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Key points The updated, narrower definition of neuropathic pain emphasises its association with a lesion or disease of the somatosensory nervous system. Neuropathic and nociceptive pain have different treatments.

A targeted history and a physical examination are important diagnostic prerequisites to medicine selection for effective pain management. Low-dose amitriptyline remains a first-line contender in the treatment of neuropathic pain. Download and print Medicinewise News: Neuropathic pain: diagnosis and treatment today Date published : 6 March Download PDF. Updated guidelines, familiar medicines The efficacy of neuropathic and other chronic pain medicines is partial at best, which makes helping patients with chronic pain very challenging.

People have asked me to amputate their leg, just to get rid of the fire that never goes away. With this desperation and distress, it is tempting to try anything in the hope that it will give relief. Being as sure as possible of the diagnosis is important in order to best help the patient.

Philip Siddall. The clinical assessment The latest guidelines use the updated definition of neuropathic pain. The first-line medicines Australian and international guidelines recommend four first-line medicines for the treatment of neuropathic pain: amitriptyline, duloxetine, gabapentin and pregabalin. What is neuropathic pain in ? Narrowing the definition excludes nervous system changes, such as central sensitisation, as well as conditions such as fibromyalgia or irritable bowel syndrome where there is little to find in terms of nerve damage.

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Pain Analysis: A Guide To Diagnosis by Rudolf Janzen

Burning, shooting and pins and needles descriptors can alert us to the possibility of neuropathic pain. Then the clinical history and examination helps to confirm that the location of the pain is anatomically consistent with a neurological lesion. Medicines as part of a pain management plan The treatment of neuropathic pain remains challenging — partial pain relief is usually considered a good result. Neuropathic pain medicines — the evidence Cumulative number-needed-to-treat NNT over the many trials can give an indication of the efficacy of the medicines.

The tricyclic amitriptyline is almost always my first-line recommendation, used at the low doses where the side effects are far less problematic. Start low, go slow is my motto. Starting the patients on a very small dose and gradually increasing it is the best way to find the balance between the analgesic benefit and the side effect burden. Tony Hall. Living with neuropathic pain It is horrible living with neuropathic pain.

Then imagine the volume being turned up, louder and louder. It becomes irritating and eventually painful to the ear. Useful links Amitriptyline for nerve pain: fact sheet for patients Provides information about what to expect when starting amitriptyline for neuropathic pain. Helping patients live with neuropathic pain: patient action plan Designed to give patients with neuropathic pain a better understanding of their condition and help manage their expectations of pharmacological treatment.

A new definition of neuropathic pain. Pain ; Neurology Expert Group. Therapeutic guidelines: Neuropathic pain: version 4. National Institute for Health and Care Excellence. Neuropathic pain in adults: pharmacological management in nonspecialist settings. Clinical guidance CG UK, updated accessed 4 October Pharmacological management of chronic neuropathic pain: revised consensus statement from Canadian Pain Society.

Pain Res Manag ; Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol ; Neuropathic pain: redefinition and a grading system for clinical and research purposes. Neurology ; Neuropathic pain: diagnosis and treatment. Pract Neurol ; Rheumatology Expert Group. Therapeutic guidelines: Rheumatology. Neuropathic pain. Nat Rev Dis Primers ; Assessment of neuropathic pain in primary care.

Am J Med ;S Diagnostic triage for low back pain: a practical approach for primary care. Med J Aust ; Hush JM, Marcuzzi A. Prevalence of neuropathic features of back pain in clinical populations: implications for the diagnostic triage paradigm. Baseline characteristics are presented in Table 1. This was a year-old man with recent onset neck pain and temporal headache and marked tenderness over the temporal artery who was referred for blood tests to rule out temporal arteritis. Data regarding the second and third questions of diagnosis are provided in tables 2 and 3 , respectively.

Identifying specific diagnostic characteristics in patients with NP upon which treatment decisions can be made has been established as a research priority [ 3 ]. This is challenging as 1 NP is multifactorial; 2 the factors that contribute to the suffering of NP patients involve somatic, neurophysiologic and psychological processes, and 3 most of the factors that contribute to this suffering cannot consistently be unequivocally identified using objective tests. Thus, NP is very much a clinical diagnosis. Further research is needed to determine the usefulness of this approach.

In addition there is a great need for research that documents the clinical processes and outcomes that occur in the "real-world" environment of clinical practice as a contributor to comparative effectiveness research [ 6 , 7 ]. This study was part of a broad research strategy to respond to the need for practice-based research by investigating the clinical utility of the DBCDG for patients with NP.

Future studies are planned that will investigate correlations and patterns among the diagnostic components and investigate the reliability and efficacy of this approach in patients with NP. Preliminary data suggests that outcomes in select patients groups may be favorable [ 10 — 13 , 10 , 11 , 66 , 67 ], but this is based on observational studies without randomization or control. Conducting further studies will require subgrouping patients according to diagnosis. In order to create subgroups it must first be determined how many different possible diagnoses are found when utilizing the DBCDG.

CONSTRUCTING A DIFFERENTIAL DIAGNOSIS

This study was the first step in this process. These signs were originally thought to reflect zygapophyseal joint pain [ 18 ] although recent evidence argues against this [ 68 ]. This difference may be due to the mix of acute and chronic patients in the present cohort or may reflect the possibility that segmental pain provocation signs may provoke pain arising from other structures in addition to those related to the zygapophyseal joints. Further work is needed to determine from what tissues the pain elicited with these signs is arising.

Centralization signs were found in Data were only gathered at the initial visit. However the usual clinical protocol at the clinic at which this study was performed calls for the determination of the centralization response to occur over the course of several visits as this has been shown to be more accurate, at least in patients with low back pain [ 75 ]. Thus, the percentage of patients who were centralizers may be underestimated here. On the other hand, as the prevalence of this finding is unknown, it is also possible that the percentage of centralizers may be overestimated in this study.

While the incidence of cervical radiculopathy in the general population has been found to be It is not clear whether this reflects a higher prevalence of this finding in NP patients in comparison to back pain patients or to the fact that the reliability of muscle palpation signs has been found to be greater in the cervical spine [ 20 , 23 , 31 ] than the lumbar spine [ 78 — 80 ]. There were three factors under the third question of diagnosis for which the prevalence was quite low. As these factors have been found to be significant in the development of chronic NP [ 55 , 56 , 81 ], it is likely that the low prevalence of the diagnosis of these factors in this study represents under-recognition.

Another possibility is that this cohort did not display these features or that sampling error led to low prevalence.


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It also may be that the means used in this study to identify these factors were suboptimal. In the case of central pain hypersensitivity, there is no well established means of identification.

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Further work on the development of non-organic signs in the cervical spine may improve the identification of these signs [ 82 ]. In addition, there may be other methods, such as pressure algometry [ 83 ], that may be useful in the detection of central pain hypersensitivity. In the case of passive coping and depression, the scales used to identify these factors have no established threshold score that identifies the presence of clinically meaningful problematic coping strategies and depression. The mean score on the coping strategies questions was 5.

A recent study found that a baseline coping score of less than 8 had the highest sensitivity and score of less than 4 had the greatest specificity in identifying a NP patient who is not likely to experience clinically meaningful improvement in pain and disability [ 84 ]. These data will be used as the basis for further investigation that attempts to establish these thresholds.

It is expected that this will increase clinical utility of these questions in identifying the patient who has problematic coping strategies and depression. In this study only fear, coping and depression were measured. Other important psychological factors that are of importance in patients with NP, such as catastrophizing and poor self-efficacy, were not specifically measured.

There is some evidence that these various psychological factors interact, rather than occurring in isolation [ 57 — 60 ] and that identification of more than one factor, but not necessarily all factors is adequate [ 61 ].

Application of a diagnosis-based clinical decision guide in patients with low back pain

As this was a practice-based research project that is part of the investigation of identification of key elements in the perpetuation of NP in a "real-world" environment, it was decided that fear, coping and depression would be measured rather than attempting to measure all potentially relevant factors. Further work is needed to determine whether this is a worthwhile approach for clinicians.

This study had several limitations. First, the sample size of 95 patients was small. In addition, all data were gathered at a single clinic and thus it is not known whether the information is generalizable. Also the design was observational and the practitioners were not blinded to the findings on each patient.


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  6. The suspicion of the presences of oculomotor dysfunction was made based on a traumatic onset of the NP. It is not known whether all patients whose NP is caused by trauma have oculomotor dysfunction or what percentage, if any, of patients with non-traumatic neck pain have this condition. The decision to use trauma as the criterion in this case was based on the common association found in the literature between oculomotor dysfunction and cervical trauma and the absence thus far of a diagnostic test that identifies this condition and that has utility in a busy clinic environment.

    The approach to oculomotor dysfunction may be revised based on the evolving evidence regarding clinical tests of oculomotor reflexes [ 47 ]. Finally, because this was a pragmatic study in which data were gathered during the normal course of clinical care detailed information regarding psychological factors was not obtained as this would have required patients filling out several questionnaires. On the other hand, the fact that this study was carried out in a real-world environment may also be a strength in that it suggests that the information applies to the environment in which patients are most commonly cared for as opposed to the controlled environment of a research center.

    It appears possible to investigate the usefulness of the DBCDG through practice-based comparative effectiveness research.

    Application of a diagnosis-based clinical decision guide in patients with neck pain

    Further research is needed to investigate the validity of the questions used in this study to identify problematic coping strategies and depression as well as to establish a threshold for a "positive" and "negative" finding for these measures. In addition, there is need to find better clinical means of identifying central pain hypersensitivity.

    Research is also needed to investigate correlations and patterns among the individual components of the approach, the reliability and validity of the diagnoses and the clinical utility and efficacy. Spine Phila Pa Med Care. Health Aff Millwood. Murphy DR, Hurwitz EL: A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain.

    BMC Musculoskeletal Disorders.