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Saturday, 30 November 2013

Neuralgia Treatments In conventional medicine perspective

Neuralgia is defined as a condition of a sudden and heavy attacks of pain that follows the path of a nerve or nerves as a result of a change in neurological structure or function due to irritation or damage to the nerves without stimulating pain receptor (nociceptor) cells. the disease affects about 2%–3% of the population.
A. In conventional medicine perspective
A.1. Medical treatment
Dr. Masudai. in the study of Diagnosis and treatment of trigeminal neuralgia suggested  "Trigeminal neuralgia is a disease affecting older individuals. The clinical hallmark of trigeminal neuralgia is a sudden, excruciating paroxysm of pain in the area of the trigeminal nerve. Drug therapy is considered the first line of treatment for trigeminal neuralgia. Anticonvulsant carbamazepine has been used. If relevant pharmacotherapy has been tried without any effect, other procedures are selected. These procedures are microvascular decompression(a radical technique), glycerol trigeminal rhizotomy, percutaneous trigeminal nerve decompression and nerve block. Nerve block with neurolytic solutions and radiofrequency thermocoagulation is a simple, less invasive therapy. In order to avoid hypesthesia and dysesthesia, nerve block using a high concentration of local anesthetics is recommended. In recent years, stereotactic radiosurgery for trigeminal neuralgia has emerged as a new therapeutic modality(55)

Other suggested that First-line treatments for PHN include tricyclic antidepressants, gabapentin and pregabalin, and the topical lidocaine 5% patch. Opioids, tramadol, capsaicin cream, and the capsaicin 8% patch are recommended as either second- or third-line therapies in different guidelines. Therapies that have demonstrated effectiveness for other types of neuropathic pain are discussed, such as serotonin-norepinephrine reuptake inhibitors, the anticonvulsants carbamazepine and valproic acid, and botulinum toxin. Invasive procedures such as sympathetic blockade, intrathecal steroids, and implantable spinal cord stimulators have been studied for relief of PHN, mainly in patients refractory to noninvasive pharmacologic interventions. The main guidelines considered here are those issued by the American Academy of Neurology for the treatment of postherpetic neuralgia (2004) and general guidelines for the treatment of neuropathic pain issued by the Special Interest Group on Neuropathic Pain of the International Association for the Study of Pain (2007) and the European Federation of Neurological Societies (2010)(56)

B.2. Non Medication Treatment 
1. Exercise
Regular moderate aerobic exercise reversed signs of neuropathic pain and increased endogenous opioid content in brainstem regions important in pain modulation. Exercise effects were reversed by opioid receptor antagonists. These results suggest that exercise-induced reversal of neuropathic pain results from an up-regulation of endogenous opioids(57). 

2. Transcutaneous electrical nerve stimulation
Dr. Yameen F and the team at the Dow University of Health Sciences and Civil Hospital suhested that Out of 31 patients, 20 females and 11 males, with a mean age of 50.1 +/- 11 years, 26 (83.7%) improved significantly with application of TENS, only 5 (16.3%) patients remained unresponsive to this form of therapy. Study also showed a better efficacy of constant mode of therapy over burst mode. Transcutaneous electrical nerve stimulation is an effective, easy to use therapy with minimal side effects in patients suffering from trigeminal neuralgia not responding to conventional treatment(58).

3. Percutaneous electrical nerve stimulation
The study conducted by Dasmesh Institute of Research and Dental Sciences, showed that on visual analogue scale (VAS), the score decreased from 8.9 (Pre Transcutaneous electric nerve stimulation (TENS)) to 3.1 at 1 month and 1.3 at 3 months, and on verbal pain scale (VPS), the score decreased from 3.5 (Pre TENS) to 1.2 at 1 month and 0.3 at 3 months. Similarly, a considerable decrease in scores was seen on functional outcome scale for different activities. No side effects like irritation or redness of skin were seen in any of the patients(59).
4.  Graded motor imagery
Some reserachers suggested that Motor imagery reduced pain and disability in these patients with complex regional pain syndrome type I or phantom limb pain, but the mechanism, or mechanisms, of the effect are not clear(60).
5. Cognitive behavioural therapy
Fourteen studies were assessed: three randomized controlled trials, three controlled before-after studies, seven uncontrolled before-after studies and one time series analysis by Erasmus University Rotterdam, Dr, Wetering EJ, and the research team indicated that The findings of the meta-analysis were not consistent with a significant effect on pain intensity. Only one study had good methodological quality; it showed some significant effects of the interventions, but only in female participants. Other studies of limited methodological quality did report positive effects on pain and quality of life(61).

6. Etc.

B.3. Pharmacology is is the branch of medicine and biology concerned with the study of drug action. More specifically, it is the study of the interactions that occur between a living organism and chemicals that affect normal or abnormal biochemical function(62).
In a study to investigate pharmacologically a rat model of trigeminal neuropathic pain: baclofen, but not carbamazepine, morphine or tricyclic antidepressants, attenuates the allodynia-like behaviour, Dr. Juhana J Idänpään-Heikkilä and Dr. Gisèle Guilbaud showed that Pharmacological studies indicated that the mechanical hyper-responsiveness could be reversibly abolished by local injections of alphacaine into the close proximity of the injured nerve. The allodynia-like behaviour was resistant to i.v. morphine. Similarly, single and repeated injections (using the respective T1/2 as an interval) of tricyclic antidepressants amitriptyline and clomipramine were devoid of effects on the mechanical allodynia-like behaviour. Carbamazepine was effective only after doses (≥10 mg/kg s.c.) that already caused disturbances in motor co-ordination in the rotarod test. Repeated injections of baclofen (3 mg/kg s.c.) partially alleviated the mechanical allodynia-like behaviour without effects on rotarod performance. The partial anti-allodynic effect of a single injection (5 mg/kg) of baclofen, which was already accompanied by slight motor disturbances, could be antagonized by CGP35348, a selective GABAB-receptor antagonist. Functional deficits in the GABAergic system may play an important role in the pathogenesis of this purely sensory rat model of trigeminal neuropathic pain(63).

B.4. Surgery
Surgical interventions are used for trigeminal neuralgia only when drug treatment fails. Dr. Joanna M Zakrzewska and Dr, Harith Akram said in the study of Neurosurgical interventions for the treatment of classical trigeminal neuralgia "There is very low quality evidence for the efficacy of most neurosurgical procedures for trigeminal neuralgia because of the poor quality of the trials. All procedures produced variable pain relief, but many resulted in sensory side effects. There were no studies of microvascular decompression which observational data suggests gives the longest pain relief. There is little evidence to help comparative decision making about the best surgical procedure. Well designed studies are urgently needed"(64)
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