Drug versus physiotherapy in neuropahic pain


Neuropathic pain is a chronic pain syndrome caused by drug-, disease-, or injury-induced damage or destruction of sensory neurons within the dorsal root ganglia of the peripheral nervous system. Characteristic clinical symptoms include the feeling of pins and needles; burning, shooting, and/or stabbing pain with or without throbbing; and numbness. Hyperalgesia and allodynia are special kind of neuropathic pain that is provoked by mechanic or thermal stimuli. Periphery mechanisms of neuropathic pain include hyperexcitability of cell membrane and periphery sensibilization. Central mechanism includes central sensibilization, central reorganization of alphabeta fibers and loss of inhibition mechanisms.
Mononeuropathy, plexopathy, radiculopathy, and myelopathy, lesions of thymus, cortex or brain stem are real cause of neuropathic pain. There is no adequate adaptation and produce suffering without biological helpfulness. The aim of treatment of patient with neuropathic pain is soothing of pain and suffering and prevention of further development of pathological process.
Although the primary goal is to alleviate pain, clinicians recognize that even the most appropriate treatment strategy may be, at best, only able to reduce pain to a more tolerable level.
Pharmacotherapy:
1. 1st line drug treatment: tricyclic antidepressants, antiepileptic drugs, topical antineuralgics, analgesics. If a patient does not respond to treatment with at least 3 different agents within a drug class, agents from a second drug class may be tried.
2. 2nd line of treatment: narcotic analgesics or refractory treatment options may provide some benefit.
3. 3rd line of drug treatment: Patients who do not respond to monotherapy with any of the first- or second-line agents may respond to combination therapy. But Carbamazepin was the drug of choice till ten years ago. Since then the leader position in treatment has belong to gabapentin in dose from 900-2400 mg daily. Currently the new drug is tested, antiepileptic pregabaline. The first experiences are promising.
4. If all of the above steps fail then candidate is a fitting case to be referred to a pain clinic. Because the techniques used at pain clinics tend to be invasive, referrals to these clinics should be reserved for patients who are truly refractory to all forms of pharmacotherapy.
Neuropathic pain continues to be one of the most difficult pain conditions to treat. A pain treatment protocol appropriate for each patient should be designed. The algorithm will also help streamline referrals to specialized pain clinics, thereby reducing waiting list times for patients who are truly refractory to traditional pharmacotherapy.
A comparison of pharmacotherapy with physiotherapy!
Physical therapy especially in the form of electromodulation of pain is the alternative or adjunct of pharmacotherapy. For example TENS can modulate primary order neuron relay of pain. And again it also can help produce beta endorphin to modulate secondary order neuronal relay of pain. Prudent applications of tens duration, frequency are sought so that both the effects could be gained in one sitting of physiotherapy. In my opinion TENS parallels the first three steps of pharmacotherapy.

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