Neuropathic pain: a practical guide for the clinician

Gilron, Ian; Watson, C. Peter N.; Cahill, Catherine M.; Moulin, Dwight E.

doi:10.1503/cmaj.060146

Cited by 379 publications

(297 citation statements)

References 133 publications

(86 reference statements)

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“…This fits with the notion that prolonged nociceptive input may lead to CS and features of NP in OA (7). The descriptions of evoked NP-like sensations (e.g., sensitivity to light touch and pressure) suggest that people with OA may have hyperalgesia (reduced pain threshold) or allodynia (pain in response to a nonnoxious stimulus), which are physical examination signs that aid the diagnosis of NP (8).…”

Section: Discussionsupporting

confidence: 81%

“…CS in OA may present with clinical features that are characteristic of neuropathic pain (NP) conditions. The diagnosis of NP is clinical, based on history, physical examination, and sometimes ancillary tests (8). The characteristic verbal descriptors include: burning, prickling, itching, electric shock like, heat, cold, pins and needles, numbness, tingling, and sensitivity to heat, cold, touch, or pressure (9).…”

Section: Introductionmentioning

confidence: 99%

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The nerve of osteoarthritis pain

Hochman¹,

French²,

Bermingham³

et al. 2010

Arthritis Care & Research

169

142

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Objective. Cumulative data suggest that central sensitization may contribute to pain in osteoarthritis (OA) and present with symptoms typically associated with neuropathic pain (NP). We evaluated the responses from focus group participants on the knee OA pain experience for pain descriptions that suggest NP. Methods. Focus group transcripts were analyzed by 2 independent assessors for unprompted use of pain descriptors that suggested NP. Items from validated NP symptom-based questionnaires were used to guide the analysis. Data on sociodemographic factors, duration of knee OA, and OA disease and pain severity (using the Western Ontario and McMaster Universities Osteoarthritis Index and a numerical rating scale) were obtained from questionnaires administered after focus group completion. These factors were compared among participants who did and did not use descriptors that suggested NP. Results. Transcripts from 80 knee OA participants were analyzed. A range of NP descriptors was used to characterize their knee symptoms, including burning, tingling, numbness, and pins and needles. The proportion of participants who used NP descriptors was 0.34 (95% confidence interval 0.24 -0.45). Those who used NP descriptors were younger (P ‫؍‬ 0.003) and, although not statistically different, more likely to be women, with higher pain intensity and OA severity and longer OA duration, than those who did not use NP descriptors. Conclusion. During focus groups, a subset of adults with chronic, symptomatic knee OA used pain quality descriptors that were suggestive of NP. Elicitation of NP descriptors in people with OA may help identify those who could benefit from further evaluation and perhaps treatment for NP.

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Section: Discussionsupporting

confidence: 81%

Section: Introductionmentioning

confidence: 99%

The nerve of osteoarthritis pain

Hochman¹,

French²,

Bermingham³

et al. 2010

Arthritis Care & Research

169

142

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“…In many cases, the adverse-effect profile guides drug selection. Recent evidence-based guidelines, based on randomized controlled trials (RCTs), [9][10][11][12][13] recommend topical lidocaine, tricyclic antidepressants (TCAs), gabapentinoids (gabapentin and pregabalin), and selective noradrenergic reuptake inhibitors (SNRIs; duloxetine and venlafaxine) as the firstline choices for NP. Carbamazepine and oxcarbazepine are the drugs of choice for trigeminal neuralgia.…”

Section: Pharmacotherapy For Npmentioning

confidence: 99%

Treatment Considerations for Patients With Neuropathic Pain and Other Medical Comorbidities

Haanpää¹,

Gourlay

Kent

et al. 2010

Mayo Clinic Proceedings

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The efficacy of drugs for neuropathic pain has been established in randomized controlled trials that have excluded patients with comorbid conditions and those taking complex medications. However, patients with neuropathic pain frequently present with complex histories, making direct application of this evidence problematic. Treatment of neuropathic pain needs to be individualized according to the cause of the pain, concomitant diseases, medications, and other individual factors. Tricyclic antidepressants (TCAs), gabapentinoids, selective noradrenergic reuptake inhibitors, and topical lidocaine are the first-line choices; if needed, combination therapy may be used. When a new drug is added, screening for potential drug interactions is recommended. The TCAs have anticholinergic adverse effects and may cause orthostatic hypotension. They should be avoided or used cautiously in patients with cardiac conduction disturbances or arrhythmias. Patients who lack cytochrome P450 2D6 isoenzyme activity are prone to adverse effects of TCAs and venlafaxine and have a weaker analgesic response to tramadol. A combination of several serotoninergic drugs may lead to serotonin syndrome. Risk of gastrointestinal tract bleeding is increased in patients taking selective serotonin reuptake inhibitors or venlafaxine, especially when combined with nonsteroidal anti-inflammatory drugs. Dose adjustment may be needed in patients with renal or hepatic impairment. Depending on the drug, the dose is reduced or the dosage interval lengthened. Slow titration and careful follow-up are needed. No drug is absolutely safe during pregnancy and lactation. Particular care must be exercised during the first trimester when drug dose should be as low as possible. Individual weighing of benefits and risks should guide therapeutic decisions.Mayo Clin Proc. 2010;85(3)(suppl):S15-S25 ADR = adverse drug reaction; BP = blood pressure; CKD = chronic kidney disease; CYP = cytochrome P450; ECG = electrocardiogram; EM = extensive metabolizer; GFR = glomerular filtration rate; MI = myocardial infarction; NP = neuropathic pain; NSAID = nonsteroidal anti-inflammatory drug; OR = odds ratio; PM = poor metabolizer; RCT = randomized controlled trial; SNRI = selective noradrenergic reuptake inhibitor; TCA = tricyclic antidepressant; UM = ultrarapid metabolizer From Rehabilitation ORTON,

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“…Visual analog scales, numerical rating scales, or verbal rating scales, which are simple to use, can provide a quantitative assessment of pain intensity and may be used to provide a baseline assessment [21]. Others have advocated assessment of pain intensity inaddition to sensory descriptors, temporal variation, and functional impact [26]. Based upon simple assessment, patients who indicate the presence of neuropathic pain can be referred to pain specialists for more in-depth evaluation and prompt treatment of the pain and associated sequelae.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of Pain Measurement Practices and Opinions of Peripheral Nerve Surgeons

Novak

Anastakis

Beaton

et al. 2009

Hand (New York, N,Y.)

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The purpose of this study was to evaluate the opinions and practices of peripheral nerve surgeons regarding assessment and treatment of pain in patients following nerve injury. Surgeons with expertise in upper extremity peripheral nerve injuries and members of an international peripheral nerve society were sent an introductory letter and electronic survey by email (n=133). Seventy members responded to the survey (49%) and 59 surgeons completed the survey (44%). For patients referred for motor or sensory dysfunction, 31 surgeons (52%) indicated that they always formally assess pain. In patients referred for pain, 44 surgeons (75%) quantitatively assess pain using a verbal scale (n=24) or verbal numeric scale (n=36). The most frequent factors considered very important in the development of chronic neuropathic pain were psychosocial factors (64%), mechanism of injury (59%), workers' compensation or litigation (54%), and iatrogenic injury (48%). In patients more than 6 months following injury, surgeons frequently see: cold sensitivity (54%), decreased motor function (42%), paraesthesia or numbness (41%), fear of returning to work (22%), neuropathic pain (20%), and emotional or psychological distress (17%). Only 52% of surgeons who responded to the survey always evaluate pain in patients referred for motor or sensory dysfunction. Pain assessment most frequently includes verbal patient response, and assessment of psychosocial factors is rarely included. Predominately, patient-related factors were considered important in the development of chronic neuropathic pain.

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Neuropathic pain: a practical guide for the clinician

Cited by 379 publications

References 133 publications

The nerve of osteoarthritis pain

The nerve of osteoarthritis pain

Treatment Considerations for Patients With Neuropathic Pain and Other Medical Comorbidities

Evaluation of Pain Measurement Practices and Opinions of Peripheral Nerve Surgeons

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