Treatment Modalities for Neuropathic Pain
NG Jenna Hei-lok, OT, Certified HT
Neuropathic pain is pain caused by lesion or disease of the somatosensory nervous system (Finnerup et al., 2016). It is a complex condition manifesting through a combination of anatomical and chemical changes in both the central and peripheral nervous systems.
A Holistic Four-Step Assessment Approach
In our practice in Hong Kong, we use a holistic assessment strategy based on traditional Chinese medicine, comprising: Observation, Listening & Smelling, Inquiring, and Palpation (Fig. 1, 2, 3 & 4). This method utilizes all five senses to gain a comprehensive understanding of the patient's condition.
Figure 1: Observation 望 Figure 2: Listening 聞Figure 3: Inquiring 問 Figure 4: Palpation 切。
Clinical Features in Neuropathic Pain
Neuropathic pain is characterized by a variety of clinical features, broadly categorized into positive and negative phenomena, as well as autonomic dysfunction (Finnerup et al., 2021).
Positive phenomena include spontaneous pain, which may be continuous or episodic without external triggers, and evoked pain, such as allodynia—pain from stimuli that typically do not cause pain. Hyperalgesia is another key feature, where responses to painful stimuli are exaggerated, making even mild pain feel intense. These phenomena significantly impact daily activities, such as experiencing pain while washing hair.
Negative phenomena encompass sensory loss, including deficits in thermal, vibratory, and soft touch sensations, indicating disrupted sensory pathways. This loss can hinder interaction with the environment and increase the risk of injuries due to an inability to sense temperature changes or pressure, ultimately diminishing quality of life.
Autonomic dysfunction may also occur, presenting as vasomotor abnormalities like changes in skin temperature and color, along with sudomotor dysfunction affecting sweating and hair distribution. These factors contribute to discomfort and altered body image.
Figure 5: Circle of Pain.
Circle of Pain
The Circle Of Pain (COP) uses a circuit model to analyze neuropathic pain, focusing on how pain is detected by nociceptors with free nerve endings in somatic and visceral areas (Fig. 5).
Pain Transmission: Pain transduction begins when noxious stimuli generate action potentials at peripheral nociceptors. These signals travel through afferent nerves to the spinal cord, synapsing with second and third-order neurons before ascending to various brain regions, resulting in pain perception. The threshold for these action potentials must be high enough to prevent disruption of daily activities but low enough to trigger before tissue damage. This threshold can shift due to physiological or behavioral factors, contributing to chronic pain through mechanisms like central sensitization (Woolf, 2011).
Pain Perception: Pain serves as a learned protective mechanism, but prolonged sensitization can turn it into a disruptive symptom affecting daily life (Shafiee et al., 2023).
Pain Modulation: The pain response results from a dynamic balance between inhibition and facilitation at peripheral, spinal, and supraspinal levels, influenced by emotional context, cognitive processes, and genetic factors (Mermet-Joret et al., 2017).
Windows of Treatment in the Circle of Pain
To effectively manage neuropathic pain within the Circle of Pain model, various treatment modalities can be employed (Fig. 6):
Figure 6: Windows of Treatment in the Circle of Pain.
Treatment Modalities
A multidisciplinary approach is paramount in managing neuropathic pain and neuromas, ensuring comprehensive care that addresses various aspects of the condition. Treatment modalities can be broadly categorized into surgical, pharmacological, and non-pharmacological interventions.
Surgical Treatments
Surgical options aim to prevent the formation of painful neuromas and phantom limb pain. Techniques such as targeted muscle reinnervation and regenerative peripheral nerve interfaces show promise in alleviating symptoms and enhancing recovery (Bogdasarian et al., 2022).
Pharmacological Treatments
Pharmacological management often follows the WHO analgesic ladder, incorporating medications specifically indicated for neuropathic pain. This may include anticonvulsants, antidepressants, and topical agents.
Physical, Cognitive & Occupationnal Treatments
Desensitization
Desensitization techniques are crucial for patients with hyperalgesia and mechanical allodynia, as they normalize sensations and reduce pain through gradual exposure to sensory stimuli (Burchiel & Gibbons, 2016). This process retrains the nervous system to tolerate previously painful stimuli. Evidence from randomized controlled trials indicates that early sensory relearning enhances long-term sensory recovery, particularly after nerve repair. A 2015 systematic review found that desensitization techniques significantly reduced pain and allodynia in patients with Complex Regional Pain Syndrome (CRPS), demonstrating their potential in broader neuropathic pain management.
Desensitization can be achieved through various modalities, including tactile, thermal, pressure, and chemical stimuli. In our hospital, we employ desensitization stands and boxes with different textures to help patients acclimate to various sensory inputs. For neuroma or fingertip hypersensitivity, we use a glove with a hole to focus sensation on the injured area, facilitating targeted desensitization (Fig. 7).
Figure 7: Desensitization stand and desensitization box using a glove with a hole at fingertip.
We have recently introduced a 3D-printed desensitization keychain cube as a versatile tool for home use. This cube features six or twelve faces made of different materials, providing a structured way for patients to engage in desensitization exercises conveniently (Fig. 8). By incorporating these innovative tools into our treatment protocols, we aim to enhance sensory recovery and improve the overall quality of life for patients with neuropathic pain.
Figure 8: 3D-printed desensitization keychain cubes.
Somatosensory Re-education
Somatosensory re-education is a vital part of rehabilitation following desensitization, focusing on spinal, supra-spinal and cortical sensitization. This process helps reorganize hand maps in the brain by integrating visual and sensory information, allowing the brain to "learn" a new sensation language (Paula et al., 2016). The re-education process consists of two overlapping phases. The first phase involves minimal sensory input, aiming to activate and maintain the hand map while educating patients on adaptive strategies to manage decreased sensation. Exercises include focusing on moving and constant touch sensations. The second phase begins when sensory signals reach the brain, combining visual and sensory information. Patients practice localizing touch with their eyes closed, answering questions about the sensation, and identifying textures and objects without visual cues.
To boost motivation in somatosensory re-education, it's crucial to make exercises functional and engaging. Enjoyable activities, such as playing mahjong during the Chinese Lunar New Year or having tactile seafood meals, can improve participation and effectiveness. Tasks like finding coins in rice or keys in a bag also make the process enjoyable, fostering a positive learning environment. A 2018 study by Vikström et al. emphasized the importance of motivation and meaningfulness in rehabilitation. Many patients found sensory relearning meaningful and capable of creating an illusion of touch, aiding their success. However, many also reported needing more support and faced challenges in maintaining motivation. This highlights the need to relate training activities to everyday life to enhance engagement in somatosensory relearning (Griffiths et al. 2023; Hoang et al., 2024).
Graded Motor Imagery Program
Mirror therapy is an innovative technique that uses visual feedback to address phantom pain and enhance motor function. Graded Motor Imagery Program has been shown to improve motor function and reduce pain perception (Moseley, 2006). It activates mirror neurons, which are essential for motor functions and pain perception. By directing spatial attention to the affected limb, mirror therapy helps individuals regain control over their movements.
The technique offers dual benefits: it improves motor function and reduces pain perception. By providing normal visual feedback, it alleviates the fear associated with using the affected limb, often heightened by phantom pain, and helps patients reconnect with their limbs.
Personally, I follow the therapy sequence in three key parts:
Moving the Unaffected Side Only: Patients move their unaffected limb while observing its reflection in a mirror, creating the illusion of movement in the affected limb.
Mental Rehearsal of the Action: Patients visualize the movement of both limbs, reinforcing the mind-body connection.
Action Execution by Moving a). One side, then b) Both Sides Together: Finally, patients practice moving both limbs simultaneously, using visual feedback from the mirror to enhance their movements.
Hand Function Training
Hand function training is vital for rehabilitation, focusing on positive learning about pain signals and breaking the cycle of "pain, anxiety, and mobility" (Bernetti et al., 2021). Key strategies include:
Just-Right Challenge: Balancing activity levels is crucial; too much or too little can worsen pain, so finding the right challenge promotes success and confidence;
Short Training Sessions: Targeted movements enhance motor relearning by stimulating specific muscles for better coordination without overwhelming the patient;
Stress Loading: Effective for patients with CRPS, activities like carrying or scrubbing provide inhibitory proprioceptive input, alleviating pain and encouraging hand use;
Empowerment: Encouraging active hand use combats movement phobia, fostering agency and confidence (Hisham et al., 2025).
Orthosis
Orthosis helps improve passive range of motion (PROM) and promote soft tissue healing. Examples like flexion mitt can assist in passive finger flexion while turnbuckle splints for elbow stiffness. Functional splinting is particularly beneficial for nerve rehabilitation, especially for patients recovering from traumatic nerve injuries in the upper limbs. These splints help prevent complications such as contractures or deformities, while also promoting early mobilization post-injury. Examples include splints for radial nerve palsy, ulnar nerve palsy, and median nerve injuries.
Pressure Therapy
Pressure therapy is a key component of neuropathic pain management, particularly for swelling and pain. It enhances venous and lymphatic flow, reducing edema and promoting healing by applying consistent pressure to tissues. This approach helps move fluid away from swollen areas, alleviating discomfort, especially in conditions like CRPS and post-operative recovery.
In cases of neuroma after digit amputation, pressure therapy is effective for managing hypersensitivity in the residual limb. Using PG finger stalls provides targeted pressure to sensitive areas, creating a protective barrier that reduces exposure to pain triggers. Over time, the constant pressure can desensitize the area, improving overall comfort.
Alternative Modalities
As treatment modalities for swelling and stiffness continue to evolve, various alternatives are available (Fig. 9). Coban tape is commonly used in our clinic for swelling in CRPS patients. After wrapping the fingers and hand with Coban, we implement sequential pumping techniques to aid in swelling control. A key tip for effective sequential pumping is to perform lymphatic drainage therapy beforehand, which helps open lymphatic valves and enhance the effects of pumping.
Kinesiotape is another modality occasionally employed for hand and upper limb swelling. The pre-tension of the tape lifts the skin, promoting lymphatic flow and directing it toward less congested pathways. Research has shown that kinesiology tape can significantly decrease pain and improve function in patients with conditions like CRPS (Wang et al., 2022).
Additionally, flossing bands have been introduced into my practice over the past year. The elastic band provides focal compression on joint and soft tissue by flushing in fresh blood and removing metabolic waste, making them particularly useful for addressing finger joint stiffness. It is the use of an elastic band to provide focal compression on soft tissue and joints, and requires active and or passive ROM while the affected structure is under compression exerted by the band (Kelly et al., 2022).
Figure 9: Alternative treatment modalities (from left to right): coban tape, kinesiotape, flossing bands.
Pain Education
Pain education is essential for managing chronic pain, especially neuropathic pain. Historically viewed through the Cartesian model, which linked pain to tissue damage, the understanding has shifted to a biopsychosocial model that considers biological, psychological, and social factors. Modern research shows that psychological and emotional elements significantly affect pain perception, leading to maladaptive experiences in neuropathic pain, which lacks the protective function of nociceptive pain (Dansie & Turk, 2013). Thus, comprehensive pain education is crucial.
The goal of pain education is to improve understanding of pain perception and modulation, empowering patients to develop effective self-coping strategies. By learning about pain pathways, patients can demystify their symptoms and gain control over their pain experiences.
To reduce fear-avoidance behaviors, patients are taught self-coping skills, including relaxation techniques and mindfulness (Fig. 10). Integrating these skills into daily routines fosters self-control in pain management. Research supports the effectiveness of self-management strategies for chronic pain. At our hospital, we emphasize pain self-management in rehabilitation, using mindfulness techniques like body scanning to promote awareness and acceptance of pain (Morone et al., 2008). This practice helps patients respond more healthily to discomfort, enhancing their coping abilities.
Figure 10: Body scanning exercise in mindfulness session for neuropathic pain patients.
Cognitive Behavioral Therapy
The Cognitive Behavioral Therapy (CBT) is gaining recognition as a valuable intervention for managing neuropathic pain, despite current low confidence in its estimated effects. A systematic review indicates positive outcomes, and ongoing studies are exploring its efficacy (Eccleston et al., 2015). CBT is based on the interconnectedness of emotions, behaviors, and thoughts in the pain experience. It aims to provide a holistic approach to pain management:
Emotion: Patients learn relaxation techniques, such as mindfulness and diaphragmatic breathing, to reduce anxiety and emotional distress related to pain;
Behavior: CBT encourages setting realistic activity goals for graded exposure to painful stimuli, particularly in hand function training, helping patients manage pain responses and improve functionality;
Thought: Cognitive restructuring helps patients identify and challenge negative thoughts about pain, enhancing self-efficacy and promoting active involvement in pain management.
By addressing emotional, behavioral, and cognitive aspects, CBT offers a multifaceted approach to improving pain management and overall quality of life.
Work Rehabilitation
Work rehabilitation is essential for patients with neuropathic pain, focusing on restoring function and facilitating a successful return to work. Occupational therapy (OT) is pivotal in assessing patients' capabilities through work capacity evaluations, which guide tailored rehabilitation plans.
Work hardening programs are implemented to enhance patients' strength and endurance for their specific job roles, combining physical conditioning and education. Given the prolonged sick leave often experienced by these patients, vocational counseling helps them navigate concerns about returning to work and sets realistic reintegration expectations.
A shared decision-making approach ensures collaborative discussions between healthcare providers and patients, weighing the benefits and risks of returning to work. Implementing ergonomic principles in the workplace is crucial to help patients perform job duties comfortably and prevent overuse injuries.
Conclusion
The management of neuropathic pain and neuromas requires a comprehensive, multidisciplinary approach tailored to individual patient needs. By integrating surgical, pharmacological, and non-pharmacological strategies, healthcare providers can enhance patient outcomes and improve quality of life. Continued research and collaboration will further refine these modalities, ensuring that patients receive the best possible care in their journey towards recovery.
Acknowledgements
My heartfelt thanks to my OT seniors, Mr. Eric CHUI and Mr. David CHIN, for their feedback on this guesteditorial.
References
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摘要
神經疼痛是一種由體感神經系統的損傷或疾病而引起的複雜病症。根據國際疼痛研究協會的定義，這種疼痛通常伴隨著中樞和周邊神經系統的化學變化。因為神經疼痛的臨床特徵和影響範圍極為廣泛，神經疼痛的診斷和治療需要全面的理解和多方面的介入
本篇文章提出了一個基於中醫的四步驟評估方法，包括觀察（望）、聆聽與嗅覺（聞）、詢問（問）和觸診（切）。這種方法強調了治療師在評估過程中應充分利用所有五種感官，以獲得對患者狀況的深入洞察，並全面了解患者的病情。
望（觀察）：對患者手部進行視覺檢查，以識別手部變形、萎縮、疤痕等可能指示潛在神經病理問題的特徵。
聞（聆聽與嗅覺）：主動聆聽患者的主要訴求和疼痛特徵 ; 嗅覺: 透過嗅覺線索了解其情緒狀態及可能的感染情況。
問（詢問）: 與患者進行詳盡的對話，了解其病史和疼痛症狀，並探討疼痛對睡眠的影響及心理或社會壓力源。
切（觸診）: 對受影響區域的評估，以評估皮膚溫度和感覺功能，這些都對確定疼痛的來源及其性質至關重要。
神經疼痛的臨床特徵可分為正向現象和負向現象。正向現象包括自發性疼痛，這種疼痛可能是持續性或間歇性。觸痛，即對通常不會引起疼痛的刺激產生疼痛反應，如輕觸。負向現象則包括感覺的喪失，這可能表現在熱覺、振動感和輕觸的喪失，進而影響患者與環境的互動，增加受傷風險。此外，也可能出現自主神經功能障礙，如皮膚溫度和顏色的變化，以及出汗的異常。這些臨床特徵的多樣性使得神經疼痛的管理更加複雜且具挑戰性。
為了有效管理神經疼痛，本文介紹了多種治療方式，這些治療可以廣泛分為外科手術、藥物治療和非藥物治療三大類。本文將會主要討論非藥物治療的方案。
在非藥物治療方面，脫敏治療、感覺教育、鏡像治療、疼痛教育和認知行為療法(CBT)等方法被廣泛應用。脫敏治療對於那些有過度敏感和機械性觸痛的患者尤其重要，因為這治療能夠通過逐步接觸感官刺激來幫助患者恢復對疼痛的耐受性。感覺教育則專注於改善患者的感覺功能，幫助其重新整合視覺和感官信息，從而促進神經重建和再學習。鏡像治療是一種創新的方法，通過視覺反饋來緩解幻肢痛並改善功能。這種技術利用患者未受損肢體的運動反射，幫助患者重新獲得對受損肢體的控制。疼痛教育則強調幫助患者理解神經疼痛的成因，以使其能夠更好地管理自己的疼痛。認知行為療法則針對情緒、行為和思維之間的相互關係，幫助患者識別並挑戰有關疼痛的負面想法，增強其自我效能感。最後，工作康復是通過工作能力評估來制定個性化的康復計劃，旨在促進患者成功重返工作崗位。
總之，神經疼痛的管理需要綜合多方面的治療媒介。通過整合外科、藥物和非藥物治療，能夠改善神經疼痛患者的治療效果，提升其生活質量。持續的研究和跨學科合作將進一步精細化這些治療方案，確保患者在康復過程中獲得最佳的護理。