Read How Professionals Learn How To Treat Neuropathic Pain

Today's post from patient.co.uk (see link below) is a long but very informative summary of how health professionals in the UK approach neuropathic pain. Normally, patients don't get to see this sort of information but it's always useful to know how health professionals are taught to approach our problems. It also helps us anticipate what the next step in our treatment might be. This article also helps us to understand how diverse neuropathy can be. Doctors need to be able to slot our cases into the overall pattern and identify both cause and appropriate treatment and as you can see here, that's by no means an easy job. There are over 100 causes of neuropathy and more than 100 different 'types' to deal with so maybe we should be a little more tolerant of our health carers as they try to fit us into the puzzle. Having done that, they and we, are faced with a disease where everybody responds differently to different treatments. While we sit and grumble at how long it's taking to get relief from the symptoms and how many different sorts of drugs we have to take; this article may at least help us to be more patient. Neuropathy can be the most complex chess game!

Neuropathic Pain and its Management Original Author: Dr Laurence Knott Current Version: Dr Colin Tidy
Last Checked:13/01/2014  
 
PatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Neuropathic pain is defined by the International Association for the Study of Pain (IASP) as pain arising as a direct consequence of a lesion or disease affecting the somatosensory system.[1]

Clinical features[2]
The discomfort is usually of a chronic nature and may be described by the patient as a burning sensation, a sharp, stabbing or shooting pain, or 'like an electric shock'.

Other features may include:
Allodynia - seemingly harmless stimuli, such as light touch, provoking pain.
Hyperpathia - a short episode of discomfort causing prolonged severe pain.
Hyperalgesia - discomfort, which would otherwise be mild, being felt as severe pain. The IASP states that hyperalgesia is a psychophysical term; it is has been suggested as the umbrella term for all conditions of increased pain sensitivity. Its definition parallels that of the physiological term 'sensitisation'.[2]

Prevalence[3]

There are no accurate figures for the overall prevalence of neuropathic pain.
The prevalence of neuropathic pain has been estimated to be between 6% and 8%.
A large study of computerised records in primary care from the Netherlands estimated the annual incidence of neuropathic pain in the general population to be almost 1%.
Painful diabetic neuropathy is estimated to affect between 16% and 26% of people with diabetes.
Prevalence estimates for postherpetic neuralgia range from 8% to 19% of people with herpes zoster when defined as pain at one month after rash onset, and 8% when defined as pain at three months after rash onset.
The development of chronic pain after surgery is also fairly common, with estimates of prevalence ranging from 10% to 50% after many common operations. This pain is severe in between 2% and 10% of these patients, and many of the clinical features closely resemble those of neuropathic pain.

Aetiology[1]

Peripheral causes

Central causes

Mononeuropathies and multiple mononeuropathies:
Diabetic mononeuropathy and amyotrophy.
Trauma: painful scars, compression, transection of a nerve, post-thoracotomy.
Neuralgic amyotrophy.
Damage to nerve plexi (plexopathy) from malignancy or radiation.
Connective tissue disease.
Rare causes - trench foot (damage due to cold exposure over several days), borreliosis.

Polyneuropathies:
Metabolic/nutritional:
Diabetic.
Alcoholic.
Amyloid.
Pellagra.
Beriberi.
Cuban neuropathy (usual cause B-group vitamin deficiency)
Burning feet syndrome.
Tanzanian neuropathy (may be Coxsackie infection).
Strachan's (Jamaican) neuropathy (orogenital ulceration, sensory neuropathy, ambylopia - cause unknown).

Drugs/toxic:
Nitrofurantoin.
Isoniazid.
Vincristine, cisplatin, arsenic.
Thallium.
Clioquinol.
Disulfiram.

Infective:
Acute inflammatory polyneuropathy (Guillain-Barré syndrome).
Chronic inflammatory demyelinating polyneuropathy (CIDP).
HIV.

Hereditary:
Anderson-Fabry disease.
Dominantly inherited sensory neuropathy/hereditary sensory and autonomic neuropathy (HSAN) - an inherited sensorimotor axonal neuropathy.[4]

Malignancy:
Carcinomatosis.
Myeloma.

Idiopathic small fibre neuropathy.

Spinal root/dorsal root ganglion:
Prolapsed disc.
Root avulsion.
Trigeminal neuralgia.
Postherpetic neuralgia (herpes simplex or varicella zoster).
Tumour.
Arachnoiditis.
Surgical rhizotomy.

Spinal cord:
Trauma.
Multiple sclerosis.
Vascular: infarction, haemorrhage, arteriovenous malformations.
HIV and syphilis.
Syringomyelia and intrinsic tumours.
Neural tube defect.
Vitamin B12 deficiency.
Anterolateral cordotomy.

Brainstem:
Lateral medullary syndrome.[5]
Multiple sclerosis.
Tumours.
Tuberculoma.
Syrinx.

Thalamus:
Infarction.
Tumours.
Haemorrhage.
Surgical lesions.

Subcortical and cortical:
Infarction.
Trauma.
Arteriovenous malformation.
Tumour.

Management 
 
The treatment of the underlying causative condition is central to the management of neuropathic pain but is outside the scope of this article. Neuropathy caused by mechanical pressure, for example, may require surgical and other interventional procedures.

The main role of the GP in the management of neuropathic pain is in the control of symptoms where the underlying cause is medical, where the condition is of a chronic, recurring or acute self-limiting nature, or whilst awaiting specialist intervention.

Prescribing of therapy with little evidence of efficacy in neuropathic pain is still common in the UK and consequently treatment is often not in line with current guidance.[6] 

When selecting a particular medication, the National Institute for Health and Care Excellence (NICE) recommends considering comorbidities, safety considerations, contra-indications, patient preference, lifestyle factors, any history of mental health problems (eg, anxiety, depression) and existing medication history.

Clear advice should be given about dosage instructions, preferably in writing.
Consider overlapping old and new treatment to prevent deterioration in pain control.

Review the patient early after starting or changing treatment.

Review the patient regularly, covering such aspects as pain control, side-effects, effect on daily living (eg, driving, working), mood, sleep and overall improvement.

Referral

Consider referring the person to a specialist pain service and/or a condition-specific service at any stage, including at initial presentation and at the regular clinical reviews, if:[3]
They have severe pain; or
Their pain significantly limits their lifestyle, daily activities (including sleep disturbance) and participation; or
Their underlying health condition has deteriorated.

Non-pharmacological measures
Psychological techniques - cognitive behavioural therapy has shown some benefit in the treatment of chronic pain.[7]
Studies of chronic pain management suggest that a combination of psychological, pharmacological and physical therapies, tailored to the needs of the individual patient, may be the best approach.[8]
Electrical stimulation - interpretation of systematic trials is difficult due to differing methodologies.[9] However, transcutaneous electrical nerve stimulation (TENS) performs consistently well compared with placebo.[10]
Percutaneous electrical nerve stimulation (PENS) has shown evidence of short-term benefit for refractory neuropathic pain.[11]
NICE recommends the use of spinal cord stimulation in patients who have had chronic pain for six months (measuring at least 50 mm on a 0-100 mm visual analogue scale) despite conventional medical management (providing a prior trial of stimulation has proved to be effective).[12]
Acupuncture - systematic evidence to support its use in neuropathic pain is limited.[13]

Pharmacological measures[3][14]

All neuropathic pain (except trigeminal neuralgia):
Offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain (except trigeminal neuralgia).
If the initial treatment is not effective or is not tolerated, offer one of the remaining three drugs, and consider switching again if the second and third drugs tried are also not effective or not tolerated.
Consider short-term tramadol only if acute rescue therapy is needed.
Consider capsaicin cream for people with localised neuropathic pain who wish to avoid, or who cannot tolerate, oral treatments.

Do not start the following to treat neuropathic pain in non-specialist settings, unless advised by a specialist to do so: cannabis sativa extract, capsaicin patch, lacosamide, lamotrigine, levetiracetam, morphine, oxcarbazepine, topiramate, long-term tramadol, venlafaxine.

Trigeminal neuralgia:
Offer carbamazepine as initial treatment for trigeminal neuralgia.
If initial treatment with carbamazepine is not effective, is not tolerated or is contra-indicated, consider seeking expert advice from a specialist and consider early referral to a specialist pain service or a condition-specific service.

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Further reading and references
Management of chronic pain; Scottish Intercollegiate Guidelines Network - SIGN (Dec 2013)
Scadding J; Advances in Clinical Neuroscience and Rehabilitation 2003;3(2)
Pain Terminology; International Association for the Study of Pain (IASP), 2008
Neuropathic pain – pharmacological management: The pharmacological management of neuropathic pain in adults in non-specialist settings; NICE Clinical Guideline (Nov 2013)
Neuropathy, Hereditary Sensory And Autonomic, Type IA, HSAN1A; Online Mendelian Inheritance in Man (OMIM)
Wallenberg's Syndrome; National Institute of Neurological Diseases and Stroke
Hall GC, Morant SV, Carroll D, et al; An observational descriptive study of the epidemiology and treatment of neuropathic pain in a UK general population. BMC Fam Pract. 2013 Feb 26;14:28. doi: 10.1186/1471-2296-14-28.
Williams AC, Eccleston C, Morley S; Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2012 Nov 14;11:CD007407. doi: 10.1002/14651858.CD007407.pub3.
Turk DC, Audette J, Levy RM, et al; Assessment and treatment of psychosocial comorbidities in patients with Mayo Clin Proc. 2010 Mar;85(3 Suppl):S42-50.
Fargas-Babjak, Angelica M.D. Acupuncture, Transcutaneous Electrical Nerve Stimulation, and Laser Therapy in Chronic Pain. Clinical Journal of Pain. Etiology, Prevention, Treatment, and Disability Management of Chronic Pain. 17(4) Supplement:S105-S113, December 2001.
Cheing GL, Luk ML; Transcutaneous electrical nerve stimulation for neuropathic pain. J Hand Surg (Br). 2005 Feb;30(1):50-5.
Percutaneous electrical nerve stimulation for refractory neuropathic pain; NICE IPG (Mar 2013)
Pain (chronic neuropathic or ischaemic) - spinal cord stimulation; NICE Technology Appraisal Guideline, October 2008
Guidelines on the management of neuropathic pain; Clinical Resource Efficiency Support Team (February 2008)
British National Formulary

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.


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