neuropathic pain - evidence based.pdf

March 25, 2018 | Author: Hari25885 | Category: Medical Diagnosis, Randomized Controlled Trial, Pain, Peripheral Neuropathy, Acupuncture


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Invited Clinical CommentaryNeuropathic pain: an evidence-based update Leica Sarah Claydon Lecturer, REAL Neurology Research Group, Centre for Physiotherapy Research, University of Otago, Dunedin, New Zealand ABSTRACT Common conditions affecting New Zealanders (e.g. diabetes, stroke, cancer) can cause neuropathic pain (NeP). NeP can be managed in primary or secondary care. The Health Strategy of New Zealand identified the need to reduce the impact of these conditions as a health priority, and targeted primary care as a service delivery area. With this health context in mind, a critique of recent literature concerning key questions surrounding neuropathic pain is provided in this paper. Key guidelines and data from systematic reviews are used in response to these questions. Evidence points to the need for a psychosocial approach in the management of NeP; not only the fact that 30-40% of patients can expect >50% pain relief, but also the impact of NeP on many areas of patients health related quality of life and the experiences of patients with NeP. In management guidelines, physiotherapy is cited as a key component of management. There are multiple research opportunities to investigate the effects of physiotherapy for patients with NeP, particularly in combination with pharmacological approaches to management. Claydon LS (2009): Neuropathic pain: an evidence-based update. New Zealand Journal of Physiotherapy 37(2): 68-74. Key Words: Neuropathic pain, Somatosensory system, sensory neuropathy, neuralgia, review BACKGROUND Neuropathic pain (NeP) 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 (Loeser and Treede, 2008). Symptoms of NeP often include a reported lack of sensation in the area and pain, with the pain being described as electriclike or lancinating. Common conditions such as diabetes, stroke, multiple sclerosis and cancer can cause NeP (Table 1). The World Health Organisation indicates that chronic or long term conditions including diabetes, cardiovascular disease and cancer, are the leading cause of preventable morbidity and mortality in New Zealand (WHO, 2008). The New Zealand Health Strategy (2000) prioritizes the reduction, impact and incidence of these conditions, and has targeted primary care as a service delivery area. It is however, anticipated that NeP may become more prevalent in years to come due to: an aging population, increased survival rates of conditions such as diabetes and cancer, and use of treatment strategies (for example medical and surgical management of cancer) which can cause NeP (Dworkin, 2002). This clinical commentary provides a critique of recent literature in response to key questions health care consumers and providers, such as physiotherapists, may have as regards NeP. How many people have neuropathic pain? Prevalence may be defined as the total number of cases (of the condition) in the population at a given time (Collins, 2009). A systematic review of the prevalence of NeP, and for NeP associated with specific conditions (Table 1) according to world regions, settings and populations (Gagnon 68 Table 1: Common causes of NeP (adapted from Dworkin 2002) Chemotherapy-induced neuropathy Complex regional pain syndrome HIV sensory neuropathy Neuropathy secondary to tumor infiltration Painful diabetic neuropathy Phantom limb pain Post-herpetic neuralgia Central post-stroke pain Multiple sclerosis pain Parkinson’s disease pain Spinal cord injury pain et al, 2007). Seventy-nine studies were included in the systematic review however only three were conducted in the general population: one in the USA (reporting prevalence of 0.021% for complex region pain syndrome (CRPS) I and 0.009% for CRPS II), one in the UK (reporting prevalence of probable NeP of 8.2%) and one in India (reporting prevalence of peripheral neuropathies) (Gagnon et al, 2007). Both USA and Indian data are based NeP caused by one or two conditions whereas UK data is based on probable NeP in the general population. The authors concluded that prevalence of NeP in the general population was higher than previously thought, although this needs to be confirmed in general populations of countries other than the UK. Therefore although the exact prevalence of NeP in New Zealand is unknown, extrapolating the UK general population figure of 8.2% to New Zealand suggests there may be nearly 340 000 people with NeP (based on general population of 4,143,279 people from 2006 Census (Statistics New Zealand, 2006)). What is the impact of neuropathic pain? The impact of NeP on health-related quality of life (HRQOL) was recently systematically reviewed by NZ Journal of Physiotherapy – July 2009, Vol. 37 (2) Fifty two studies were identified which examined the association between a wide variety of HRQOL domains and NeP. It is unclear whether HRQOL can predict treatment outcome. and completed a score regarding HRQOL (EuroQol) The mean age of patients was 62. 2008b). What are patient experiences of neuropathic pain? Qualitative research focuses on answering the ‘why’ and ‘how’ questions (Kuper et al. 76% visited the physician at least once a month. conventional medications. 69 . p426). and 9. 2007). 2009). and emotional HRQOL domains indicates the needs for a psychosocial approach to the assessment and management of NeP.”(Closs et al 2007. social function and vitality (Ware. 2007). 2004). or observations (Kuper et al. social. their criticality of investigating alternative theories that included a critical examination of deviant cases. Pain severity was associated with poorer EuroQol scores 93% of patients took medications. emotional role. bodily pain. social. One of these studies is presented in Figure 1 to illustrate the percentage of people with moderate to severe pain and the association with HRQOL variables. 2007). These studies commonly use HRQOL measures such as the SF-36 and the Brief Pain Inventory. 2008b). physical role. The SF-36 is a generic measure with 8 dimensions covering physical function. with moderate pain severity as 4-6. social isolation (Closs et al. 2009. Themes which emerged from the data concerning symptomatic management included: self management using alternative strategies. The authors of these qualitative studies all suggested that there is a need to validate the theoretical findings that they proposed in larger studies. 2007) and managing symptoms (Closs et al. Patients completed the SF-36 at baseline (no treatment period) and at the end of each treatment. 2007). Pain presence was also significantly associated with sleep interference and a negative impact on role and social functioning. and integrity of the number of repetitive checks of by different authors of the data to explore alternative meanings. Limitations of the reviewed research were that almost all studies were descriptive or correlational designs therefore causal relationships could not be established. 37 (2) on pain. Peripheral and central NeP conditions (for example painful diabetic neuropathy and post-stroke pain. and trying to accept pain adjusting to the situation (Closs et al. emotional or practical support to help them try to accept their pain (Closs et al. Most patients reported moderate (54%) or severe pain (25%) on the BPI. As associations were generally stronger with pain-specific measures of HRQOL such as the Brief Pain Inventory compared to the SF-36 physical function subscale. the authors suggest the brief pain inventory maybe a useful tool in clinical practice and clinical trials. social consequences (Sofaer-Bennett et al. 2007) and the invisibility of pain causing issues with communication and the resultant fear of being labeled mentally ill (Closs et al. One study investigated whether HRQOL could predict analgesic effect of treatment in patients with painful polyneuropathy (Otto et al. At baseline all SF-36 scores were lower than the normal population and regression analysis indicated that baseline scores predicted response to treatment. Results from the systematic review indicated that pain presence and severity was significantly associated with impairments in physical functioning and had a negative impact on emotional functioning (Jensen et al. Qualitative research aims to generate in-depth accounts from individuals or groups. Qualitative research surrounding patient experiences of NeP includes impact on relationships (Closs et al. 2009). 2007). general health.they weren’t any good really… . The authors reported that they could not identify any other studies on HRQOL predicting treatment outcome in chronic pain conditions. Patients reported little or no psychological.I was four years trying all different medications to try and control the pain….5 days of employment. and health care utilization using the brief pain inventory (see text). Jensen and colleagues (2007).pain experience. well-being. medication use and the sensory and reactive components of pain (Keller et al. Vol.9 years. respectively) showed similar associations between pain severity and HRQOL. 2009). focus groups. The Brief Pain Inventory is a 17 item self-rated scale which includes demographic data.8% missed an average of 5. The authors conclude that the negative effects of NeP on physical. inadequacy and frustration (Closs et al. 2008a). Themes which emerged from the data concerning the social impact of NeP include: the loss of ability to maintain established roles leading to feelings of guilt. These studies were conducted in the UK therefore it is unclear whether all the findings might be applicable or transferable to the health care context of New Zealand. with data usually being gathered via interviews (semistructured or unstructured). placebocontrolled studies testing the effect of different drugs NZ Journal of Physiotherapy – July 2009. and severe pain as 7-10. Repeated cycles of seeking help to manage pain were also described with each unsuccessful attempt followed by new attempts (Closs et al.The researchers may be commended for the credibility of their research in establishing the experiences of patients with NeP.Figure 1: Study by McDermott et al: 2006 Burden of NeP: results from a cross-sectional survey • • • • • • A cross-sectional survey of 602 patients with NeP (from six countries) was conducted Patients reported functional health.’…. 2007). SofaerBennett et al. Data from 93 patients were included in the analysis and were obtained from three randomized. 2009).. Data analysis is usually inductive (reasoning by drawing general rules from individual cases) allowing meaning to emerge from the data as opposed to deductive ‘hypothesis driven’ quantitative approaches (Kuper et al. It comprises numeric rating scales (0-10). mental health. Guidelines of the management of NeP also highlight the importance of an accurate history and examination with characteristics of NeP being defined within: spontaneous (stimulus independent. No No Patient NZ Journal of Physiotherapy – July 2009. 2008). Experts (neurologists and pain specialists) have reached consensus concerning a grading system regarding the likelihood of the certainty of the presence of NeP in an individual patient (Treede et al. However. (1) a diagnostic test confirming a lesion or disease. The grading system is as follows: • Possible neuropathic pain: If the patients’ history suggests a relevant lesion or disease and a temporal link between the lesion or disease causing the pain. the abnormal sensory signs being neuroanatomically compatible with a definite lesion site (Cruccu et al. The European Federation of Neurological Sciences guidelines of NeP assessment recommend that in the clinical setting a neurological exam. electric shocklike pain) and stimulus evoked pains (evoked by mechanical. Painful area compared to an non-painful area (not neuroanatomical) • Patient rubs area • Patient presses Patient DN4 (Bouhassira et al. use of a body drawing) • Probable neuropathic pain: The possible criteria and either. static pressure evoked. No temporal questions with history. It is important to recognize that these tools do not include questions concerning the patient’s medical history. and pain distribution is in a neuroanatomically plausible area (e. e. Screening tools based primarily on pain description/pain symptoms have been developed to identify NeP. No questions about pain and sensation. 2008). or (2) negative or positive sensory signs confined to the neuroanatomical area There is no ‘gold standard’ test used for the diagnosis of NeP (Treede et al. Not in a neuroanatomical area • Pain with touch • Pain with pin-prick • Pain with brushing Clinician Neuropathic Pain Questionnaire (NPQ) (Krause and Backonja. Specifically. dynamic brush evoked and cold allodynia (pain evoked by cold)) (CREST. such questionnaires may serve as a triage to inform subsequent assessment and decision making. 2007). For example. some of these tools have been Table 2: Some screening tools of NeP and their characteristics (see text for further details) 70 Tool and reference Population Space for Medical History Body map Sensory testing Clinician or patient completes Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) (Bennett. 2005) Chronic pain of any origin No questions about pain and sensation. clinicians and physicians use information gained from the subjective history to inform further assessment such as the neurological examination. The authors concluded that these questionnaires offered guidance regarding diagnosis as they could not correctly identify 10 – 20% of patients with clinically diagnosed NeP.g. 37 (2) . No Yes. In patients with suspected NeP. No temporal questions with history. thermal or chemical stimulus. Yes Yes. 2008). Painful area compared to non-painful area (not neuroanatomical) • Stroke with cotton wool • Pin-prick Clinician S-LANSS (Bennett et al. intermittent shooting. burning sensation. and only some of the tools include limited sensory testing (Table 2). They also recommend the use of diagnostic screening tools (such as the DN4 or the LANSS. NeP results from disease or injury to the nervous system therefore positive and negative sensory symptoms and signs are typical (Dworkin et al. It has been suggested that the main clinical role of these screening tools is that they may aid diagnosis of NeP particularly by non-specialists (Bennett et al. 2003) Chronic pain of any origin No questions about pain and sensation. 2001) Chronic pain of any origin No Yes. this critical review did not explore potential clinical and methodological sources of variation (heterogeneity) of the studies which might explain this level of diagnostic accuracy. 2003). which includes an accurate sensory exam. In addition. clinical diagnosis of NeP is usually based on diagnosis by a physician where it is often not stated which tests are used to make the diagnosis. 2004). Vol. see Table 2) to differentiate NeP and nociceptive (NP) (CREST. No temporal questions with history.g. No temporal questions with history. 2008).How is neuropathic pain diagnosed? validated for administration by a clinician whilst others are self-rated by the patient. e.g. 2007). 2005) Chronic pain of any origin No questions about pain and sensation. is often sufficient to reach a diagnosis (Cruccu et al. A previous critical review of such screening tools provided an overview of their diagnostic accuracy by referring to primary diagnostic studies (Bennett et al. 2004). social. The third RCT compared two forms of needling and found deep needling to increase the therapeutic effect in trigeminal neuralgia (Zhang. and (2) pharmacological interventions such as unconventional and conventional analgesics (CREST. What are current management strategies for neuropathic pain? CREST guidelines recommend that the evaluation of NeP (in addition to diagnosis. key guidelines or the most recent systematic reviews are used for evidence. 2005). Four RCTs were identified which investigated electrostimulation (TENS with electrodes or PENS with needles) (Pittler and Ernst. NeP can be managed in primary or secondary care. 2000) or placebo (Kumar et al. For physiotherapy searches were conducted for systematic reviews in this area. Hamza et al. 2008). 2008). spinal cord stimulation. The main screening tools to differentiate NP and NeP are listed in table two. A review of systematic reviews on TENS and chronic pain (osteoarthritis. low-back pain) found that two out of six reviews reported that high intensity (strong but tolerable) intensities of TENS were more effective compared to placebo than low intensity (strong but comfortable) applications (Claydon and Chesterton. psychology (if predominantly psychological issues) or a pain management programme (if significant physical. 1998) for post-herpetic neuralgia and HIV induced peripheral neuropathy. 2008). They found that pain scores improved compared to baseline (Forst et al. Studies to provide evidence (or not) for these criteria are required as currently there is level C evidence (retrospective study evaluated by a blinded assessor) for bed side sensory testing and quantitative sensory testing has never been used to make a differential diagnosis between NeP and NP pains (Cruccu et al.g. Cheing and Luk. Although these results are encouraging. or acupuncture compared to placebo (Shlay et al. 2008). and opioids (Dworkin et al. and pain management programmes as recommended in the CREST guidelines for the management of NeP (2008). quality. and duration of pain. 2005). 2004. 2005) in diabetic neuropathy or hypersensitivity of the hand. local anaesthetic type drugs (lidocaine). and 4) response to previous treatment (CREST. as these have the lowest risk of side affects and must be offered early. 2008). occupational therapy. and functional issues).” The authors should be commended for this classification system as opposed to the alternative situation whereby the neuropathic pain syndrome is stated and it is assumed that pain is NeP. 2007). 2004). The medical history. respectively. rheumatoid arthritis. Three RCTs were identified which investigated acupuncture. for example by including symptoms in the grading. cause of NeP and history) should include 1) location. 1997.• Definite neuropathic pain: The possible criteria and both of the probable criteria. However. These results were based on a total of eight high quality (adequate randomization and blinding) trials which used validated pain intensity or relief visual analogue (VAS) or numeric rating scales 71 . calcium channel A2-D ligands (gabapentin and pregabalin). What is the evidence-base for these strategies? For strategies other than physiotherapy. Initial treatment options for NeP include: (1) nonpharmacological options. it should be noted that only 30-40% of patients will receive >50% pain relief. along with an indication of the classification criteria they may satisfy. 3) psychological factors including effect on mood. with possible referral to physiotherapy. 2007). No analgesic benefit of acupuncture compared to mock TENS was reported (Hempenstall et al. Recommendations for trials investigating combinations of pharmacological treatments and/ or pharmacological and non-pharmacological treatments have therefore been made (Dworkin et al. pain distribution on a body drawing. neuropathy) and physiotherapy using the search strategy identified by Montori (2005) in MEDLINE via Pubmed. These recommendations are based on randomized controlled trial data. Non-Pharmacological interventions This section primarily focuses on physiotherapy. 2) functional impact include activities and sleep pattern. An important question to ask is “where do screening tools ‘fit’ in this grading system?” Treede (et al. Few studies were indexed under the heading ‘neuropathic pain’ therefore Mesh (medical subject word headings) headings of NeP conditions were used (e. Complex regional pain syndrome. and sensory testing are pivotal to these diagnostic criteria. 2008 p1634) state that “future studies are required to determine the utility of this grading system and possible necessity for revision. it is also not reported which stimulation parameters were used. Physiotherapy Neuropathic pain and physiotherapy A systematic review of complementary therapies for NeP and neuralgia pain included randomized controlled trials (RCTs) and systematic reviews for acupuncture and electrostimulation (including transcutaneous electrical nerve stimulation (TENS)) (Pittler and Ernst. Future trials should use an appropriate sham needle (rather than mock TENS) and dosage of acupuncture before the efficacy of this modality is known (White et al 2008). Vol. Pharmacological interventions Evidence-based pharmacological strategies for the management of NeP suggest that first line NZ Journal of Physiotherapy – July 2009. intensity. 37 (2) treatments may be: antidepressants (tricyclics or dual re-uptake inhibitors of serotonin or noradrenaline). This review indicates there is little evidence for the use of acupuncture in NeP conditions. fractures and pain are considered) (Coelho et al. and this effect is maintained for 6 months. Complex regional pain syndrome and physiotherapy A systematic review recently reported on the effectiveness of physiotherapy management for adult complex regional pain syndrome (CRPS) type I (Daly and Bialocerkowski. A search for Parkinson’s disease and pain and physiotherapy. (3) at short term there is no evidence in favour of physiotherapy. Parkinson’s Disease) and physiotherapy Systematic reviews on stroke pain and physiotherapy included: supportive devices for preventing and treating subluxation of the shoulder (Ada et al. The authors made treatment recommendations based on literature reviewed previously and on the following Cochrane systematic review on exercise for peripheral neuropathy. The authors also reported that there is no evidence to support frequently recommended treatments in guidelines such as stress loading. none showed a significant benefit. Moseley. However. The systematic review by Pittler and Ernst (2008) did not rate the studies for quality and did not report the search strategy (inclusion criteria and sources searched). 2008) and the authors of this Cochrane review systematically looked for RCTs or quasiRCTs on any treatment for this disease. assistive devices. They found that small trials of exercise have been performed. and (4) no evidence was found regarding acupuncture. 2004) and traction in back pain with and without sciatica (Clarke et al. The authors stated that they could not conclude whether clinicians should prescribe physiotherapy. or TENS for this type of neuropathy. This evidence was graded as good to very good (scored 11-14/16 on quality tool) level II (properly designed RCT(s)) based on the work by Moseley (Moseley. 2006). 2009). 2004. 2005) and electrical stimulation for preventing and treating post-stroke shoulder pain (Price and Pandyan. the effects of which were negative (Warke et al. it was not reported which patients had pain apart from two trials of TENS for back pain in Multiple Sclerosis. bed rest. 2004). It appears that systematic reviews for TENS and chronic pain may have not extensively searched for various neuropathic as opposed to nociceptive conditions. the non-pharmacological evidence is considered here (Visovsky et al. 72 Neuralgia and physiotherapy A systematic review recently reported on interventional RCTs concerning conservative treatments (including physiotherapy) for lumbrosacral radicular syndrome (Luijsterburg et al. Ada (et al 2005) found that strapping the hemi-shoulder could prevent the onset of pain but not decrease pain severity. The role of exercise for individuals with peripheral neuropathy (sensory.(NRS) as the outcome measure. 2003). Multiple Sclerosis. chemotherapyinduced neuropathy (Visovsky et al. bed rest. Applying the classification of NeP considered earlier. As regards Multiple Sclerosis. Vol. The authors found that a six week graded motor imagery programme is effective in reducing pain by a clinically relevant amount. 2007). 2007). The chemotherapy-induced peripheral neuropathy systematic review included evidence for pharmacological and non-pharmacological strategies. Conclusion: Physiotherapy An indication of the RCT evidence for physiotherapy in various NeP conditions has been outlined. 2008). This parallels the evidence reviewed in Cochrane reviews concerning bed rest in back pain and sciatica (Hagen et al. however. 2005. Neuropathy and physiotherapy Systematic reviews of interventional RCTS for neuropathy include: Charcot-Marie-Tooth disease (Young et al. However it is unclear whether the pain was NeP or due to tissue injury (NP). 2000). (2) at short term there is no evidence in favour of traction compared to placebo or other treatments. There appears to be an absence of quality research for physiotherapy management of various neurological conditions NZ Journal of Physiotherapy – July 2009. Al-Samadi et al. 2007). The authors also stated that pain was infrequently reported in the primary studies. The authors reported that there are no RCTS concerning acupuncture. Generally the RCTs reported benefits for people with MS. 2004). physical activity and exercise. and exercise for peripheral neuropathy (White et al. or manipulation as there was no evidence of treatment superiority (Luijsterburg et al. Price and Pandyan (2000) found that electrical stimulation improved pain free lateral rotation but did not decrease pain incidence or intensity. Moseley. psychosis. They found that: (1) at long-term there is no evidence in favour of corticosteroid injections compared to placebo. 2007). 37 (2) . manipulation or medication compared to other treatments or surgery. 2008). Central pain (Stroke. 2007). only resulted in a review for the treatment options for nonmotor symptoms in late-stage Parkinson’s (where treatments for dementia. Charcot-MarieTooth disease covers a lot of different forms of sensory and motor neuropathies (Young et al. 2008). motor or combined) found that there was inadequate (quality) evidence to evaluate the effect of exercise in this population (White et al. 2006. Only one trial was randomized or quasi-randomised comparing the effects of exercise to drugs or nonpharmacological management on outcomes at least 8 weeks after randomization. one systematic review reported an overview of RCTs concerning physiotherapy (Wiles. most RCTs stated diagnosis of the NeP condition rather than indicating pain distribution and sensation testing making it unclear whether NeP was present. Attal N. ! RCTs usually state the neurological condition making it unclear whether NeP is present. (2007): Managing the symptoms of neuropathic pain: An exploration of patient experiences. (2009): The impact of neuropathic pain on relationships. The authors of this guideline state that the ‘majority of the patients which attend these programmes have musculoskeletal pain (NP) although a minority have NeP or central pain p13. (2005): Transcutaneous electrical nerve stimulation for neuropathic pain. Freynhagen R Scholz J et al. Bouter LM. the utility of which needs investigating. van Tulder MW. (2005): The S-LANSS for indentifying pain of predominantly neuropathic origin: validation for use in clinical and postal research. Reid I. ! Management strategies for NeP includes pharmacological and non-pharmacological treatments. healthy function. ! Patients seek management for symptoms via conventional and unconventional treatments and attempt to accept the pain.: CD003010. (2007): Traction for lowback pain with or without sciatica. Walsh D. Wilson I. Clinical Rehabilitation 17: 742-749 Bennett MI. ADDRESS FOR CORRESPONDENCE: Dr Leica Claydon. Journal of Pain and Symptom Management 34:422-433 Clinical Resource Efficieny Support Team (CREST). Article 1. Staples V. (2005): Supportive devices for preventing and treating subluxation of the shoulder after stroke. 2009). Boreay F. Foongchomcheay A. de Vet HCW. 37 (2) Key points: ! Neuropathic pain (NeP) may affect 340. Journal of Hand Surgery 30: 50-55 Clarke JA. 2007). apart from the physiotherapy management of CRPS type I. impact of NeP on HRQOL. (2005): Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Cochrane Database of Systematic Reviews. Dunedin.uk 73 . Luk ML. Key points of this review are summarized below. relaxation. Art. Pain 92: 147-147 Bennett MI. University of Otago. Alchaar H. Claydon LS.: CD003863 Al-Samadi J. the following areas of research have been highlighted. The Journal of Pain 6: 149-158 Bouhassira D. (2001): The LANSS pain scale: the Leeds Assessment of Symptoms and Signs. • What are New Zealanders experiences of NeP? What research would they like to be conducted in this area? What outcomes are important to them? • How do physiotherapists identify possible NeP? How useful do they find the assessment and management guidelines? • What are possible sources of variation in the screening tools for NeP? Which tool has the highest quality (best)? • How valid is the classification system for NeP? Does it need to include screening tools? • Is TENS effective for NeP? • Is exercise effective for NeP? Studies concerning these key questions are currently underway. Pain 127: 199-203 Bennett MI. Centre for Physiotherapy Research. changing habits which are contributing to disability. Briggs M. Canning C. Journal of Advanced Nursing 65: 402-411 Closs JS. Briggs M. Brocheta B Bruxelle J et al. high quality RCTs appear to be lacking in other neurological conditions which can cause NeP. ! Patients experience social isolation and lose the ability to maintain established roles. The programmes consist of education on pain physiology. Brønfort G. Spinal cord stimulation is a device implanted in the epidural space which stimulates the dorsal columns of the spinal cord. No.000). psychology. Spinal cord stimulation A recent health technology assessment was commissioned to evaluate the effects of spinal cord stimulation in patients with NeP or ischaemic pain (Simpson et al. Vol. Potter J. Bennett MI. van der Heijden G. (2003): A pilot investigation of the hypoalgesic effects of transcutaneous electrical nerve stimulation upon low-back pain in people with multiple sclerosis. PO Box 56. ! NeP affects multiple domains of life (physical. (2007): Using Screening tools to identify neuropathic pain. goal setting. ! A diagnostic classification system for NeP has been proposed. Baron R. Cramp F. Noble G. Chesterton LS. and diagnostic and management strategies. (2008): Guidelines for the management of neuropathic pain. The authors found three RCTs concerning spinal cord stimulation and NeP and concluded that it is effective for NeP associated with failed back surgery syndrome (persistent pain after anatomically correct surgery) and CRPS type I (Simpson et al.000 (£10. patient experiences of NeP. and changing unhelpful beliefs. Attal N. Staples V. NZ Journal of Physiotherapy – July 2009.what does the future hold? Evidence has been reviewed concerning the prevalence of NeP.org. With consideration for the New Zealand scene. and emotional function and sleep). Bouhissira D. 2009).which cause NeP. Backonja MM. Cochrane Database of Systematic Reviews. Bennett MI. and/or any NeP component is unspecified. The references regarding evidence of effectiveness for these programmes are largely based on musculoskeletal pain. Reid I. social. 9054. Torrance N. New Zealand. the implantation costing around $30. 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