Mechanistic-Based Treatment for Common Neuropathic Pain and the Treatment Dilemma of the Elderly

Abstract

Neuropathic pain is a complicated disorder. This complexity arises not because the characteristics of the pain differ from nociceptive inflammatory symptoms, but because of its complex mechanism. Peripheral transduction, ectopic impulse, central sensitization, low threshold A-beta fiber mediated pain, and loss of inhibitory control all play a role in the mechanism. Nevertheless, the outcomes are still unsatisfactory for physicians and patients with regards to treatment. For example, certain disorders such as central post-stroke pain are extremely difficult to treat, not only because of the intolerable side effects of the medications but also because of the unknown effectiveness of pain reduction, especially in the elderly. Under-treatment frequently occurs in the absence of attention to the pain characteristics, and because physicians are concerned of adverse effects or inappropriate up-titration of neuropathic drugs such as anti-epileptic medicines. Multidisciplinary approaches including non-pharmacological management, rehabilitation, biofeedback, acupuncture, education on stepwise pain reduction, and keeping a diary are somewhat helpful in clinical practice but not easily implemented without the cooperation of multidisciplinary teams. Physicians prescribe opioids to alleviate the symptoms, however this carries the risk of addiction. Therefore, it is important that clinicians are made aware of common neuropathic disorders in order to establish strategies to manage such types of pain.