Ten Step Approach to Treatment of Neuropathic Pain

What nonpharmacologic and interventional treatments should be considered in neuropathic pain?

In general, treatment of neuropathic pain should include a combination of pharmacological and nonpharmacological strategies. Here is the table for a general approach to treatment. Physical therapy with emphasis on balance and gait training is particularly important in distal, symmetric neuropathies, as well as radiculopathies. Graded motor imagery and mirror therapy take advantage of neuroplasticity and may be useful in those with phantom limb pain, poststroke pain, or CRPS, as patients learn to “move” or “unclench” phantom limbs out of painful positions and change perception of their affected extremity. Transcutaneous electrical stimulation (TENS) may also be applied to painful areas as stimulation of peripheral C-beta sensory fibers has been shown to suppress nociceptive processing by A-delta fibers.

Ten-Step Approach to Treatment of Neuropathic Pain

1. Establish diagnosis and cause of neuropathic pain.
2. When possible, treat underlying cause or refer to appropriate specialist (e.g., primary care physician for diabetes management, surgeon for carpal tunnel release).
3. Identify comorbidities and medication interactions that may affect choice of treatment (e.g., renal impairment may require reduced dosing of gabapentin).
4. Initiate therapy with one or more of the following:• TCA (nortryptiline, amitryptiline, desipramine)• Antiepileptic (gabapentin, pregabalin, carbamazepine)• Serotonin reuptake inhibitors (duloxetine, venlafaxine)• Topical agents such as lidocaine or capsaicin gels or patches• Opioid analgesics (tramadol, methadone tapentadol, oxycodone, morphine, etc., in select patients with acute onset or cancer-related neuropathies)
5. Consider interventional approaches such as epidural steroid injections or peripheral nerve blocks with local anesthetic and/or steroid depending on source.
6. Consider appropriate nonpharmacologic strategies:• Physical and occupational therapy• Transcutaneous electrical stimulation unit• Yoga, Tai Chi, and other exercise for balance and gait training• Specialized therapies such as mirror therapy in phantom limb pain• Pain psychology approaches: cognitive behavioral therapy, mindfulness, acceptance
7. Evaluate effectiveness of treatment after adequate dosage and duration of medication trial reached.
8. If ineffective, consider rotation to alternative first-line medications or addition of medications of different mechanism (“rational polypharmacy”).
9. Consider non-first-line therapies or agents under investigations such as mexelitine or memantine.
10. If quality of life and function remain inadequate or medications are poorly tolerated, evaluate for more invasive treatment options, including spinal cord stimulation and intrathecal drug delivery.
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