Letters Neuropathic pain

Management is more than pills

BMJ 2009; 339 doi: http://dx.doi.org/10.1136/bmj.b3502 (Published 01 September 2009) Cite this as: BMJ 2009;339:b3502
  1. Michael Thacker, senior lecturer1,
  2. G Lorimer Moseley, NHMRC senior research fellow2,
  3. Herta Flor, professor3
  1. 1Academic Department of Physiotherapy and Wolfson Centre for Age Related Diseases, King’s College London, London
  2. 2Prince of Wales Medical Research Institute and Faculty of Medicine, University of New South Wales, Sydney, Australia
  3. 3Department of Clinical and Cognitive Neuroscience, University of Heidelburg, Heidelburg, Germany
  1. michael.thacker{at}kcl.ac.uk

    We have one important caveat in relation to Freynhagen and Bennett’s review—that evidence based non-pharmacological treatment for neuropathic pain was absent.1

    Several randomised controlled trials show that graded motor imagery reduces pain and disability in chronic complex regional pain syndrome 1 (CRPS1) and phantom limb pain after amputation or brachial plexus avulsion injury.2 The number needed to treat for a 50% decrease in pain and a four point drop on a 10 point scale of disability is around 4,3 which compares favourably with any other treatment for chronic CRPS1, including spinal cord stimulation.1 Cognitive behavioural programmes reduce disability and pain in a range of neuropathic pain states,4 and sensory discrimination training reduces pain in chronic phantom limb pain and possibly chronic CRPS1.5

    These treatments were devised, and continue to be refined for people with chronic neuropathic pain, since the discovery of robust and profound changes within the central nervous system, including the brain. Continuing progress in this field suggests that we can train the brain and reduce pain and disability.

    Freynhagen and Bennett state that traditional acupuncture in neuropathic pain is not supported by current evidence but imply support for acupuncture on the basis that it is comparatively harmless. Other comparatively harmless non-pharmacological treatments with level I or II evidence of efficacy were not mentioned. We believe that general practitioners and clinicians should be aware of all the evidence based pharmacological and non-pharmacological treatments available to patients with neuropathic pain, not just the pills.


    Cite this as: BMJ 2009;339:b3502


    • Competing interests: None declared.