| One-Minute Clinician

Chronic Pain and Neuromuscular Disorders

When you go to the textbooks, historically speaking, there was no mention of pain associated with neuromuscular disorders. Most--including Charcot-Marie-Tooth (which is a hereditary neuropathy) amyotrophic lateral sclerosis, most forms of muscular dystrophy--conditions were described as painless and that was just not adding up in my clinical experience. It turns out that these people have a lot of problems with pain; not surprisingly, the neuropathies like Charcot-Marie-Tooth disease, they have typical neuropathic pain--burning and dysesthetic pain in their arms and legs. Diseases like ALS can be accompanied by pain from immobility coupled with spasticity, and probably depression. Similarly in advanced cases of muscular dystrophy, patients may be dependent on a wheelchair for mobility. They have loss of range of motion in their joints, joint contractures, they may have scoliosis, or pressure points on their skin.

As a rehabilitation physician, I always make sure these patients are in an appropriate range of motion program. There are physical modalities, like ultrasonic heat over a joint, 1 to 2 watts of ultrasonic energy gives a good deep heat that will decrease the viscosity of the joint fluid and also bring in more blood, increase blood flow. Anti-inflammatory medications, like the COX-1 and COX-2 inhibitors, Tylenol also has some efficacy. And then after that, maybe a mild opiate--something like tramadol. If there’s neuropathic pain, I would certainly bring in antiepileptic medications, like pregabalin or gabapentin, and either a tricyclic antidepressant or some of the newer SNRIs like Cymbalta or Effexor. And then, of course, I also do recommend cannabis in that setting as well.

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