Rehabilitation
When activity-limiting pain is decreased by the use of medication,
surgery, nerve blocks, and primary physical therapy, the expectation is that the
patient's range of activity will increase. Because many patients with neuropathic
pain become physically deconditioned and emotionally devastated, assisted treatment
aimed at physical and psychosocial rehabilitation is often necessary. Physical therapy
includes many modalities for easing pain including heat, ice, massage, and ultrasound.
Transcutaneous Electrical Nerve Stimulation
One of the most versatile treatment devices is transcutaneous
electrical nerve stimulation (TENS).[139]
Basically,
this is a non-medication, non-invasive, cutaneous, portable therapy which the patient
"controls"—that is, he or she decides the frequency and duration of use as
well as the frequency and strength of the stimulation from the battery-powered unit.
The physical basis for TENS is that the hyperstimulation of the nervous system drowns
out the pain.[26]
[139]
[140]
There is also activation of the descending
pain modulation system in the CNS, and some mediation of pain by neurotransmitters
such as adenosine and endorphins. Because TENS has few if any
side effects, it is highly recommended as an adjunct therapy for patients with neuropathic
pain.
As with other forms of stimulation-produced analgesia, such as
acupuncture and massage, the TENS electrodes are usually placed near the painful
area. The stimulators provide low-intensity stimuli of 5 to 200 Hz, which produce
a tingling or vibration sensation. TENS seems to work best in patients with musculoskeletal
pain, peripheral nerve injuries, phantom pain, and stump pain, whereas it is less
effective in patients with post-surgery spinal pain. TENS is not effective in most
patients that have no peripheral nociceptive source for their pain, such as central
pain states and psychosocial-based pain, and in those with physiologic or psychologic
dependence on drugs.
Acupuncture
Acupuncture can be thought of as one of a plethora of complementary
therapies for pain management.[141]
[142]
Previously, the term "alternative medicine" was used, but this seemed to bias patients
by creating the impression that such treatments were experimental or less than valuable.
Acupuncture is a minimally invasive technique founded in Eastern medicine that has
neurophysiologic consequences related to the augmentation of neural input or the
provocation of modulating physiologic influences.[141]
[142]
The focus of sensory input is created by
the
insertion of needles into specific points along lines of energy, called meridians,
on the body's surface. Today, gentle electrical current may be applied to the needles,
rather than their simply being placed and/or twirled.
The added expense of a therapist makes acupuncture less available
than TENS, but the public demand for it and other complementary therapies is high.
[143]
Recent reviews have been critical of acupuncture,
but it has been endorsed by the National Institutes of Health for nausea and vomiting
associated with pregnancy, surgery, and chemotherapy, as well as having a role in
managing postoperative dental pain.[144]
Chiropractic Therapy
Chiropractic therapy is another popular therapy that is sought
by many but which needs further study.[145]
