Neuralgia: Understanding Nerve Pain

• Neuralgia is a type of nerve dysfunction, also described as "nerve-pain."

Neuralgia Overview:

• Pain occurs in the distribution of nerves without objective signs or structural damage.
• Any nerve is susceptible, though neuralgia is common in trigeminal (Cranial Nerve 5) and intercostal nerves.
• Appears as sudden, excruciating attacks described as "lightning-like" or throbbing.
• No tissue damage or injury exists in the affected nerve.
• Trigger zones cause attacks when stimulated.

Causes of Neuralgia:

• Local compression from neuroma or previous injury.
• Demyelinating conditions like MS, which can lead to scar tissue formation.
• Bony callus from a previous injury.
• Prolonged exposure to cold.

Key Characteristics of Neuralgia:

• Produces paroxysmal, intense, unilateral pain along the nerve distribution, often described like a knife or electric shock.
• Pain lasts from seconds to minutes.
• Neuralgias are often clustered and have trigger zones

Trigger Zones:

• Stimuli include light touch, temperature extremes (especially cold), and intense light.
• Sometimes movement stimulates trigger zones

Precaution:

• Avoid stimulating the trigger zone during assessment, manual techniques, or positioning.

Intercostal Neuralgia:

• Characterized by a trigger zone distributed along the affected spinal segment and laterally in the intercostal space.

Intercostal Neuralgia:

• Described as horrible, lightning-like pain with no apparent cause.
• Shingles, marked by skin eruptions turning into scabs, can be a cause, with pain fading as vesicles heal.
• Manifests as unilateral pain in nerve distribution
• It is not a condition of nerve degeneration but requires extreme caution due to trigger zones.

History Questions for Neuralgia:

• Identifying triggers (stimuli, location, predictability, patterns)
• Sensitivity to touch and pressure
• Doctor's diagnosis, prognosis, and ongoing treatments
• Onset, progression (better, worse, same), and rate of change

Assessment for Neuralgia:

• Avoid touching trigger zones, especially if a diagnosis exists

Differential Diagnosis:

• None specified

Treatment for Neuralgia:

• During acute phase and immediately following the most recent attack, focus on treating areas other than the affected site.
• Relaxation techniques, including diaphragmatic breathing
• Abdominal massage with diaphragm release
• Rib springing for thoracic mobility, unless contraindicated by osteoporosis, bone conditions, or muscle spasm
• Only touch the trigger zone if you have asked about the triggers and you are sure your touch will not trigger pain
• Work around the trigger zone with diaphragm, then rib, intercostal, and thoracic work that does not touch the trigger zone
• Treat intercostal muscle TrPs that are not trigger zones

Home Care for Intercostal Neuralgia:

• Diaphragmatic breathing.
• Pain-free thoracic mobility exercises that do not trigger pain.

Trigeminal Neuralgia Trigger Zone:

• Includes lips, face, and tongue.
• Most commonly involves areas innervated by the maxillary division (V2), or sometimes the maxillary and mandibular divisions (V3).

Key Sign of Trigeminal Neuralgia:

• Horrible, lightning-like pain with no apparent cause

Manifestations of Trigeminal Neuralgia:

• Unilateral pain in nerve distribution
• Facial tics
• Inflammation of sclera or iris, possibly glaucoma
• Hearing loss due to paralysis of the tensor tympani
• Locked jaw due to paralysis of muscles of mastication

Differential Diagnosis for Trigeminal Neuralgia:

• Acute migraine and cluster headaches
• Myofascial pain

Treatment for Trigeminal Neuralgia:

• Avoid treatment over the trigger zone.
• Address muscle spasms and trigger points to reduce facial tics
• Warm face cloth to reduce tension.
• Promote relaxation, including diaphragmatic breathing.
• Decrease facial pain with light massage of the face or scalp.
• Decrease trigger points in muscles of mastication
• Decrease tension using warm compress on affected area

Home Care for Trigeminal Neuralgia:

• Facial exercises

Cranial Nerve 5 (V) (Trigeminal):

• Has three main branches: ophthalmic, maxillary, and mandibular.
• Each main branch divides into several named cutaneous nerves.

Cranial Nerve 7 (VII) (Facial):

• Branches include: temporal, zygomatic, buccal, marginal mandibular, and cervical.
• Pathway: Pons > internal acoustic meatus > inner ear > stylomastoid foramen > through parotid gland.
• Has general somatic sensory fibers innervating the skin of the ear canal and tympanic membrane.
• Has special sensory fibers which supply taste to the anterior two thirds of the tongue.
• Compression sites: Inner ear (intracranial) and parotid gland
• Functions:
  • Motor (Facial expression, Mastication)
  • Sensory (Taste)
  • Autonomic Lacrimation, Sweating)

Palpation for Cranial Nerve 7:

• Palpate or percuss the parotid gland or zygomatic arch
• Assess flaccidity of muscles around forehead, eye, nose & mouth
• Detect boggy edema around parotid gland on affected side

Bell's Palsy:

• Neurological condition affecting 25 out of 100,000 people each year, most common between ages 15 and 45.
• Rapid onset of symptoms, progressing quickly from weakness to flaccidity

Key Signs of Bell's Palsy:

• Eye closure is difficult or impossible (orbicularis oculi).
• Eye opening is fine because of different innervation (levator palpebrae superioris via cranial nerve 3).

Manifestations of Bell's Palsy:

• All are unilateral
• Forehead wrinkles disappear
• Overall droopy appearance
• Difficult or impossible to blink
• Nose runs and constantly feels stuffed
• Difficulty speaking, eating, drinking
• Sensitivity to low tones (hyperacusis)
• Excess or reduced salivation (autonomic)
• Facial swelling
• Pain in or near the ear
• Drooling
• Excessive or reduced tearing (autonomic)
• Brow droop
• Lower eyelid droop
• Sensitivity to light
• Loss of taste in anterior 2/3 of tongue

Etiology of Bell's Palsy:

• Cause is not well understood
• Herpes simplex or zoster reactivation or other infection in inner ear
• Parotid gland infection (mumps)
• Trauma, especially to temporal bone
• Tumors (acoustic neuroma, parotid gland)
• Increased risk with diabetes mellitus and pregnancy (3rd trimester).

History Questions for Bell's Palsy:

• Systemic disorders (diabetes, pregnancy, cardiovascular conditions)
• Doctor's diagnosis, prognosis, and treatments.
• Approved for local massage
• Onset, progression (better, worse, same), and rate of change
• Sensory changes (taste, hearing)
• Changes to normal function (sweating, lacrimation, dry eyes)
• Pain (not common)

Assessment for Bell's Palsy:

• Observation:(Drooping/downward pulling on affected side, eye and mouth droop, loss of wrinkles, excessive lacrimation)
• AROM and RROM of facial expression muscles

Differential Diagnosis for Bell's Palsy:

• Stroke typically affects lower muscles of the face, whereas Bell’s Palsy affects all muscles

Precautions for Bell's Palsy Treatment:

• It is a condition of nerve degeneration.
• Avoid prone positioning
• Modify pressure for flaccid tissue
• Prevent traction on the nerve with dragging strokes
• Work towards the affected side to prevent dragging
• Extra support around the stylomastoid foramen when supine
• Avoid traction of the supraclavicular area (platysma)
• Do not use fascial techniques

Treatment for Bell's Palsy:

• Supine position, towel for tearing and drooling, towel between therapist and affected side
• Warm cloth on affected area, cool washes on affected tissues, avoid local heat over unaffected side
• Block to protect tissues, encourage diaphragmatic breathing
• Treat unaffected side of chest, post neck, shoulder, scalp, and face with pressure towards lesion
• On affected side use techniques that move from mid-line toward the lesion , cue and assist with facial expressions and use light brushing/stroking towards lesion

Home Care for Bell's Palsy:

• Apply cool cloth before exercise, moist heat for relief.
• Practice facial expressions in mirror 2-3 times per days for 2-5min each time.
• Get MD for eye treatment and use eye cover

Test your knowledge of neuralgia, a type of nerve pain. Questions cover causes, symptoms, and diagnosis. Explore trigeminal and intercostal neuralgia.