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Letter to the BMJ – Neuropathic pain – Management is more than pills



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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.

Letter to the BMJ 2009,339:b3502

Michael Thacker, senior lecturer(a), G Lorimer Moseley, NHMRC senior research fellow(b), Herta Flor, professor(c)
(a) Academic Department of Physiotherapy and Wolfson Centre for Age Related Diseases, King’s College London, London,
(b) Prince of Wales Medical Research Institute and Faculty of Medicine, University of New South Wales, Sydney, Australia,
(c) Department of Clinical and Cognitive Neuroscience, University of Heidelburg, Heidelburg, Germany


1. Freynhagen R, Bennett MI. Diagnosis and management of neuropathic pain. BMJ 2009;339:b3002.
2. Daly A, Bialocerkowski A. Does evidence support physiotherapy management of adult complex regional pain syndrome type one? A systematic review. Eur J Pain 2009;13:339-53.
3. Moseley GL. Graded motor imagery for pathologic pain—a randomized controlled trial. Neurology 2006;67:2129-34.
4. Turk DC. Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. Clin J Pain 2002;18:355-65.
5. Flor H, Denke C, Schaefer M, Grusser S. Effect of sensory discrimination training on cortical reorganisation and phantom limb pain. Lancet 2001;357:1763-4.

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