Behavioural Neurology / 2019 / Article / Tab 4

Review Article

Therapeutic Approaches for Peripheral and Central Neuropathic Pain

Table 4

Nonpharmacological therapeutic options for neuropathic pain.


Interventional therapies
Nerve blockadeDrug-refractory NPLocal anaesthetics or combination with opioids, clonidine, or steroids; inconclusive recommendation[2, 79, 80]

Epidural corticosteroid injectionDrug-refractory painful radiculopathyMethylprednisolone, triamcinolone, betamethasone, dexamethasone; moderate quality of evidence; weak strength of recommendation[2, 79, 80]

Sympathetic nerve/ganglion treatmentIntractable NPBlockade, neurolysis, or neuroablation[2, 7981]

Intrathecal drug deliveryDrug-resistant NPMorphine, ziconotide[2, 80, 82, 83]

Peripheral nerve/field stimulationIntractable low back painSubcutaneous application[8487]

Transcutaneous electrical nerve stimulation (TENS)Intractable NPVery low level of evidence[8789]

Dorsal root ganglion stimulationDrug-refractory CRPS and causalgia of the lower limbHigh level of evidence[87, 91]

Spinal cord stimulation (SCS)Drug-refractory painful diabetic neuropathy, truncal PHN, SCI-associated NP, CPSP, FBSS with radiculopathy, CRPS I and IIWeak recommendation[80, 87, 92]

Epidural motor cortex stimulationIntractable NPWeak recommendation[87, 92]

Repetitive transcranial magnetic stimulation (rTMS) of the primary motor cortexIntractable NPWeak recommendation[87, 92]

Transcranial direct current stimulation (tDCS) of the primary motor cortexIntractable NPWeak recommendation[87, 92]

Deep brain stimulation (DBS); repetitive transcranial magnetic stimulation (rTMS) of the dorsolateral prefrontal cortex; transcranial direct current stimulation (tDCS) of the dorsolateral prefrontal cortexIntractable NPInconclusive[87, 92]

Transcranial direct current stimulation (tDCS) of the primary motor cortexIntractable spinal cord injury-associated NPInconclusive[87, 92]

Physical therapies
Heat and cold applications, fluidotherapy, whirlpool, massage, ultrasound, short-wave diathermy, low-frequency currents (e.g., TENS, diadynamic currents and interferential currents), high-voltage galvanic stimulation, laserSpinal cord injury-associated NP, chronic postsurgical pain, painful radiculopathies, and painful diabetic neuropathyInconclusive[93]

Rehabilitation techniques (relaxation techniques, acupuncture, mirror therapy, graded motor imagery, visual illusion)Spinal cord injury-associated NP, phantom pain, CRPS, and chronic poststroke NPNot well-established[2, 93]

Exercise trainingAll types of NPBeneficial effect[94]

Exercise therapy combined with psychological therapyPainful diabetic neuropathyModerate effect[95]

Psychological therapies
Cognitive behavioural therapy (CBT)Chronic NP; painful diabetic neuropathy, cancer-associated NP, HIV-associated NPEffective in improving mood and catastrophizing outcomes; good practice point[2, 96, 101]

Internet-delivered psychological therapiesNonheadache chronic painSimilar effect to that of conventional face-to-face psychological intervention[97]

HypnosisChronic phantom limb pain, spinal cord injury-related NP, and multiple sclerosis-associated NPLow level of evidence[101]

Abbreviations: CRPS = complex regional pain syndrome; HIV = human immunodeficiency virus; NP = neuropathic pain.

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