Peripheral Neuropathy

What is peripheral neuropathy?

Neuropathy is damage to nerves that causes pain, numbness and/or tingling. While technically many conditions are a form of neuropathy, most people tend to think of peripheral neuropathy when using the term neuropathy.

Peripheral neuropathy is nerve damage in the peripheral nerves. Peripheral nerves are any nerve in the body, which is not part of the brain or spinal cord. While peripheral neuropathy can start in any nerve of the body outside the brain and spinal cord, it usually starts in the nerves of the hands or feet. Symptoms usually begin as numbness or tingling. Over time, these symptoms can progress to pain. Patients most often describe the pain as a burning type of pain.

The most common cause of peripheral neuropathy in the hands or feet is diabetes. It is then commonly referred to as ‘diabetic neuropathy.’ Other causes can be kidney disease, HIV, or alcohol dependence. It can also occur for unknown reasons. In the latter case, it is called ‘idiopathic peripheral neuropathy.’

Is there a cure for peripheral neuropathy?

When the cause of neuropathy is diabetes, therapy involves aggressive treatment of diabetes. In such cases, treatment consists of medications to control blood sugars, dietary changes, exercise, and, most importantly, weight loss. Conventional wisdom is that if the diabetes is controlled early, the neuropathy can be reversed. However, diabetic neuropathy is often permanent.

When the cause of peripheral neuropathy is some other condition, like kidney disease, HIV or alcoholism, these primary diseases must also be managed.

In any of these cases, the pain of peripheral neuropathy is also a focus of care.

Therapies & procedures for neuropathy

Common symptom management therapies include antidepressant medications, anticonvulsant medications, opioid medications, mild aerobic exercise, cognitive behavioral therapy, and chronic pain rehabilitation programs.

Antidepressant medications

Because some antidepressants are heavily advertised for use in diabetic neuropathy, patients are commonly familiar with them. When considering their use, it is important to understand the types of antidepressants and their relative effectiveness.

Roughly, there are three types of antidepressant medications. Serotonin norepinephrine reuptake inhibitors (SNRI’s) are the newest type of antidepressant medications. SNRI’s are typically the ones that are advertised for use in either diabetic neuropathy or depression. Selective serotonin reuptake inhibitors (SSRI’s) are the second type and are a little older. They were originally developed for use in depression. They are now sometimes also used for diabetic neuropathy. Tricyclic antidepressants are the third type. They are the oldest type of antidepressants. They too were originally developed for use in depression. However, they also have a long history of use for diabetic neuropathy and chronic pain in general.

Surprisingly, the newest type of antidepressant medications, the SNRI’s, are not the most effective.1 The most effective type of antidepressant are the tricyclics. These are the oldest type. They are very likely to reduce pain by at least 50%.

The SSRI’s, the second oldest type of antidepressants, are somewhat likely to reduce pain by at least 50%.

The SNRI’s, the newest type of antidepressants – and the ones that are heavily advertised on television and in magazines -- are the least likely to reduce pain by at least 50%.

Anticonvulsant medications

Anticonvulsant medications are medications that were originally developed for the management of seizures. However, they have also been shown to be helpful in managing neuropathic pain.

Tricyclic antidepressants and anticonvulsants are largely equally effective in reducing pain.2, 3 

Opioid medications

Opioid, or narcotic, pain medications are commonly used in clinical practice. However, there are few research studies that support their use for peripheral neuropathy.

Gimbel, et al.,4 showed that the use of opioid medications was statistically better than placebo, but the actual clinical difference was minimal. Those who were treated with an opioid rated their pain on average at a 4 out of 10 whereas those who were treated with a placebo rated their pain at a 5 out of 10.

In a much smaller trial, Watson, et al.,5 also found a minimally better response.

Mild aerobic exercise

Mild aerobic exercise, such as walking, bicycling, or pool exercises, is an important part of self-managing peripheral neuropathy. Balducci, et al.,6 showed that mild aerobic exercise is able to reduce the likelihood of developing peripheral neuropathy due to diabetes.

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is a standard and effective treatment for chronic pain syndromes in general.7 While there are no controlled trials of CBT for peripheral neuropathy, it is commonly pursued on the assumption that it is effective, based on its demonstrated effectiveness for other pain conditions.

Chronic pain rehabilitation programs

Chronic pain rehabilitation programs are interdisciplinary programs designed to help patients learn to self-manage chronic pain. Their goals are to reduce pain, reduce secondary stressors associated with living with chronic pain, reduce the use of narcotic medications, and return to work or some other meaningful regular activity. They are effective in achieving these goals, and there is high quality research evidence demonstrating their effectiveness.8 However, there are no clinical trials assessing the effectiveness of chronic pain rehabilitation programs solely for peripheral neuropathy. One observational study of a limited version of a chronic pain rehabilitation program showed promise.9 

References

1. Wong, M., Chung, J. W., & Wong, T. K. (2007). Effects of treatments for symptoms of painful diabetic neuropathy: A systematic review. British Medical Journal, 335, 87. doi: 10.1136/bmj.39213.565972.AE

2. Chou, R., Carson, S., & Chan, B. K. (2009). Gabapentin versus tricyclic antidepressants for diabetic neuropathy and post-herpetic neuralgia: Discrepancies between direct and indirect meta-analyses of randomized controlled trials. Journal of General Internal Medicine, 24, 178-188.

3. Collins, S. L., Moore, R. A., McQuay, H. J., & Wiffen, P. (2000). Antidepressants and anticonvulsants for diabetic neuropathy and post-herpetic neuralgia: A quantitative systematic review. Journal of Pain and Symptom Management, 20, 449-458.

4. Gimbel, J. S., Richards, P., & Portenoy, R. K. (2003). Controlled-release oxycodone for pain in diabetic neuropathy: A randomized controlled trial. Neurology, 60, 927-934.

5. Watson, C. P., Moulin, D., Watt-Watson, J., Gordon, A., & Eisenhoffer, J. (2003). Controlled-release oxycodone relieves neuropathic pain: A randomized controlled trial in painful diabetic neuropathy. Pain, 105, 71-78.

6. Balducci, S., Iacobellis, G., Parisi, L., Di Biase, N., Calandriello, E., Leonetti, F., & Fallucca, F. (2006). Exercise training can modify the natural history of diabetic peripheral neuropathy. Journal of Diabetes and its Complications, 20, 216-223.

7. Morley, S., Eccleston, C., & Williams, A. (1999). Systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy and behavior therapy for chronic pain, excluding headache. Pain, 80, 1-13.

8. Gatchel, R., J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793.

9. Norrbrink Budh, C., Kowalski, J., & Lundeberg, T. (2006). A comprehensive pain management programme combining educational, cognitive and behavioural interventions for neuropathic pain following spainl cord injury. Journal of Rehabilitation Medicine, 38(3), 172-180.

 

Date of publication: April 27, 2012

Date of last modification: May 27, 2017

Murray J. McAllister, PsyD, is the executive director of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Its mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides Academic quality information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.

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