FYI - Treatment of Symptoms of Neuropathy

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Treatment of Symptoms of Neuropathy

The symptoms of neuropathy may be treatable even if the cause of the

neuropathy is untreatable or unknown. With simple measures, many patients can

have meaningful relief of symptoms.

The ankle-foot orthosis is a simple device that compensates for footdrop. The

main benefit offered by an ankle-foot orthosis is greater stability at the

ankle, resulting in better balance and overcoming the tendency to catch the

toes on edges of steps, curbs, and carpets. A lightweight, properly fitted

ankle-foot orthosis that slips into the shoe is usually the most comfortable.

Patients with weakness of wrist and finger extensors may be helped by a brace

that keeps the wrist and fingers in a neutral position. Unfortunately, this

type of splint is of little help when there is significant concomitant

weakness of intrinsic hand muscles.

Pain, particularly in the feet, often accompanies the sensory disturbances of

neuropathy. Paradoxically, in polyneuropathies with prominent pain, the

neurologic deficits are often minor and there is a dissociation between the

actual disability and the level of the patient's distress. Patients may

interpret pain as a sign of a serious disorder that threatens their

independence or their life. Sometimes, simple reassurance, emphasizing how

little neurologic function has been lost, helps the patient cope effectively

with neuropathic pain.

Nonpharmacologic measures may be as efficacious as medications. Careful

attention should be paid to footwear. Loose-fitting, soft-soled shoes and

thick socks are advisable. Neuropathic pain tends to be aggravated by

extremes of temperature-especially heat-and open-toed sandals may give

relief. Prolonged weight bearing often worsens neuropathic pain; patients

whose work requires them to be on their feet may be helped by frequent short

sitting breaks.

Foot soaking produces short-lived relief in many patients. Soaking the feet

in ankle-deep cold tap water (without ice) for 15 to 20 minutes can be

particularly helpful at bedtime. Although the relief is short-lived, it may be

sufficient to allow the patient to fall asleep and to sleep well. For some

patients, warm water is better than cold, and others find that alternating

cold and hot (so-called contrast soaks) provides the best relief. Daily

inspection of the feet for undetected injuries-an important habit that

patients with neuropathy should develop-can be conveniently combined with

nightly foot soaks.

Medications can be useful in the management of neuropathic pain, though the

goals of therapy should be realistic. Complete pain relief is unlikely. The

aim should be to make the pain more tolerable without adding intolerable side

effects of medication. Of the many drugs that can be tried for neuropathic

pain, amitriptyline and carbamazepine are most frequently used. Lancinating,

paroxysmal pains are more likely to respond to carbamazepine (200 mg three

times a day), whereas amitriptyline (10 to 30 mg at bedtime) is the usual

first choice for the more common, continuous burning numbness. A trial of at

least 1 month should be undertaken before any conclusions are drawn about the

usefulness of a drug for neuropathic pain. In addition to amitriptyline and

carbamazepine, salicylates and other simple analgesics give relief to some

patients. As is the case with other types of chronic pain, narcotics are best

avoided.

If adequate trials of amitriptyline or carbamazepine are unsuccessful,

several second-line drugs may be tried, including baclofen, mexiletine, and

prazosin. Topical capsaicin ointment causes depletion of the neurotransmitter

substance P in the dorsal horn of the spinal cord and helps some patients.

For most patients, however, the expense and inconvenience of topical

capsaicin outweigh any benefits. Gabapentin, one of the new anticonvulsant

drugs, is increasingly being used for neuropathic pain, though evidence of

its efficacy to date is mostly anecdotal. 51

Some patients remain refractory to all of these measures and present

difficult management problems. Concurrent depression can complicate the

situation, and psychiatric referral may be worthwhile. Referral to a

multidisciplinary pain management center should also be considered.

COLIN H. CHALK, M.D., C.M.

PETER JAMES DYCK, M.D.