Does neuropathic pain require multidisciplinary pain management?
Many people with neuropathic pain can be treated successfully by a primary care provider or neurologist familiar with the diagnostic and management principles relevant to their condition. That said, neuropathic pain states are often difficult to treat for the following reasons:
- • Many established treatments are of limited efficacy.
- • Many established pharmacologic interventions have limiting adverse effects. This is not surprising, as medications designed to impact neurotransmission or neuromodulatory systems are inherently more likely to cause undesirable centrally mediated symptoms such as difficulty concentrating, nausea, and weight gain.
- • Much like people with other causes of chronic pain, people with neuropathic pain often have musculoskeletal, psychological, and medical comorbidities that are best managed by a multidisciplinary team. These can include the following:
- • Musculoskeletal: Neuropathic pain often results in guarding, disuse, or unconscious excessive muscle contraction that leads to secondary musculoskeletal and myofascial pain. Physical therapists with expertise in treating people in pain are skilled in diagnosing and managing these comorbidities.
- • Behavioral: Pain and distress can be alleviated or exacerbated by a person’s psychological traits and state. Mental health professionals with experience in pain management can be instrumental in making an initial assessment, providing counseling when indicated, and implementing behavioral interventions, such as cognitive-behavioral therapy and relaxation techniques that can alleviate pain, distress, and pain-related disability.
- • Medical and pharmacological: Anxiety, sleep disturbances, and alterations in physical functioning related to pain impact medical comorbidities and general health. Medications for pain have the potential for adverse effects and drug-drug interactions that require monitoring.
Awareness of the following principles increases the likelihood of satisfactory outcomes in management of neuropathic pain:
- • Identify the patient’s goals and concerns at the outset of care. Obtaining medical care is a complex process and therefore does not occur without motivation. Find out what is motivating the patient; typically it is not pain per se but distress due to pain, questions about their diagnosis or prognosis, or concerns about disability or loss of life roles. Knowing the patient’s goals and concerns enables the provider to focus their efforts appropriately. As an example, in people with painful distal symmetric polyneuropathy, an explanation of the possible causes and prognosis of their condition is often more important to the patient than achieving pain relief.
- • Make an accurate and precise diagnosis. Utilizing the principles enumerated previously, determine as accurately as possible whether the pain is neuropathic and, if it is, what syndrome is represented. In the author’s experience imprecise or inaccurate diagnoses, such as use of the term “neuropathy” as a catch-all for sensory symptoms, or “CRPS” as a catch-all for unexplained severe limb pain, are common and lead to inappropriate diagnostic and therapeutic interventions.
- • Establish realistic goals of therapy early. Often people expect complete pain relief when in fact alleviation of distress and disability are more realistic and, in fact, more important goals. In such cases it is prudent to discuss this early in the management process.