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.

Comments

Post a Comment

Popular posts from this blog

Entrapment of medial calcaneal nerve (MCN)

-
Image
Peripheral nerve entrapment is a rare, but important, cause of foot and ankle pain that often is underdiagnosed and mistreated. A peripheral nerve may become entrapped anywhere along its course, but certain anatomic locations are characteristic (2). The medial calcaneal nerve (MCN) The Tibial nerve is called the planter nerve in the sole. The tibial nerve passes to the sole of the foot takes a turn on the medial side of the calcaneum is called MCN. The medial calcaneal nerve arises from tibial nerve of the inner side of the ankle, perforates the laciniate ligament, travels downwards passing below the bony projection on the inner side of the ankle, and supplies the skin over the medial aspect of the heel. Hence it is the most important nerve for heel sensations. MCN have 2 branches. The anterior branch dominate the cutaneous sensation of the anterior part of the medial calcaneal and heel weight loading field, while the posterior branch dominate the sensation of the posterior an...
Read more

Differential diagnosis of Anatomic (Radial) snuffbox pain: It is not always DeQuervain’s tenosynovitis.

-
Image
Tendon, Bone & Ligament causes: 1. DeQuervain’s tenosynovitis: Swelling of tendon of APL (Abductor pollicis longus) & extensor pollicis brevis at lateral wrist near anatomic snuff box.  The primary complaint is radial sided wrist pain that radiates up the forearm with grasping or extension of the thumb. The pain has been described as a “constant aching, burning, pulling sensation." Pain is often aggravated by repetitive lifting, gripping, or twisting motions of the hand. Swelling in the anatomical snuff box, tenderness at the radial styloid process, decreased CMC abduction ROM of the 1st digit, palpable thickening of the extensor sheaths of the 1st dorsal compartment and crepitus of the tendons moving from the extensor sheath may be found upon examination. Other possible findings include weakness and paresthesia in the hand. Finkelstein’s diagnostic test will present positive provoking the patient’s symptoms. If left untreated, the inflammation and progressive narro...
Read more

Chronic fatigue syndrome

-
Introduction: Severe fatigue is a common complaint among patients. Often, the fatigue is transient or can be attributed to a definable organic illness. Some patients present with persistent and disabling fatigue, but show no abnormalities on physical examination or screening laboratory tests. In these cases, the diagnosis of chronic fatigue syndrome (CFS) should be considered. According to Centers for Disease Control and Prevention (CDC, USA) Chronic fatigue syndrome (CFS) currently is defined as: (1) fatigue of at least 6 months' duration, seriously interfering with the patient's life; and (2) without evidence of various organic or psychiatric illnesses that can produce chronic fatigue. The World Health Organization classifies myalgic encephalomyelitis/chronic fatigue syndrome (ME/cfs) as a nervous system disease. Together with other diseases under the G93 heading, ME/cfs shares a triad of abnormalities involving elevated oxidative and nitrosative stress (O&NS), activat...
Read more