Integrative medicine approach to neuropathic pain treatment – effective pain control with pharmacotherapy and acupuncture

Kocot-Kępska M, Dobrogowski J, Zajączkowska R, Wordliczek J, Przeklasa-Muszyńska A.

Aim
The aim of this paper is to present effective pain control with combination of standard antineuropathic analgesics and acupuncture in patient with severe neuropathic pain following traumatic left brachial plexus avulsion. Neuropathic pain after brachial plexus avulsion is one of the most challenging neuropathic pain syndromes for clinicians, mainly due to complex pathogenesis (peripheral and central component) and lack of satisfactory treatment. Standard antineuropathic drugs are effective in less than 50% patients, intervention techniques are not easily available, thus the integrative medicine approach may be beneficial in certain clinical situations.

Case history
The male patient AB, aged 47, had in 2012 a motorcycle accident with polytrauma (brain injury, left brachial plexus avulsion, multiple bone fractures). In 2018 patient was referred to Pain Clinic in Kraków due to severe, intractable pain of left upper limb.
Pain characteristics:
•	Constant pain (NRS 5) with paroxysms (NRS 10) 10-15 times per day 
•	Paroxysms evoked by emotional stress and cold 
Clinical examination of left upper limb revealed trophic changes of skin, muscle atrophy and weakness, sensory abnormalities – decreased touch and cold sensations.
Clinical diagnosis – neuropathic pain due to left brachial plexus avulsion
Patient reported that nothing relieved the pain and the pain negatively influenced daily activities.
Before referral to Pain Clinic patient was treated with amitriptiline (50 mg OD) and gabapentin (600 mg TID), but ineffectively.
Treatment applied in Pain Clinic:
1.	Increase in doses of amitriptyline (75 mg OD) and gabapentin (800 mg TID) – increased doses were not effective, additionally induced side effects, but tapering off resulted in pain exacerbation
2.	Intravenous infusions of lidocaine 5 mg/kg OD – not effective 
3.	Tapentadol 100  mg BID – partially effective, 20% pain relief of pain paroxysms, no AE
4.	Acupuncture – 30% pain relief (constant and paroxysmal), but only during needle application in HeGu (LI4) point
Treatment continuation:
•	Amitriptiline 50 mg OD, gabapentin 600 TID, tapentadol 100 mg BID
•	acupuncture with semi-permanent needles (Pyonex) inserted in HeGu point (5 days on, 2 days off) – needle application performed by the patient trained by acupuncturist from Pain Clinic
•	Physiotherapy

Results 
Clinical outcome:
•	Mild constant pain, not interfering with daily activities – maximum NRS 3
•	50% less pain paroxysms, less intensity of paroxysms (NRS 6)
•	Better functioning at home and better general well-being (patient’s self-report)
•	No tolerance to analgesic effect of acupuncture observed

Conclusions
In clinical settings, especially in patients with intractable, severe pain of neuropathic origin, integrative medicine approach should be always considered, and may result in better pain control and better patients’ well-being. Acupuncture may be recommended due to its low invasiveness, low costs, but high safety and patients’ acceptance.

INTEGRATIVE MEDICINE APPROACH TO NEUROPATHIC PAIN TREATMENT - EFFECTIVE PAIN CONTROL WITH PHARMACOTHERAPY AND ACUPUNCTURE