akyuz2014

Authors:
Gulseren Akyuz, MD
Ozge Kenis, MD
Pain
Affiliations:
From the Department of Physical
Medicine and Rehabilitation (GA, OK)
and Department of Algology (GA),
Marmara University, School of
Medicine, Istanbul, Turkey.
Correspondence:
All correspondence and requests for
reprints should be addressed to:
Fevzi Cakmak Mah, Mimar Sinan Cad,
Marmara Üniversitesi, Hastanesi No:
41, 34899 Üst Kaynarca, Istanbul,
Turkey.
LITERATURE REVIEW
Physical Therapy Modalities and
Rehabilitation Techniques in the
Management of Neuropathic Pain
Disclosures:
ABSTRACT
Financial disclosure statements have
been obtained, and no conflicts of
interest have been reported by the
authors or by any individuals in control
of the content of this article.
Akyuz G, Kenis O: Physical therapy modalities and rehabilitation techniques in the
management of neuropathic pain. Am J Phys Med Rehabil 2014;93:253Y259.
0894-9115/14/9303-0253
American Journal of Physical
Medicine & Rehabilitation
Copyright * 2013 by Lippincott
Williams & Wilkins
DOI: 10.1097/PHM.0000000000000037
Neuropathic pain is an important problem because of its complex natural history,
unclear etiology, and poor response to standard physical therapy agents. It causes
severe disability unrelated to its etiology. The primary goals of the management of
neuropathic pain are to detect the underlying cause, to define the differential
diagnosis and eliminate risk factors, and to reduce the pain. The physician should
also know the functional and psychologic conditions of the patient. Therefore, a
multimodal management plan in neuropathic pain is essential. This review aimed to
reflect a diverse point of view about various physical therapy modalities and rehabilitation techniques. Physical therapy modalities and rehabilitation techniques
are important options and must be considered when pharmacotherapy alone is not
sufficient. In addition, psychosocial support and cognitive behavioral therapy could
also be taken into consideration. It has been suggested that the importance of pain
rehabilitation techniques will increase in time and these will take a larger part in the
management of neuropathic pain. However, it is now early to comment on these
methods because of the lack of adequate publications.
Key Words:
Management
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Physical Therapy Modalities, Rehabilitation Techniques, Neuropathic Pain,
Management of Neuropathic Pain
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
253
N
europathic pain can be defined as pain caused
by a lesion or a disease of the somatosensory system.1
It can last a long time and increase gradually, leading
to serious disability.2 There are many causes of neuropathic pain, which can be classified according to
etiology, localization, or anatomy3 (Table 1). As it is
well known, neuropathic pain affects the quality-oflife, decreases physical functionality and activities of
daily living, and creates severe difficulties in both
professional and personal life. It also causes psychologic problems resulting in sleep disorders, anxiety,
and depression. There are also some consequences
associated with neuropathic pain, such as deterioration in sexual and marital life and family relationships, that lead to social isolation. These problems
increase over time, which, in turn, worsen the pain
and cause a vicious circle. Neuropathic pain also has a
bad impact on the economy because of considerable
loss in working days, disability, and increasing
healthcare costs.4 Therefore, neuropathic pain must
be approached as a big health problem that has to be
resolved as quickly and as efficiently as possible.
At the beginning of the treatment of neuropathic pain, pain must be defined and goals of
treatment must be established. Comorbidities and
psychosocial factors, which can be related to pain,
should also be evaluated. It is important to determine an underlying cause of neuropathic pain and
the functional status of the patient. As a result, a
target-based treatment algorithm must be planned
and executed step by step. In a well designed management plan of neuropathic pain, pharmacotherapy,
physical therapy modalities, rehabilitation techniques,
cognitive behavioral therapy/psychotherapy/relaxation
therapy methods, and invasive procedures should
all be taken into consideration. In pharmacologic
treatment, the European Federation of Neurological Societies guideline suggests the use of antiepileptic drugs such as gabapentin and pregabalin
and antidepressants such as duloxetine, venlafaxine,
and tricyclic antidepressants as first-line drugs.5
Namaka et al.6 also advocate topical analgesics such
as capsaicin and lidocaine as an addition to first-line
drugs. As a second-line drug, weak opioids such as
tramadol are preferred.
Physical Therapy Modalities
Physical therapy modalities include pain modulators such as hot and cold packs, ultrasound, short-wave
diathermy, low-frequency currents (trancutaneous
electrical nerve stimulation [TENS], diadynamic currents, and interferential currents), high-voltage galvanic
stimulation, laser, and neurostimulation techniques
such as deep brain stimulation and transcranial magnetic stimulation (Table 2). Hot and cold applications could also be used together as in contrast baths.
Sometimes, fluidotherapy or whirlpool could also
be chosen for this purpose. All these superficial heat
agents should not be applied in high degrees because of possible risk for increase in pain. Although
TABLE 1 Main causes of neuropathic pain
Central Causes of Neuropathic Pain
Peripheral Causes of Neuropathic Pain
Compression myelopathy caused by spinal stenosis
HIV myelopathy
Multiple sclerosis pain
Pain of Parkinson disease
Myelopathy after ischemia or radiation
Pain after stroke
Pain caused by posttraumatic medulla spinalis injury
Syringomyelia
Acute and chronic inflammatory demyelinating
polyradiculoneuropathy
Alcohol-induced polyneuropathy
Chemotherapy-induced polyneuropathy
CRPS
Compression neuropathies
HIV sensory neuropathy
Idiopathic sensory neuropathy
Tumor infiltration of nerves
Neuropathy of nutrition deficiency
Diabetic neuropathy
Phantom pain of extremity
Postherpetic neuralgia
Plexopathy after radiation
Radiculopathy (cervical, thoracic, lumbosacral)
Neuropathy caused by toxic exposure
Trigeminal neuralgia
Posttraumatic neuralgia
Peripheral nerve injury
Bogduk and Merskey.2
HIV, human immunodeficiency virus.
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Akyuz and Kenis
Am. J. Phys. Med. Rehabil. & Vol. 93, No. 3, March 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
TABLE 2 Physical therapy modalities used in
neuropathic pain and their main
indications
Physical Therapy
Modalities
Heat and cold
applications
Fluidotherapy
Whirlpool
Massage
TENS
Indications
Chronic pain
SCI
SCI
Acute, subacute, and chronic
postoperative pain
Radiculopathy
Diabetic neuropathy
Transcranial magnetic SCI
stimulation
Stroke
Brachial plexus lesions
Trigeminal nerve lesions
CES
SCI
these modalities have been found effective in chronic
pain, there is a definite need of studies that support
their effectiveness.7 In general, deep heating agents
such as ultrasound and short-wave diathermy should
not be recommended in the treatment of neuropathic
pain. Although these are helpful especially in the
improvement of joint contractures and adhesions by
increasing the flexibility of collagen fibers and circulation of connective tissues, these might increase
neuropathic pain. Massage is also not proven to be
effective in neuropathic pain. In acquired immunodeficiency syndrome patients with neuropathic pain,
massage therapy has been applied, but there have
been no significant changes on pain intensity.8 There
is another study that has investigated the role of
massage in spinal cord injury (SCI) patients. Although the study claims that massage seems as one
of the effective therapies, it does not specify the type
of pain.9 Pieber et al.10 have evaluated the effectiveness of different types of electrotherapy. In that review, the studies that involve the largest groups
are usually about TENS in addition to other studies
with smaller groups that investigate other techniques
such as electromagnetic neural stimulation, pulse
and static electromagnetic field application, and
high-frequency external muscle stimulation. Possible
action mechanisms of electrotherapy have been suggested to be local release of neurotransmitters such
as serotonin, raised levels of adenosine triphosphate,
release of endorphins, and its own anti-inflammatory
effects. Dorsal column activation is another mechanism of electrotherapy. It has been shown that lowfrequency currents increase microcirculation and
www.ajpmr.com
endoneural blood flow. Electrotherapy could also be
effective in correcting the disrupted microcirculation in diabetic polyneuropathy and increase oxidative capacity in muscles via metabolic effect.
TENS is one of the best modalities that has been
shown to be effective in the treatment of neuropathic
pain.11 It has been suggested that TENS activates
central mechanisms to provide analgesia. Lowfrequency TENS activates K-opioid receptors in the
spinal cord and the brainstem, whereas highfrequency TENS produces its effect via C-opioid receptors. The European Federation of Neurological
Societies has published a guideline about the use of
therapeutic electrical neurostimulation techniques
in chronic neuropathic pain.12 The guideline suggests that the effectiveness of TENS depends on the
intensity, frequency, duration, and number of sessions. McQuay et al.13 have published a review about
the use of TENS in outpatient conditions for nonspecific chronic pain, which suggests that it is effective in chronic nonspecific pain. Randomized
controlled trials that were done by Akyuz et al.14 and
Guven et al.15 have also shown the efficacy of TENS in
fibromyalgia and postoperative pain. In another study
investigating the effect of different TENS applications
compared with placebo in 11 radiculopathy patients,
TENS has been found effective when compared with
placebo.16 Cheing and Luk17 found that highfrequency TENS is significantly effective in reducing the hypersensitivity of the hand. In a randomized
controlled trial, low-frequency TENS (G2 Hz) and
placebo (4 wks, 30 mins daily) have been compared in
patients with diabetic neuropathy. Eighty-three percent of the patients in the treatment group have
reported sudden decrease in pain and discomfort.18
Forst et al.19 compared the effects of low-frequency
TENS and placebo TENS in a randomized controlled
trial and showed that visual analog scale (VAS) and
NTSS-6 [Neuropathy Total Symptom Score 6] scores
have improved significantly in the treatment group.
Acupuncture-type TENS (0Y4 Hz) has been found more
acceptable when compared with high-frequency
TENS because of increased sensation of numbness,
but there is no sufficient evidence.12 As a result, TENS
can be effective in the treatment of painful peripheral
neuropathy. However, inadequate trial designs and
short follow-up durations still prevent the authors
to comment on TENS objectively. There is need for
more randomized, double-blind studies done with
larger patient groups.
Laser is another physical therapy agent that can
be used in the treatment of neuropathic pain. Very
low level of laser has been shown effective in patients
with neuropathic pain.20 When very low laser therapy
Management of Neuropathic Pain
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255
is applied, it decreases pain and inflammation, in addition to improving functional ability. In rats, low-level
laser therapy decreases the level of hypoxia-induced
factor 1->, which is an important modulator in inflammation and released after chronic constrictive
nerve injury.21 There are other studies that study the
effectiveness of laser therapy in neuropathic pain that
are also done in rats.22,23 In humans, the effectiveness of
helium-neon laser therapy was studied. In a study, it
has been shown to induce a 55.3% pain decrease in 36
patients who have been experiencing postherpetic
neuralgia.24 Another study that had investigated the
effects of helium-neon therapy in 18 postherpetic
neuralgia patients found a 44% decrease in pain after 50
sessions of therapy.25 A study also points out a good
improvement rate of 60% among postherpetic neuralgia patients who have received low-level laser therapy.26
Still, there is not enough evidence to suggest that it is
effective in neuropathic pain.
Neurostimulation techniques including transcranial magnetic stimulation and cortical electrical
stimulation (CES), spinal cord stimulation, and deep
brain stimulation have also been found effective in the
treatment of neuropathic pain. In the Cochrane review
published in 2011, the effects of repetetive transcranial
magnetic stimulation (rTMS) and CES over chronic
pain such as neuropathic pain, chronic neck and back
pain, osteoarthritis, and fibromyalgia were investigated and found to be not significantly different from
those of sham stimulation.27 Lefaucheur et al.28 investigated 60 patients with chronic unilateral neuropathic pain caused by one of the following lesions:
thalamic stroke, brainstem stroke, spinal cord lesion,
brachial plexus lesion, or trigeminal nerve lesion.
Transcranial magnetic stimulation was applied 3 wks
apart in two sessions, with a 10-Hz frequency. The
patients’ pain level was assessed with the VAS. Thirtynine patients reported a decrease in pain depending on
the localization and the cause of pain. Capel et al.29
have done a randomized, placebo- controlled study
and evaluated the effects of CES in 27 patients with
SCI. Fourteen patients received CES for 2 hrs, two
times a day, for 4 days, whereas 13 patients received
placebo CES at the same protocol. Pain was assessed
with the VAS and the McGill Pain Questionnaire, but
other functional-related factors such as depression,
anxiety, and analgesic use were also monitored. In
this study, patients receiving CES reported decrease
in pain intensity and the need for pain medication. However, in both groups, there was no significant functional improvement. Another randomized
placebo-controlled trial was done by Tan et al.30 in
38 SCI patients who had chronic neuropathic and
musculoskeletal pain for at least 3 mos. CES was
256
Akyuz and Kenis
applied to 18 patients for 21 days at a maximum of
100 KA. Twenty patients received placebo. The patients in the CES group reported a decrease in pain
intensity immediately, and this decrease did not change
over time. However, there was no statistically significant difference between the groups. Although
there are many studies that have been done about
neurostimulation techniques, these are far from
giving a definite result with patient groups being so
small and mainly including patients with SCI. There
is need for further research in the efficacy of neurostimulation techniques in other causes of neuropathic pain.
Rehabilitation Techniques
Rehabilitation is also an essential part of
treatment in neuropathic pain (Table 3). The main
aims of rehabilitation are to decrease pain and
amount of medication, improve dysfunction, increase quality-of-life and physical activity, and bring
the patient’s self-esteem back. Although one of the
major parts of rehabilitation methods is therapeutic
exercise, there is no sufficient evidence supporting
this idea in the treatment of neuralgia. Many kinds
of therapeutic exercises have already been used in
the rehabilitation program such as conditioning,
strengthening, and stretching exercises. Kuphal
et al.31 developed a neuropathic pain model in rodents by making a peripheral nerve injury in their
sciatic nerve and showed that 25 days of exercises in
water and swimming decreased pain. In this study,
extended exercises in water and swimming have
been shown to reduce edema, inflammation, and
peripheral neuropathic pain in this animal model.
The purposes of psychotherapy are to treat
emotional, behavioral, or mental dysfunction; remove negative symptoms such as anxiety or depression; modify or reverse problem behaviors; help the
individual cope with situational crises such as bereavement, pain, or prolonged medical illnesses;
TABLE 3 Rehabilitation techniques used in
neuropathic pain and their indications
Rehabilitation Techniques
Cognitive behavioral
therapy
Relaxation techniques
Acupuncture
Mirror therapy
GMI
Visual illusion
Indications
Elderly patients with
neuropathic pain
Chronic pain
SCI
Phantom pain
CRPS
Stroke
Stroke
SCI
Am. J. Phys. Med. Rehabil. & Vol. 93, No. 3, March 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
improve the individual’s relationships; manage conflict; and enhance positive personality growth and
development. In a study done by Turk et al.,32 psychosocial treatment approaches, cognitive behavioral
methods, and the prevalence of emotional stress have
been investigated and the effectiveness of psychologic
treatment has been evaluated. It showed that psychosocial support increases the efficacy of treatment.
Psychosocial management programs should be added
to standard therapy regimens in neuropathic pain.
The primary goal of cognitive behavioral therapy is to
find and correct the negative, irregular, and irrational
thoughts that have become automatic by being repeated. Automatic thoughts come into mind when a
person experiences a new thing or recalls a past event.
In persons with depression and anxiety, negative
automatic thoughts are experienced more often. The
use of cognitive behavioral therapy is gradually increasing in neuropathic pain. Especially in elderly
patients, relaxation techniques, the accurate planning of activity-rest cycles, cognitive reconstruction,
meditation, and distraction techniques can be used.33
Relaxation therapy is a process that focuses on using a
combination of breathing and muscle relaxation to
deal with stress. Relaxation therapy is useful in decreasing anxiety, autonomic hyperactivity, and muscle tension. Their adaptability for use at home and in
other environments is another advantage. Progressive muscle relaxation, imaging, controlled breathing,
or listening to relaxation tapes has been started to be
used in chronic pain although there is still not enough
evidence for its effects on neuropathic pain. There is no
clear evidence about the effectiveness of acupuncture
on neuropathic pain as well. Cha et al.34 investigated
the healing effect of acupuncture in neuropathic pain
induced in rats and found out that acupuncture is
effective in the treatment of neuropathic pain. Rapson
et al.35 applied electroacupuncture to 36 SCI patients
with neuropathic pain five times a week for 30 mins
and suggested that pain intensity decreased after
therapy and that there were no side effects.
It is now well known that in various cases of
chronic pain such as phantom limb pain and chronic
low back pain, the organization of the primary somatosensory cortex changes.36 Mirror therapy and
graded motor imagery (GMI) are rehabilitation procedures developed with the hope of correcting this
disorganization and thus decreasing the pain. Mirror
therapy is one of the rehabilitation methods that is
widely used in patients with neuropathic pain. In
mirror therapy, the patient puts his/her affected limb
into a mirror box and keeps the unaffected side in
front of the mirror. The unaffected limb in front
of the mirror makes simple movements, and the pawww.ajpmr.com
tient imagines doing the same movements with the
affected limb. Although the pain may increase at the
time, the patient tries to tolerate it. This method has
been used in patients with stroke, phantom limb
pain, and complex regional pain syndrome (CRPS)
and found effective in increasing upper extremity
functionality.37 During these studies, decrease in
pain accompanied functional improvement. Therefore, studies have been designed to further investigate
the effect of mirror therapy in neuropathic pain.
McCabe et al.38 did a study on eight patients with
CRPS type 1, in whom mirror therapy has been applied. They found that it was effective in decreasing
pain in the patients who had the condition for less
than 8 wks, whereas it was effective in reducing
only stiffness in the patients who had this condition for less than a year. However, in cases of CRPS
lasting more than 1 yr, it was not effective. In another
randomized controlled trial with 22 patients with
amputated limbs, 4 wks of mirror therapy were
compared with covered mirror therapy (sham mirror
therapy) and mental imagery.39 There was a significant decrease in the VAS in the mirror therapy group
compared with the others. In a similarly designed
study done by Caccio,40 24 patients with stroke were
given 4 wks of mirror therapy, sham mirror therapy,
and mental imagery. There was also a significant
difference only with mirror therapy. GMI is a comprehensive program designed to sequentially activate
cortical motor networks and improve cortical organization in three steps: laterality training, imagined
hand movements, and mirror visual feedback.41
There is one randomized controlled trial done by
Moseley42 in CRPS type 1 patients who received GMI
for 6 wks, 2 wks in each step, and compared with
conventional physical therapy and medication. The
study was done with 51 patients and showed significant decrease in pain in the GMI group compared
with other groups. However, a study by Johnson
et al.43 failed to show the effectiveness of GMI in
CRPS patients. Instead, in this study, one patient
even reported an increase in pain intensity. Although mirror therapy and GMI are promising new
ways of rehabilitation in the treatment of neuropathic
pain, there is definitely a need for more evidence.
Moseley44 has done another interesting study
that uses visual feedback through creating a visual
illusion and compares its effectiveness with other
experimental therapies such as guided imagery and
watching another person walking. This study is also
based on the principle of disorganization of the
primary somatosensory cortex. In this study, five
paraplegic patients with SCI were taken, and first,
the three different therapies mentioned above were
Management of Neuropathic Pain
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257
applied. In visual illusion, the patients’ body from
waist above were reflected in a mirror and the legs
of the patients were blocked. Instead, an image of a
man walking on a treadmill was reflected where the
patients’ legs were supposed to be. The patients
were also encouraged to move their body accordingly. The pain, foreignness, and heaviness levels
were all measured by the VAS, and these were all
decreased in the visual illusion technique compared
with others. After this, four patients received visual
illusion therapy for 15 days consecutively; their
pretask pain and the duration of pain relief all increased during these 15 days. This study also shows
that there is much area for improvement of these
kinds of problems, and many techniques can be
developed using visual feedback.
As a conclusion, physical therapy modalities
such as superficial and deep heat agents, analgesic
currents, and laser are not sufficient in the management of neuropathic pain when applied alone.
Even though neurostimulation techniques are
being used more frequently, their effectiveness in
the treatment of neuropathic pain are still disputed.
Rehabilitation programs must be emphasized and
combined with pharmacotherapy in daily practice.
The emotional component of neuropathic pain is
more striking and cannot be controlled by pharmacotherapy alone. Rehabilitative methods that are
effective in treating pain behavior such as cognitive
behavioral therapy, psychotherapy, virtual reality,
and GMI increase overall treatment success. Pain
rehabilitation techniques seem promising in the
management of neuropathic pain; however, there is
a requirement for more randomized controlled
trials with larger patient groups.
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