Como Reconhecer Uma Dor Neuropática
Regenerati - Dr. Willian Rezende
[{'start': '0.040', 'end': '4.640', 'text': 'If you want to know how to recognize'}, {'start': '2.200', 'end': '6.650', 'text': 'neuropathic pain, stay until the end of this'}, {'start': '4.640', 'end': '9.809', 'text': "video and I'll talk more about it"}, {'start': '6.650', 'end': '9.809', 'text': '[Music]'}, {'start': '9.880', 'end': '15.160', 'text': "today.  Hello, I'm Dr. William Rezende, I'm a"}, {'start': '12.759', 'end': '17.960', 'text': 'neurologist and on the channel I talk'}, {'start': '15.160', 'end': '19.840', 'text': 'about pain, sleep, parking, emotions and'}, {'start': '17.960', 'end': '21.880', 'text': 'general neurology as a whole.  If you'}, {'start': '19.840', 'end': '24.279', 'text': "don't want to be left out and don't want to"}, {'start': '21.880', 'end': '26.599', 'text': 'miss any news, subscribe to the'}, {'start': '24.279', 'end': '28.920', 'text': 'channel, click on the bell, and you will'}, {'start': '26.599', 'end': '31.480', 'text': 'receive notifications of new videos'}, {'start': '28.920', 'end': '34.079', 'text': 'that are scientifically based, have'}, {'start': '31.480', 'end': '36.200', 'text': 'language accessible to everyone and that'}, {'start': '34.079', 'end': '38.000', 'text': 'talk about content that'}, {'start': '36.200', 'end': '40.640', 'text': "interests you.  So, guys, today I'm going to"}, {'start': '38.000', 'end': '42.640', 'text': 'talk about neuropathic pain, how to'}, {'start': '40.640', 'end': '45.239', 'text': 'recognize neuropathic pain.  And'}, {'start': '42.640', 'end': '48.280', 'text': 'neuropathic pain is that pain caused by an'}, {'start': '45.239', 'end': '49.879', 'text': 'injury or dysfunction in the nervous system.'}, {'start': '48.280', 'end': '52.559', 'text': 'Here I want to'}, {'start': '49.879', 'end': '54.440', 'text': 'fundamentally address peripheral nerves.'}, {'start': '52.559', 'end': '58.199', 'text': 'It can also be central to the brain and'}, {'start': '54.440', 'end': '60.840', 'text': 'spinal cord, but neuropathic pain in the'}, {'start': '58.199', 'end': '63.600', 'text': 'peripheral system is the most common and is the one'}, {'start': '60.840', 'end': '66.040', 'text': 'we have to try to understand.   It'}, {'start': '63.600', 'end': '68.200', 'text': 'may seem simple, but'}, {'start': '66.040', 'end': '70.880', 'text': 'diagnosis is not always easy.'}, {'start': '68.200', 'end': '73.799', 'text': 'Neuropathic pain often disguises itself,'}, {'start': '70.880', 'end': '74.880', 'text': 'mimicking other conditions and making it a'}, {'start': '73.799', 'end': '78.439', 'text': 'real'}, {'start': '74.880', 'end': '81.560', 'text': 'puzzle to know what the'}, {'start': '78.439', 'end': '84.159', 'text': "patient's pain is.  Why is it so difficult?"}, {'start': '81.560', 'end': '87.479', 'text': 'First because pain is'}, {'start': '84.159', 'end': '90.000', 'text': 'subjective.  Each person feels and describes'}, {'start': '87.479', 'end': '91.880', 'text': 'pain differently.'}, {'start': '90.000', 'end': '94.320', 'text': 'Furthermore, neuropathic pain can'}, {'start': '91.880', 'end': '97.320', 'text': 'manifest itself in different ways.  There are'}, {'start': '94.320', 'end': '99.960', 'text': 'many ways in which the complaint can'}, {'start': '97.320', 'end': '104.119', 'text': 'come to her.  It is a complaint of burning, a complaint'}, {'start': '99.960', 'end': '107.000', 'text': 'of shock, tingling, pins and needles,'}, {'start': '104.119', 'end': '109.880', 'text': 'numbness.  The list is long.  All the'}, {'start': '107.000', 'end': '113.200', 'text': 'complaints that the patient may'}, {'start': '109.880', 'end': '116.680', 'text': 'have can really confuse'}, {'start': '113.200', 'end': '120.280', 'text': 'us when trying to distinguish what is'}, {'start': '116.680', 'end': '123.200', 'text': 'what.  But then, how can we'}, {'start': '120.280', 'end': '124.920', 'text': 'unravel this diagnosis?'}, {'start': '123.200', 'end': '128.200', 'text': 'First, eh, we have to explore'}, {'start': '124.920', 'end': '130.679', 'text': 'the clues we see together with the patient.'}, {'start': '128.200', 'end': '133.239', 'text': 'First, it is to detail the clinical history.   The'}, {'start': '130.679', 'end': '135.680', 'text': 'basis of everything is the clinical history.'}, {'start': '133.239', 'end': '137.800', 'text': 'First, when does the pain start?'}, {'start': '135.680', 'end': '140.319', 'text': 'I always ask, when did the'}, {'start': '137.800', 'end': '143.319', 'text': 'pain start?  You always have to know if this'}, {'start': '140.319', 'end': '146.239', 'text': 'was now, if it was a long time ago, what'}, {'start': '143.319', 'end': '149.959', 'text': 'happened?  It was after a trauma,'}, {'start': '146.239', 'end': '153.760', 'text': 'surgery, treatment, he had another'}, {'start': '149.959', 'end': '155.720', 'text': 'disease like diabetes.  And what'}, {'start': '153.760', 'end': '158.760', 'text': 'is the distribution of pain?  Where does it'}, {'start': '155.720', 'end': '162.239', 'text': 'hurt?  It follows a specific path,'}, {'start': '158.760', 'end': '164.239', 'text': 'it is diffuse, it affects both sides of the'}, {'start': '162.239', 'end': '165.680', 'text': 'body, it affects just one side.  This is'}, {'start': '164.239', 'end': '168.319', 'text': 'extremely important.  Like, for'}, {'start': '165.680', 'end': '172.200', 'text': 'example, a patient came in complaining'}, {'start': '168.319', 'end': '173.879', 'text': 'of post-herpetic pain, getting it here.  Then I'}, {'start': '172.200', 'end': '176.080', 'text': 'asked, great, and where did the SS go?'}, {'start': '173.879', 'end': '177.760', 'text': 'No, it was from here on the left side.  Aps was'}, {'start': '176.080', 'end': '180.599', 'text': 'on the left side and your pain is on the'}, {'start': '177.760', 'end': '184.640', 'text': 'right side.  No, impossible.  Your pain'}, {'start': '180.599', 'end': '187.560', 'text': 'is not from herpes.  So, it seems silly, but'}, {'start': '184.640', 'end': '191.640', 'text': 'like, it was being treated as'}, {'start': '187.560', 'end': '193.840', 'text': 'neuropathic pain, but it never was.  Like, it'}, {'start': '191.640', 'end': '196.159', 'text': 'was on the left side, her pain was on the'}, {'start': '193.840', 'end': '199.400', 'text': 'right side.  Like, knowing how to'}, {'start': '196.159', 'end': '202.200', 'text': 'ask where it hurts, details of that'}, {'start': '199.400', 'end': '204.640', 'text': 'path, that location, what the'}, {'start': '202.200', 'end': '207.040', 'text': 'pain is like, sometimes I have to give'}, {'start': '204.640', 'end': '209.680', 'text': 'words to patients.  I describe pain in terms of'}, {'start': '207.040', 'end': '212.599', 'text': 'tightness, pressure, pulsation and throbbing,'}, {'start': '209.680', 'end': '214.400', 'text': 'stabbing, burning, shock, cold,'}, {'start': '212.599', 'end': '215.920', 'text': 'tingling, so that the patient'}, {'start': '214.400', 'end': '218.480', 'text': 'can sometimes translate what he'}, {'start': '215.920', 'end': '221.040', 'text': 'feels.  What makes the pain worse, cold makes'}, {'start': '218.480', 'end': '224.000', 'text': 'the pain worse, heat makes the pain worse,'}, {'start': '221.040', 'end': '227.200', 'text': 'movement, rest.  There are other'}, {'start': '224.000', 'end': '230.400', 'text': 'symptoms associated with the pain, such as the foot'}, {'start': '227.200', 'end': '233.799', 'text': 'turning purple, turning white, changes in'}, {'start': '230.400', 'end': '236.400', 'text': 'accessibility, increased'}, {'start': '233.799', 'end': '238.720', 'text': 'or dry sweating, no longer sweating.  All of this'}, {'start': '236.400', 'end': '241.000', 'text': 'is important in making a diagnosis.'}, {'start': '238.720', 'end': '245.000', 'text': 'All these clues, this'}, {'start': '241.000', 'end': '248.879', 'text': 'detailed conversation is the anamnesis, which is sometimes the'}, {'start': '245.000', 'end': '251.280', 'text': 'basis for being able to understand whether it is'}, {'start': '248.879', 'end': '253.640', 'text': 'neuropathic pain or not.  But in addition to that,'}, {'start': '251.280', 'end': '258.000', 'text': 'we have tools,'}, {'start': '253.640', 'end': '260.160', 'text': 'standardized tools that help the doctor to have'}, {'start': '258.000', 'end': '262.160', 'text': 'an idea of \u200b\u200bwhether it is neuropathic pain or'}, {'start': '260.160', 'end': '266.560', 'text': 'not, such as the'}, {'start': '262.160', 'end': '269.440', 'text': 'DN4 questionnaire, which is a French-language'}, {'start': '266.560', 'end': '272.400', 'text': 'neuropathic 4 question.  I may have said it'}, {'start': '269.440', 'end': '276.120', 'text': "all wrong, but it's the N4 questionnaire."}, {'start': '272.400', 'end': '278.600', 'text': 'It is a simple tool with only'}, {'start': '276.120', 'end': '280.720', 'text': 'seven clinical assessment items that'}, {'start': '278.600', 'end': '283.120', 'text': 'investigates pain, for example, if there is'}, {'start': '280.720', 'end': '285.919', 'text': 'burning, a sensation of painful cold,'}, {'start': '283.120', 'end': '287.680', 'text': 'electric shock, other signs such as'}, {'start': '285.919', 'end': '290.039', 'text': 'hypoesthesia, which is the loss of'}, {'start': '287.680', 'end': '292.680', 'text': 'sensitivity to touch, hypoesthesia in'}, {'start': '290.039', 'end': '295.840', 'text': 'stings, the sting when it gives a little prick'}, {'start': '292.680', 'end': '299.080', 'text': 'in the feeling, pain evoked by touch or'}, {'start': '295.840', 'end': '301.440', 'text': 'brushing with four or more points'}, {'start': '299.080', 'end': '303.320', 'text': 'strongly suggests the presence of'}, {'start': '301.440', 'end': '307.199', 'text': 'neuropathic pain, okay?  The application of the'}, {'start': '303.320', 'end': '311.919', 'text': 'DN4 questionnaire is a simple method that'}, {'start': '307.199', 'end': '314.520', 'text': 'the doctor must use to have a'}, {'start': '311.919', 'end': '317.320', 'text': 'basis for knowing whether'}, {'start': '314.520', 'end': '319.319', 'text': 'or not there is a probability of neuropathic pain.   There'}, {'start': '317.320', 'end': '323.039', 'text': 'are other questionnaires such as the'}, {'start': '319.319', 'end': '325.680', 'text': 'lance or the pain detect, which'}, {'start': '323.039', 'end': '328.000', 'text': 'are also useful and can be used'}, {'start': '325.680', 'end': '330.080', 'text': 'on a daily basis.  These are all'}, {'start': '328.000', 'end': '333.080', 'text': 'screening tools, they are not a'}, {'start': '330.080', 'end': '336.800', 'text': 'definitive diagnosis, they increase the suspicion of a'}, {'start': '333.080', 'end': '339.919', 'text': 'diagnosis of neuropathic pain, but'}, {'start': '336.800', 'end': '343.360', 'text': 'in the questionnaire it is not a'}, {'start': '339.919', 'end': '345.720', 'text': 'definitive diagnosis.  The doctor needs to examine the'}, {'start': '343.360', 'end': '347.880', 'text': 'patient.  There must be a'}, {'start': '345.720', 'end': '350.840', 'text': 'neurological examination, for example, testing'}, {'start': '347.880', 'end': '354.280', 'text': 'sensitivity, testing perception of'}, {'start': '350.840', 'end': '358.360', 'text': 'touch, pain, stinging,'}, {'start': '354.280', 'end': '360.960', 'text': 'temperature, vibration, fine touch,'}, {'start': '358.360', 'end': '364.039', 'text': 'like cotton wool,'}, {'start': '360.960', 'end': '365.840', 'text': 'rough touch.  This is all extremely'}, {'start': '364.039', 'end': '369.080', 'text': 'important.  You have to compare, for'}, {'start': '365.840', 'end': '371.360', 'text': 'example, a region on the leg, the leg'}, {'start': '369.080', 'end': '375.000', 'text': 'with the leg itself, like the thigh, the'}, {'start': '371.360', 'end': '378.639', 'text': 'leg and the foot, one leg with another leg,'}, {'start': '375.000', 'end': '381.759', 'text': 'the hand with the leg, like, and you have to'}, {'start': '378.639', 'end': '384.199', 'text': 'test this and compare it to'}, {'start': '381.759', 'end': '385.639', 'text': 'see if it has changed or not.  And the'}, {'start': '384.199', 'end': '387.680', 'text': 'doctor also has to have the feeling that'}, {'start': '385.639', 'end': '389.880', 'text': 'sometimes the patient is so worried and'}, {'start': '387.680', 'end': '391.880', 'text': 'thinks that the track is'}, {'start': '389.880', 'end': '394.039', 'text': 'minimal, like that, he'}, {'start': '391.880', 'end': '396.080', 'text': 'wants to force the change, you know?  Well, you can'}, {'start': '394.039', 'end': '397.919', 'text': 'test muscle strength'}, {'start': '396.080', 'end': '400.360', 'text': 'extremely well and also look for other signs'}, {'start': '397.919', 'end': '403.120', 'text': 'of neuropathy, such as loss of'}, {'start': '400.360', 'end': '406.759', 'text': 'muscle strength, which sometimes if the nerve is'}, {'start': '403.120', 'end': '408.840', 'text': 'damaged, in addition to the pain, there is also loss'}, {'start': '406.759', 'end': '410.759', 'text': "of strength.  And sometimes the patient doesn't even"}, {'start': '408.840', 'end': '413.639', 'text': 'notice that reflexes are'}, {'start': '410.759', 'end': '417.080', 'text': 'altered, the hammer test, for'}, {'start': '413.639', 'end': '419.479', 'text': 'example, shows the reflex tests'}, {'start': '417.080', 'end': '422.560', 'text': 'or reflex tests with, for example,'}, {'start': '419.479', 'end': '424.759', 'text': 'a risk.  There are several reflexes that'}, {'start': '422.560', 'end': '428.080', 'text': 'we can test to see if they are'}, {'start': '424.759', 'end': '430.639', 'text': 'preserved or not.  There are also signs'}, {'start': '428.080', 'end': '433.479', 'text': 'of autonomic dysfunction, for example,'}, {'start': '430.639', 'end': '436.759', 'text': 'changes in sweating, which is'}, {'start': '433.479', 'end': '440.280', 'text': 'perspiration, skin temperature,'}, {'start': '436.759', 'end': '443.759', 'text': 'skin color, hair growth.  All of these'}, {'start': '440.280', 'end': '446.680', 'text': 'give signs that there is innervation, whether'}, {'start': '443.759', 'end': '449.680', 'text': 'it is working or not.  There must'}, {'start': '446.680', 'end': '452.879', 'text': 'also be a neurological pattern.'}, {'start': '449.680', 'end': '454.960', 'text': 'Neuropathic pain necessarily needs to'}, {'start': '452.879', 'end': '459.199', 'text': 'follow a neurological pattern of'}, {'start': '454.960', 'end': '460.560', 'text': 'nerve, root and dermatome distribution.'}, {'start': '459.199', 'end': '464.000', 'text': "So you can't have"}, {'start': '460.560', 'end': '467.360', 'text': 'neuropathic pain that runs through your body'}, {'start': '464.000', 'end': '470.319', 'text': 'or that hits you here and so on, you know?  Kind of'}, {'start': '467.360', 'end': '473.720', 'text': 'like that, right?  Correct neurology,'}, {'start': '470.319', 'end': '477.159', 'text': 'things have to come within a'}, {'start': '473.720', 'end': '480.560', 'text': "neurological pattern, okay?  And that's mathematical.   You"}, {'start': '477.159', 'end': '482.879', 'text': 'also have to be careful, because there are'}, {'start': '480.560', 'end': '486.879', 'text': 'catches, okay?  Pranks are'}, {'start': '482.879', 'end': '489.240', 'text': 'things, pathologies that mimic'}, {'start': '486.879', 'end': '491.919', 'text': 'neuropathic pain, it increases the challenge and'}, {'start': '489.240', 'end': '495.400', 'text': 'diagnosis and this is common.  For example,'}, {'start': '491.919', 'end': '498.680', 'text': 'referred myofascial pain is caused by'}, {'start': '495.400', 'end': '501.720', 'text': 'trigger points in tense muscles that'}, {'start': '498.680', 'end': '503.720', 'text': 'refer pain to another area, okay?  It'}, {'start': '501.720', 'end': '505.599', 'text': "'s not a pain that comes from here in the muscle and goes"}, {'start': '503.720', 'end': '509.039', 'text': 'there, no.  It is a pain that the person'}, {'start': '505.599', 'end': '511.960', 'text': 'feels in the other area.  So,'}, {'start': '509.039', 'end': '514.479', 'text': 'deep, careful palpation of the'}, {'start': '511.960', 'end': '517.000', 'text': 'muscles is also important when'}, {'start': '514.479', 'end': '518.680', 'text': 'we are evaluating neuropathic pain.  And it is'}, {'start': '517.000', 'end': '521.839', 'text': 'very common to sometimes'}, {'start': '518.680', 'end': '523.800', 'text': 'have myofascial pain along with neuropathic pain, okay?'}, {'start': '521.839', 'end': '526.000', 'text': 'And one is one, another is another.  And sometimes the'}, {'start': '523.800', 'end': '528.839', 'text': 'two things go together and sometimes there is no'}, {'start': '526.000', 'end': '531.680', 'text': 'neuropathic pain and it is just the facial pain.'}, {'start': '528.839', 'end': '533.440', 'text': "And there's also central neuropathic pain,"}, {'start': '531.680', 'end': '535.440', 'text': "okay?  Sometimes it's hunting in the"}, {'start': '533.440', 'end': '538.040', 'text': "periphery, it's hunting for"}, {'start': '535.440', 'end': '541.120', 'text': 'peripheral neuropathic pain, but the cause is'}, {'start': '538.040', 'end': '543.160', 'text': 'in the brain.  It could be due to an injury, such as a'}, {'start': '541.120', 'end': '545.680', 'text': 'stroke, multiple sclerosis,'}, {'start': '543.160', 'end': '547.399', 'text': "Parkinson's, which cause very"}, {'start': '545.680', 'end': '550.440', 'text': 'similar pain, peripheral neuropathic pain'}, {'start': '547.399', 'end': '553.320', 'text': ', except that the cause is not'}, {'start': '550.440', 'end': '555.839', 'text': 'peripheral, it is central.  The'}, {'start': '553.320', 'end': '557.959', 'text': 'doctor has to be aware of all this, okay?'}, {'start': '555.839', 'end': '561.440', 'text': 'because the treatment is different.  In addition to the'}, {'start': '557.959', 'end': '563.880', 'text': 'entire process of anamnesis and'}, {'start': '561.440', 'end': '567.040', 'text': 'physical examination, we also use'}, {'start': '563.880', 'end': '570.040', 'text': 'complementary and propaedeutic tests'}, {'start': '567.040', 'end': '572.680', 'text': 'to obtain a more definitive diagnosis,'}, {'start': '570.040', 'end': '574.959', 'text': 'such as an electroneuromyography test.'}, {'start': '572.680', 'end': '577.240', 'text': 'an exam that evaluates the function of'}, {'start': '574.959', 'end': '580.360', 'text': 'peripheral nerves, identifying the pattern of'}, {'start': '577.240', 'end': '583.760', 'text': 'injury, whether the nerve is demyelinating, it is an'}, {'start': '580.360', 'end': '587.680', 'text': 'aconal injury, if there is no injury, whether'}, {'start': '583.760', 'end': '590.560', 'text': 'nerve conduction is normal.  And it is an exam'}, {'start': '587.680', 'end': '593.040', 'text': 'that helps a lot to identify'}, {'start': '590.560', 'end': '595.480', 'text': 'neuropathic disease and where that'}, {'start': '593.040', 'end': '598.240', 'text': 'neuropathy is.  So electroneuromyography is very important'}, {'start': '595.480', 'end': '600.680', 'text': '.  We also have'}, {'start': '598.240', 'end': '604.160', 'text': 'thermography, which measures'}, {'start': '600.680', 'end': '607.320', 'text': 'skin temperature and detects patterns of changes in'}, {'start': '604.160', 'end': '610.320', 'text': 'blood flow on the surface of the skin'}, {'start': '607.320', 'end': '612.399', 'text': 'that are associated with'}, {'start': '610.320', 'end': '613.720', 'text': 'neuropathic disease and neuropathic pain.  It is a'}, {'start': '612.399', 'end': '617.120', 'text': 'non-invasive exam and is'}, {'start': '613.720', 'end': '619.760', 'text': 'extremely useful for this pain that is'}, {'start': '617.120', 'end': '621.680', 'text': 'so complex.  And well, in'}, {'start': '619.760', 'end': '624.279', 'text': 'some selected cases we also have'}, {'start': '621.680', 'end': '625.800', 'text': 'skin biopsies to study the fine fibers, okay?'}, {'start': '624.279', 'end': '629.079', 'text': 'When we are very suspicious, we'}, {'start': '625.800', 'end': '630.880', 'text': "don't find anything and it's like, there is still"}, {'start': '629.079', 'end': '633.040', 'text': 'a characteristic, we do this'}, {'start': '630.880', 'end': '635.160', 'text': 'biopsy to see the study of the'}, {'start': '633.040', 'end': '637.200', 'text': 'nerve fibers that are related to'}, {'start': '635.160', 'end': '639.320', 'text': 'sensitivity to pain, temperature and if there is'}, {'start': '637.200', 'end': '641.279', 'text': 'a reduction in the density of these'}, {'start': '639.320', 'end': '644.639', 'text': 'fibers, it is a strong indication of a'}, {'start': '641.279', 'end': '647.279', 'text': 'small fiber neuropathy, ok?  Which is'}, {'start': '644.639', 'end': '649.839', 'text': 'a common cause of neuropathic pain.  And'}, {'start': '647.279', 'end': '652.320', 'text': 'obviously for'}, {'start': '649.839', 'end': '654.200', 'text': 'central neuropathic pain exams we also do'}, {'start': '652.320', 'end': '657.160', 'text': 'magnetic resonance imaging or'}, {'start': '654.200', 'end': '661.360', 'text': 'tomography exams that help see herneas'}, {'start': '657.160', 'end': '663.839', 'text': 'compressing roots, tumors, stroke,'}, {'start': '661.360', 'end': '666.000', 'text': "Parkinson's, multiple sclerosis, and several"}, {'start': '663.839', 'end': '668.399', 'text': 'other things that make up the picture of'}, {'start': '666.000', 'end': '670.440', 'text': 'neuropathic pain.  Well, so to know'}, {'start': '668.399', 'end': '672.639', 'text': "whether it's true neuropathic pain or"}, {'start': '670.440', 'end': '675.880', 'text': "not, it's a combination of these."}, {'start': '672.639', 'end': '678.880', 'text': 'Clinical history, anamnesis, detailed physical examination'}, {'start': '675.880', 'end': '681.760', 'text': ', complementary tests, and then'}, {'start': '678.880', 'end': '683.760', 'text': 'we arrive at the appropriate diagnosis or'}, {'start': '681.760', 'end': '685.839', 'text': 'not for each patient, okay?  Many'}, {'start': '683.760', 'end': '688.120', 'text': 'patients arrive thinking it is'}, {'start': '685.839', 'end': '689.680', 'text': 'neuropathic pain, because even some'}, {'start': '688.120', 'end': '692.240', 'text': 'doctor told them it is'}, {'start': '689.680', 'end': '695.040', 'text': 'neuropathic pain, it looks like neuropathic pain,'}, {'start': '692.240', 'end': '698.600', 'text': 'but sometimes it is not.  or sometimes the pain is'}, {'start': '695.040', 'end': '701.600', 'text': 'neuropathic pain, but it is'}, {'start': '698.600', 'end': '703.399', 'text': 'central, not peripheral.  And having the'}, {'start': '701.600', 'end': '706.920', 'text': 'correct diagnosis of this is extremely'}, {'start': '703.399', 'end': '709.200', 'text': 'important.  I had a patient who was'}, {'start': '706.920', 'end': '712.440', 'text': 'being diagnosed with'}, {'start': '709.200', 'end': '715.839', 'text': 'peripheral neuropathic pain.  The guy is an'}, {'start': '712.440', 'end': '717.920', 'text': 'important guy from Bahia and has resources. He had'}, {'start': '715.839', 'end': '720.079', 'text': 'already come and seen several doctors from'}, {'start': '717.920', 'end': '721.880', 'text': 'São Paulo. He had done an'}, {'start': '720.079', 'end': '725.279', 'text': 'electromyography, he had even done a'}, {'start': '721.880', 'end': '728.120', 'text': 'skin fiber biopsy with a'}, {'start': '725.279', 'end': '730.560', 'text': 'fine fiber count. It had decreased, but he did'}, {'start': '728.120', 'end': '732.480', 'text': 'not respond to the neuropathic pain medications'}, {'start': '730.560', 'end': '735.320', 'text': 'and was always very'}, {'start': '732.480', 'end': '737.440', 'text': 'intolerant.  And then what happened was that by'}, {'start': '735.320', 'end': '739.360', 'text': 'examining him neurologically in a'}, {'start': '737.440', 'end': '741.480', 'text': 'complete manner, the neurological examination'}, {'start': '739.360', 'end': '743.440', 'text': 'could not be directed only at'}, {'start': '741.480', 'end': '744.920', 'text': 'neuropathic pain.  I saw that he had'}, {'start': '743.440', 'end': '747.800', 'text': 'tremors and a'}, {'start': '744.920', 'end': '750.880', 'text': 'slowness.  Oh boy, that seems'}, {'start': '747.800', 'end': '753.399', 'text': 'like a pittance.  I gave him levodopa, he gave him prolopa, it'}, {'start': '750.880', 'end': '755.240', 'text': "improved the guy's neuropathic pain and"}, {'start': '753.399', 'end': '756.920', 'text': "that was it.  It's a diagnosis that"}, {'start': '755.240', 'end': '759.360', 'text': 'makes all the difference.  So, having the'}, {'start': '756.920', 'end': '762.519', 'text': 'correct diagnosis'}, {'start': '759.360', 'end': '764.920', 'text': 'of the cause of the patient’s neuropathic pain'}, {'start': '762.519', 'end': '766.480', 'text': 'makes all the difference.  And sometimes this is'}, {'start': '764.920', 'end': '769.079', 'text': 'a puzzle, and we have to put'}, {'start': '766.480', 'end': '771.880', 'text': 'the pieces together to get a diagnosis.   That is'}, {'start': '769.079', 'end': '774.079', 'text': 'why it is so important to'}, {'start': '771.880', 'end': '777.000', 'text': 'contact a neurologist'}, {'start': '774.079', 'end': '778.360', 'text': 'who specializes in pain to obtain the'}, {'start': '777.000', 'end': '781.560', 'text': 'correct diagnosis, the correct'}, {'start': '778.360', 'end': '783.120', 'text': "treatment and relief for the patient's pain"}, {'start': '781.560', 'end': '785.120', 'text': '.  If you liked the video,'}, {'start': '783.120', 'end': '788.079', 'text': 'write in the comments what you'}, {'start': '785.120', 'end': '790.360', 'text': 'think about it, about knowing whether a pain'}, {'start': '788.079', 'end': '792.160', 'text': 'is neuropathic or not.  Have you ever been'}, {'start': '790.360', 'end': '794.120', 'text': 'diagnosed with neuropathic pain?'}, {'start': '792.160', 'end': '797.120', 'text': 'Was she really neuropathic or'}, {'start': '794.120', 'end': '799.040', 'text': 'not?  If you know someone who has this'}, {'start': '797.120', 'end': '800.639', 'text': 'possibility, neuropathic pain,'}, {'start': '799.040', 'end': '803.760', 'text': 'send the link to this video to that'}, {'start': '800.639', 'end': '805.639', 'text': 'person, give them a like, give them a thumbs up,'}, {'start': '803.760', 'end': '807.839', 'text': 'give the channel some support, subscribe'}, {'start': '805.639', 'end': '810.279', 'text': 'to the channel and click on the bell, so you will'}, {'start': '807.839', 'end': '811.880', 'text': 'receive notifications of new videos.  And'}, {'start': '810.279', 'end': '813.920', 'text': 'share, because the'}, {'start': '811.880', 'end': '816.920', 'text': 'more knowledge you share, the better for everyone.  A'}, {'start': '813.920', 'end': '816.920', 'text': 'hug, see you soon'}]