1.Neuropathic pain affects quality of life 

Neuropathic pain (NP) is a common and often complex clinical presentation, defined as ‘pain caused by a lesion or disease of the somatosensory system’ (IASP 2021). 

Distinct from other pain types such as nociceptive and nociplastic pain, NP represents a significant public health issue due to its impact on quality of life. 

It can present with a range of symptoms, including pins and needles, numbness, tingling, burning and electric shock-type pain (Rugnath et al 2024). 

Neuropathic pain affects approximately seven to 10 per cent of the population (Baskozos et al 2023), with a higher prevalence in women than men (Torrance et al 2006). 

Neuropathic pain is associated with substantial psychological impacts including anxiety, depression and sleep disturbances. 

Symptoms are frequently severe, often becoming chronic, and can have a significant impact on an individual’s quality of life (Bernetti et al 2021). 

2. A range of conditions can result in NP 

The overarching definition of NP encompasses insult to the central or peripheral somatosensory nervous system. 

However, clinical manifestation of NP symptoms can vary significantly depending on the nature of the pathology and the anatomical structures implicated. 

NP can be caused by mechanical compression of neural structures, direct trauma, metabolic or inflammatory diseases, neurotoxic agents (eg, medications, excessive alcohol consumption, chemotherapy) or vascular insufficiency. 

Pathologies of the central nervous system giving rise to NP include cerebrovascular accidents (eg, central post-stroke pain), spinal cord injury and neuroinflammatory conditions such as multiple sclerosis. 

Radicular NP commonly originates from cervical or lumbar spine pathologies including intervertebral disc herniation, spondylolisthesis and osteoarthritis. 

Such conditions can compromise spinal nerves or nerve roots (Schoenfeld et al 2012). 

NP may also be caused by peripheral nerve injuries resulting from a range of mechanisms, including direct trauma, traction injuries (eg, ‘stingers’ of the brachial plexus), entrapment and compression (eg, carpal tunnel syndrome). 

People with diabetes are susceptible to the development of NP and prevalence estimates of 20–30 per cent have been reported (Abbott et al 2011). 

Individuals tend to develop symptoms distally and symmetrically in the lower limbs, eg, pins and needles and/or burning in the feet. 

Over time, the upper limbs can also be affected distally (Said 2007). 

Neuralgia is a type of neuropathic pain characterised by recurring, unilateral, paroxysmal pain (HCCIHS 2018) lasting from a second to two minutes along a specific nerve distribution, most commonly the trigeminal nerve (Jeong et al 2026). 

Neuralgia can also arise following viral infection, eg, HIV, herpes zoster virus, coronavirus and cytomegalovirus (Xu et al 2024). 

Common clinical presentations associated with viral mechanisms include Bell’s palsy and shingles. 

3. There are complex mechanisms in persistent NP 

The physiological processes that contribute to chronic NP (ie, when present for three months or more) are complex and vary depending on the nature of the underlying disease and injury. 

However, chronic neuropathic pain is understood to involve a complex interaction between sensitisation of the central and peripheral nervous systems, neuroinflammatory processes and dysfunction of descending nociceptive modulatory systems (ie, the ‘top-down’ brain to periphery system that can inhibit the nociception and therefore the experience of pain) (May & Serpell 2009). 

4. NP can be assessed clinically 

NP can be difficult to diagnose because many pains can have neuropathic characteristics. 

It is also possible to have mixed nociceptive, neuropathic and/or nociplastic pain.

The degree of injury or pathology rarely correlates with the intensity of pain experienced (May & Serpell 2009). 

For physiotherapists to diagnose NP, a thorough subjective and objective examination is essential. 

NP is often described as a burning and shooting pain, with electriclike sensations. 

A key subjective feature is pain associated with somatosensory symptoms. 

These can be classed as either ‘loss’ or ‘gain’ signs. 

Loss signs include hypoaesthesia (numbness or reduced sensation) within the distribution of the affected nerve. 

Gain signs include paraesthesia (crawling, tingling sensations), hyperalgesia (an increased sensitivity to noxious stimuli), allodynia (pain in response to non-noxious stimuli) and summation (pain that progressively worsens with repetitive stimulation) (Bannister et al 2020, Ahmadi et al 2024). 

Certain conditions can be diagnosed based on the distribution of these loss and gain signs. 

Objective assessment includes examination of sensation, motor function, reflexes and coordination. 

Patient-reported outcome measures such as the DN4 Questionnaire, the LANSS Pain Scale and PainDETECT can be very useful, particularly in conjunction with a clinical assessment. 

In some cases, investigations may be required to confirm diagnosis, exclude serious pathology or guide treatment planning. 

These might include MRI, CT and nerve conduction studies. 

5. Physiotherapy is integral to NP management 

NP can have a significant impact on an individual’s mood, quality of life, function and independence. 

A holistic, multidisciplinary approach is recommended, with the aim of reducing disability and improving quality of life (Bernetti et al 2021). 

While there is limited evidence to support the management of NP, recent studies show that physiotherapy treatments may provide modest but meaningful improvements in pain, disability and quality of life. 

Physiotherapy appears to be a very safe treatment choice, with minimal adverse events reported in the literature (Jesson et al 2020). 

Physiotherapy treatment of NP can include a combination of education and ‘sense making’, ie, helping the person to understand their pain; sensory and motor training, aiming to prevent and/or reverse changes in sensation, strength, coordination and motor function; balance retraining; aerobic exercise, which can improve general health and physical reconditioning and potentially facilitate pain modulation via descending pathways as well as addressing any neural mechanosensitivity (eg, with nerve sliders and tensioners); and manual therapy in the tissues surrounding the affected nerve (Jesson et al 2020). 

There is also some evidence to support the use of transcutaneous electrical nerve stimulation for localised peripheral neuropathy and diabetic neuropathy (Bernetti et al 2021). 

Beyond symptom management, physiotherapists are well placed to support people with NP to return to work and valued activity. 

This includes engaging in exercise and enjoying its social, recreational and health benefits (Jesson et al 2020).

>>Zoë Harper MACP is an APA Titled Pain Physiotherapist and an APA Titled Musculoskeletal Physiotherapist. Zoë is the senior clinician physiotherapist and clinical coordinator at the Barbara Walker Centre for Pain Management at St Vincent’s Hospital Melbourne. She is the chair of the APA Pain national group. 

>>Karri Field MACP is an APA Titled Pain Physiotherapist and the physiotherapy principal at the Headache, Neck and Jaw Clinic in Brisbane. Karri is the chair of the Queensland branch of the Pain group. 

>>Cameron Dickson MACP is an APA Titled Pain Physiotherapist and an APA Titled Research Physiotherapist. Cameron is a lecturer and researcher in physiotherapy at Adelaide University. He is the chair of the South Australian branch of the Pain group.

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