anno: 2016 lavoro: 4538-EJprM Mese: december titolo breve: trEatMENt of NEuropathic aNd phaNtoM liMb paiN Volume: 52 primo autore: fErraro No: 6 pagine: 855-66 rivista: European Journal of physical and rehabilitation Medicine citazione: Eur J p hys rehabil Med 2016;52:855-66 cod rivista: Eur J p hys rehabil Med , © COPYRIGHT 2016 EDIZIONI MINERVA MEDICA © 2016 EdiZioNi MiNErVa MEdica online version at http://www.minervamedica.it European Journal of physical and rehabilitation Medicine 2016 december;52(6):855-66 SPECIAL ARTICLE THE ITALIAN CONSENSUS CONFERENCE ON PAIN IN NEUROREHABILITATION - PART II dIagnosIs and treatment of paIn In plexopathy, radiculopathy, peripheral neuropathy and phantom limb pain Evidence and recommendations from the italian consensus conference on pain on Neurorehabilitation francesco fErraro 1 *, Marco JacopEtti 2, Vincenza spalloNE 3, luca padua 4, 5, Marco traballEsi 6, stefano bruNElli 6, cristina caNtarElla 7, cristina ciotti 7, daniele coraci 8, Elena dalla toffola 9, 10, silvia MaNdriNi 9, Giovanni MoroNE 6, costanza paZZaGlia 5, Marcello roMaNo 11, angelo schENoNE 12, rossella toGNi 9, stefano taMburiN 13 on behalf of the italian consensus conference on pain in Neurorehabilitation (iccpN) 1section of Neuromotor rehabilitation, department of Neuroscience, asst carlo poma, Mantova, italy; 2university of parma, parma, italy; 3department of systems Medicine, university of tor Vergata, rome, italy; 4department of GerIatrIcs, NeuroscIences and orthopaedics, catholic university, rome, italy; 5don carlo Gnocchi foundation, Milan, italy; 6irccs santa lucia foundatIon, rome, italy; 7physical and rehabilitation Medicine unit, university of tor Vergata, rome, italy; 8department of orthopedics, sapIenza university, rome, italy; 9department of clinical, surgical, diagnostic and pediatric sciences, university of pavia, pavia, italy; 10physIcal Medicine and rehabilitation unit, irccs policlinico san Matteo foundation, pavia, italy; 11Neurology Unit, Villa Sofa Cervello hospitals, palermo, italy; 12department of Neuroscience, rehabilitation, ophthalmology, Genetics, and Maternal and child health (diNoGMi), university of Genoa, Genoa, italy; 13department of Neurosciences, biomedicine and Movement sciences, unIversIty of Verona, Verona, italy *corresponding author: francesco ferraro, section of Neuromotor rehabilitation, department of Neuroscience, asst carlo poma, presidio di riabilitazi- one Multifunzionale di bozzolo, Via XXV aprile 71, 46012 bozzolo (MN), italy. E-mail: [email protected] abstract pain may affect all aspects of social life and reduce the quality of life. Neuropathic pain (Np) Is common in patients affected by plexopathy, radiculopathy, mononeuropathy, peripheral neuropathy. phantom limb pain (plp) is a painful sensation that is common after amputation, and its pathophysiological mechanisms involve changes in the peripheral and central nervous system. Given the lack of conclusive evidence and specifc guidelines on these topics, the aim of the italian consensus conference on pain on Neurorehabilitation (iccpN) was to collect evidence and offer recommendations to answer currently open questions on the assessment and treatment of Np associated with the above conditions and plp. When no evidence was available, recommendations were based on consensus between expert opinions. current guidelines on the assessment and pharmacological treatment of Np can be applied to plexopathy, radiculopathy, mononeuropathy, peripheral neuropathy, while evidence for invasive treatments and physical therapy is generally poor because of the low quality of studies. treatment of plp Is still unsatisfactory. data on the functional outcome and Impact of pain on neurorehabilitation outcome in these conditions are lacking. in most cases, a multidisciplinary approach is recommended to offer a better outcome and reduce side effects. high quality studies are requested to address the unmet needs in this feld. (Cite this article as: ferraro f, Jacopetti M, spallone V, padua l, traballesi M, brunelli s, et al.; italian consensus conference on pain in Neurore- habilitation (iccpN). diagnosis and treatment of pain in plexopathy, radiculopathy, peripheral neuropathy and phantom limb pain. Evidence and recommendations from the italian consensus conference on pain on Neurorehabilitation. Eur J phys rehabil Med 2016;52:855-66) Key words: pain - brachial plexus neuropathies - radiculopathy - Mononeuropathies - peripheral nervous system diseases - phantom limb. Vol. 52 - No. 6 EuropEaN JourNal of physical aNd rEhabilitatioN MEdiciNE 855 This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted personal for use to download and only save one file and print only one of copy (either either this sporadically printedArticle. or or systematically, electronic) of the Article any for purpose. It is not permitted to make additional copies It is not permitted to distribute the electronic of copy the article through online internet and/or intranet file sharing systems, electronic mailing or means any other which allow may access to the Article. The use of all or any part of the Article any for Commercial Use is not permitted. The creation of works derivative from the not Articlepermitted. is not permitted. obscure, or block, change It any copyright is notices not or The overlay, permittedtermsproduction of to cover, of reprintsremove, use which personal for the or Publisher commercial post may use on is the Article. It is not permitted to frame or use framing techniques to or enclose other any proprietarytrademark, logo information of the Publisher. , © COPYRIGHT 2016 EDIZIONI MINERVA MEDICA fErraro trEatMENt of NEuropathic aNd phaNtoM liMb paiN Introduction was scored according to a scale from a to good practice ain may infuence mood, sleep, activities of daily point (Gpp) and is reported in parentheses after each 8 plife, and social activities, thus reducing the patient’s recommendation. We systematically searched pubMed quality of life (Qol).1 Neuropathic pain (Np) is caused and EMbasE using the key words pain, neuropathic by a lesion or disease of the somatosensory system.2, 3 pain, peripheral neuropathy, plexopathy, radiculopathy, Nociceptive pain commonly derives from the involve- mononeuropathy, methods, evaluation, pain assess- ment of musculoskeletal structures, and biomechanical ment, measurement, standardized criteria, classifcation, alterations secondary to neurological diseases.3 Mixed defnition, predictive factors, drug, (pharmacological) pain may result from the coexistence of conditions and/ therapy/treatment, surgical treatment, rehabilitation, or mechanisms of nociceptive and Np.3, 4 physical therapy carpal tunnel syndrome, ulnar nerve damage to different components of the peripheral entrapment, tarsal tunnel syndrome, predictors, ampu- nervous system (pNs), including plexopathy, radicu- tation, amputees, phantom limb, corresponding Mesh lopathy and mononeuropathy, regardless of the etiology, when available, and all the possible combinations of may cause Np that results in disability, reduced partici- these keywords for original research studies published pation in daily life activities, impaired Qol,1 and may from 1993 to 2013, and from 1983 to 2013 for papers on limit the effcacy of neurorehabilitation procedures. Ra- treatment. later on, the search was updated to 2015 and diculopathy is frequently associated with mixed pain, some selected papers were added to the review. a con- because of the coexistence of Np secondary to radicu- sensus was reached to obtain recommendations from lar damage and nociceptive pain deriving from osteo- current evidence, and expert opinion when no evidence articular structures, such as intervertebral disc, facets, was available. joints, or ligaments.5 the large number of underlying etiologies, the variety of clinical features and neuro- Results and recommendations physiological changes, as well as the biopsychosocial variables, may cause a delay in diagnosing pain in pNs Question 6.1. What are the main characteristics of pain diseases, thus facilitating pain chronicization, which in in plexopathy, radiculopathy, mononeuropathy, pe- turn may reduce the therapeutic response.6 ripheral neuropathy and phantom limb pain? phantom limb pain (plp) is the subjective experience PlexoPathy, radiculoPathy and mononeuroPathy of persistent painful perception of a physical segment of the body after its amputation. New fndings on its un- Np represents the most common type of pain in derlying neurophysiological mechanisms changed the plexopathy, radiculopathy, and mononeuropathy. pa- view of plp from a psychogenic phenomenon and/or a tients with radiculopathy, however, may experience pNs condition to a process where central nervous sys- mixed pain, where nociceptive pain secondary to disc tem plasticity plays a key role, offering new premises herniation, facet joint disease, and other osteoarticular for neurorehabilitation approaches, despite the treat- conditions may coexist with Np. Np is described as lan- ment of this condition is still debated.7 cinating, stabbing, or shooting, with the possible pres- the aim of the italian consensus conference on pain ence of hyperalgesia to thermal and punctate stimuli on Neurorehabilitation (iccpN) is to collect evidence and allodynia to mechanical stimuli.9 paroxysmal pain, and offer recommendations to answer open questions allodynia and constant spontaneous pain are frequently on the assessment