweigh the benefits, at least in the long-term. Of course people who experience involuntary muscle movements and pain or anxiety should have their labs checked to make sure they don't have any electrolyte imbalances.
Wednesday March 23, 2011 12:30 Steven P. Cohen
[Comment From RehireRehire: ] 
what does "burning" a nerve entail and do you recommend such a procedure when all else fails?
Wednesday March 23, 2011 12:30 Rehire
Steven P. Cohen: 
Burning a nerve for pain is generally done by creating a "controlled", predictable lesion by the use of a radiofrequency generator. Although radiofrequency nerve lesioning is the standard treatment for back pain due to arthritis, most pain physicians do not advocate this for nerve pain. This is because burning a nerve always creates more nerve damage, and nerve injury is the underlying cause of nerve pain to begin with. Approximately 10%-15% of people with nerve pain can get worse after "lesioning" their nerve(s).
Wednesday March 23, 2011 12:33 Steven P. Cohen
[Comment From WillWill: ] 
What treatments are available for chronic pudendal nerve pain?
Wednesday March 23, 2011 12:33 Will
Steven P. Cohen: 
Many people with pudendal nerve entrapment can alleviate their symptoms by lifestyle alteration (i.e. changing the seat on their bicycle). Sometimes, nerve blocks using local anesthetic and steroids can be helpful, especially when there is acute inflammation. A nerve block is also the reference standard for diagnosing this as the source of pain. If nerve blocks fail, either nerve medications (e.g. antidepressants such as nortriptyline), or a nerve release operation can be considered.
Wednesday March 23, 2011 12:36 Steven P. Cohen
[Comment From TomTom: ] 
I have severe bouts of pain due to damage to my spinal cord. I am also prone to urinary tract infections. Whenever I have a UTI my pain is much worse. Why is ther a cinnection between these events?
Wednesday March 23, 2011 12:39 Tom
Steven P. Cohen: 
There are several types of pain associated with spinal cord injury. These include "central pain", a very challenging form of "neuropathic" pain that sometimes follows damage to the central nervous system, which consists of the brain and spinal cord (the most common form of central pain); pain from spasticity; and pain in the internal organs from abnormal functioning (e.g. distension of the bowel or bladder). Doctors have known for sometime that there is a relationship between "stress" and pain (i.e. either physical stress or emotional stress in the form of anxiety can worsen symptoms). The best thing to do when this occurs is to treat the underlying problem (e.g. antibiotics, behavioral therapy for anxiety).
Wednesday March 23, 2011 12:43 Steven P. Cohen
[Comment From DebbieDebbie: ] 
I have RSD and Diabetic neuropathy. I am in a pain management program but I am still in pain and I am tired of feeling high all the time. Is there anything I can do to help? I had 2 sympathectamies and that made it worse. Please help.
Wednesday March 23, 2011 12:44 Debbie
Steven P. Cohen: 
For "RSD" (reflex sympathetic dystrophy, now known as complex regional pain sydnrome), in addition to the typical drugs used to treat nerve pain, there is very strong evidence for the use of a class of drugs called "bisphosphonates", which are also used to treat osteoporosis (e.g. Fosamax). One other treatment for which there is reasonably strong evidence for "RSD" and anecdotal evidence for diabetic neuropathy, is spinal cord stimulation.

One of the treatments for complex regional pain syndrome that has generated a lot of interest in the past few years is the use of ketamine infusions. Although some studies have shown modest benefit for refractory complex regional pain syndrome, others have not. The downside of ketamine infusions is that they generally require inpatient hospitalization, which is usually not covered by insurance.
Wednesday March 23, 2011 12:49 Steven P. Cohen
[Comment From GuestGuest: ] 
I have Diabetic Neuropathy in both legs and feet and all of the medicines that I have tried so far have affected my blood sugar. Is there anything that can help to ease the pain and not raise my blood sugar?
Wednesday March 23, 2011 12:50 Guest
Steven P. Cohen: 
Increased blood sugar from the most commonly used medications to treat diabetic neuropathy (e.g. gabapentin, nortriptyline, amitriptyline, duloxetine, pregabalin) is very, very unusual. If this is the case, I would consult an endocrinologist to see if there is not another reason for the fluctuations in your blood sugar. If your pain is localized to a small area, you may also consider a topical cream (e.g. capsaicin), which has demonstrated benefit in well-designed studies in patients with neuropathy. The main benefit of a topical cream is that it is devoid of systemic side effects (e.g. sleepiness, weight gain, and in your case, changes in blood sugar).
Wednesday March 23, 2011 12:54 Steven P. Cohen
[Comment From GuestGuest: ] 
Does hypnosis help with nerve pain?
Wednesday March 23, 2011 12:56 Guest
Steven P. Cohen: 
Good question. The relationship between nerve or tissue damage is complex, in that some people with severe pathology (e.g. arthritis, degenerative disc disease) have no pain, and others with no or minimally detectable pathology have severe pain (e.g. fibromyalgia). This is because pain encompasses a multitude of different processes, which include context (i.e. pain may be more bothersome at night than during a baseball game), memory and other cognitive processes, anxiety, and one's body's ability to modulate the pain via secretion of inhibitory nerve transmitters. This is why relaxation techniques such as hypnosis and biofeedback work well for some people and some conditions. Anxiety also stimulates a part of the nervous system called the sympathetic nervous system, which is responsible for our "fight or flight" response. Stimulation of this part of the nervous system, which can also occur during cold weather, can worsen some pain.

Relaxation techniques should be considered as part of a multimodal treatment approach, but tend to work better in patients who are motivated, willing to assume an active role in their treatment plan, and have a good relationship with their therapist.
Wednesday March 23, 2011 1:03 Steven P. Cohen
[Comment From GuestGuest: ] 
My daughter was injured at work almost 10 years ago. A case of wine fell on her neck and she has been disabled since. She is in constant pain and takes methadone, oxycocet, Demerol as well as lyrica and gabapentin and ketamine. Nothing seems to help and the neurologist claims they can't probe the nerves to try a pain blocker until she is off all medications. Obviously that can't happen. Nothing shows on CTs or MRIs. She had a botox injection that provided relief for 2 days and then right back to normal. She also had a pic line with Novocaine on top of all the other meds and nothing seems to help. Any ideas?
Wednesday March 23, 2011 1:05 Guest
Steven P. Cohen: 
Many people experience trauma in their life, which can include external factors (e.g. motor vehicle accident or gunshot wound) and "planned", or iatrogenic trauma, such as surgery. Although most people heal without long-lasting problems after these events, some people don't. The reasons for this are still being worked out, but probably include psychological factors, genetic factors, treatment, and factors relating to the trauma itself.

Under the best of circumstances, only about 30% of people with spinal pain with experience longer than 6 months of relief from narcotic pain medications, and an even smaller percentage will improve function on them. Because your daughter continues to have significant pain and poor function on these medications, I would consider her a "treatment failure" and taper them off. These medications, though they can be helpful in some people, are associated with significant long-term side effects such as decreased immune function, accelerated osteoporosis, increased sensitivity to pain, and all sorts of hormonal changes. The fact that her CTs and MRIs are normal suggests that there may be some other issues going on here (e.g. anxiety, untreated depression). There is some evidence to suggest that people with less abnormalities on imaging studies will not respond as well to injections or operations as those with clear-cut abnormalities, though these may still be worth a shot considering she's failed multiple medication trials.

Since she has had pain for so long, and failed so many different treatments, there is a strong chance that her pain will never totally resolve. I would therefore suggest changing her goals from "pain eradication" and "finding the cause" to improving her function, both physically and psychologically. In addition to tapering her off these medications which don't seem to be helping, seeing a physical medicine and rehabilitation doctor and a pain psychologist might be helpful.
Wednesday March 23, 2011 1:14 Steven P. Cohen
Baltimore Sun Health: 
OK, that's all the time we have today. Thanks for your great questions. We'll be back at in 2 weeks on another pain topic.
Wednesday March 23, 2011 1:15 Baltimore Sun Health
Steven P. Cohen: 
Thank you all for your time and effort on this important topic. I am sorry that time constraints did not enable me to get to all of your questions, but hopefully this was helpful.
Wednesday March 23, 2011 1:16 Steven P. Cohen
Baltimore Sun Health: 
Thank you Dr. Cohen.
Wednesday March 23, 2011 1:16 Baltimore Sun Health