Regardless of the etiologies and mechanisms of neuropathic pain, those who suffer from it and those who treat it agree the great deterioration that this condition represents in the quality of life of those who suffer from it. Next, we will see the testimony of a person who has suffered for a long time this clinical condition and who is going to tell us about the deterioration in her living conditions. You told me that this pain started about 15 years ago. Yes, no, it's a little more. Tell me how you would have imagined or how you would feel if your life, These years, if you had been without this pain. Well, they would have been just following the first ones, that we woud go out, We walked, we enjoyed ourselves, but nothing hurt me at that time, doctor. I didn't have to complain, bother anyone, bother others. Very different, doctor. Do you feel that it has a high impact on your quality of life? I do in deed, doctor. And specifically, what activities Do you feel that you have limited or that you have stopped doing? Everything in the house, doctor. I can't do everything I used to do at home, doctor. Were your going out and doing activities also limited and marked by pain? Of course, doctor, because pain started to attack me, I was got in the car and everything began to hurt, ..the legs, you name it, I got tired... that's right, doctor, And we liked to go out and we walked a lot. Tell me, all this time, how could you survive the pain, what have you had to do, what have you appealed to, or what have you invented to be able to control and live a little better with this pain. First of all, well, go to a doctor. They prescribed me medications and I went to the pain clinic. OK. I have had therapies, which did not help me. OK. And especially, to survive this pain, be patiente. Patience. Have you done anything else physically around the house, some care, have you thought about any special routine to be able to control the pain a little? No. At all? Not at all. What you reamrk the most ; is it patience? Yes, patience, but of course sometimes it wears you out, it upsets you and you are no longer the same person. From the narration of our patient, It is necessary to highlight several elements, whose timely recognition will allow a better diagnosis and, eventually, a better treatment: first, the chronic nature of this condition that she presented; second, multiple visits to different health professionals and, Therefore, multiple treatments whose result, in general, were neither beneficial in terms of analgesia nor in terms of functionality. An essential diagnostic is key to approach the diagnosis of neuropathic pain are the pain descriptors formulated by the same patient. For example, our patient referred the burning sensation, to the burning feeling, in the presence of pain spontaneous or associated with activity and cold as a trigger for pain. Within all the scales that we use today in clinical practice, these descriptors have an essential pplace because they contribute to a diagnostic approach. Taken together, knowledge of these conditions that are given through a clinical history detailed information, and a careful physical examination will improve diagnostic accuracy and, subsequently, the achievement of better results with the treatment. Through the modules of this course "Neuropathic pain", we will be emphasizing these aspects basic but essential approach to the patient. Doctor, tell us a little about your experience in your practice. I am an emergency care physician, with low and high complexity patients. I have been in this position for approximately a year with a good volume of patients daily. When you hear the expression "neuropathic pain", what comes to your mind? The term neuropathic pain, in my opinion, brings to my head synonymous of trobles, chronic patients, complex patients, difficult to treat, patients who recur and that many times the initial treatment, that at least I leave for these patients, It doesn't turn out to be very efficient. And patients starting reconsultation frequently leading to more problems and, in many cases, complications are functionally limiting and this makes that become a little more demanding and becomes a diagnostic challenge, personally, in the primary care part. Do you have difficulty diagnosing neuropathic pain? Of course. I think that, within the pathologies and among the most frequent symptoms in emergencies, it is one of the challenges and one of the most difficult signs and pathologies to diagnose, since they have many differential diagnoses, features vary depending on location, and many times when you ran accross findings that make one suspect it, but they do not give one certainty in the treatment. It is very difficult to be certain that we are definitely dealing with neuropathic pain or that it may be common pain, so, it is very difficult to diagnose it and it is very difficult to address it. What knowledge do you have about diagnostic tools for neuropathic pain and how do you apply them or have you applied them? Initially, the tools with which I have knowledge in have to do more towards a good anamnesis, a good clinical history of the characteristics of the pain, how it appears, its location, where the pain goes, and other types of tools in the physical examination, that help us show a little, definitely, if there are some certain findings that may correlate with this type of pain. Always using the tuning fork can help us, reflexes, evaluate the sensitivity, both to puncture and touch, how these types of tools can help us. Suddenly a little more complex and extended, It is not a bit of other types of exams, such as tests at the level of electromyography or evocative potentials, but this is something that is not handy in primary care and we do not have this. Initially, for a patient with neuropathic pain, we are not going to carry out this type of diagnostic tests, but we stay more with the clinic. Do you have difficulty performing the treatment of neuropathic pain? Of course. I believe that the greatest difficulty is knowing what kind of medication is appropriate for this type of patient. And what I jsut mentioned to you, I believe that in most of these patients, The large percentage of these patients They recur despite being treated. treatment is started, even these medications begin to be titrated, several types of drugs are combined, and still patients persist with pain, persist with functional limitation. There is a point where one goes blank, because you don't know whether to keep increasing the doses, whether to increase more drugs, even with patients who carry three, four or five drug groups or what kind of behavior to take, because they are difficult patients to treat and the pain recurs and recurs and recurs. How often do you encounter this type of disease? In my personal and professional plan, many patients are seen; one, from ARL, occupational risk and middle-aged patients, which in this type of patients is frequent to find patients with neuropathic pain. More or less, this is a figure, I couldn't give it, but I could talk about one or two patients for every 10 patients, 10 to 20 patients seen with pain, speaking specifically of pain. What behavior do you take regarding neuropathic pain? and when do you decide to refer him to a specialist? As my attention is purely in emergencies, tracking is a bit difficult but yes, my initial behavior is always to initiate treatment, try to start all the altic points in the treatment to start to improve a little the quality of life of this type of patient and, obviously allow him to have his controls as an outpatient for specialized medicine. It is always wonderful to see when they are patients of difficult control, difficult to treat, refer them to a specialist. In this case, the one I use the most or the one I can use most frequently is the pain clinic, but that obviously depends on the evolution of the patient. Initially, as a first behavior, I do not refer patients. I am honest, in that aspect, I try to treat them and see how they will evolve with the initial treatment, but probably the follow-up that a colleague does on an outpatient basis and depending on whether or not he responded to the initial treatment, probably, I, if it were that second colleague who would assess him, then I would see the possibility of referring him to an appointment by a specialist
