NNT, numbers needed to treat to achieve pain relief in 1 patient;

NNH, numbers needed to treat to harm in 1 patient; CI, 95% confidence interval.

NNT, numbers needed to treat to achieve pain relief in 1 patient;

NNH, numbers needed to treat to harm in 1 patient; CI, 95% confidence interval.

Topical Nitrate

A controlled study suggested that the local application to the feet of isosorbide dini-trate spray was effective in relieving overall pain and a burning discomfort of painful neuropathy (62). More recently, the use of nitrate patches has also been shown to be useful (63). However, both of these studies were small and single center and a multicenter trial is now indicated for this agent.


A preliminary study of topically-applied 5% lidocaine by a patch demonstrated improvements in pain and QoL outcomes during a 3-week treatment period (64). However, as this was not a controlled trial, a properly designed study is required before this can be recommended.

Psychological Support/Counselling

It is vital to provide all patients with a full explanation of their condition, to allay the fear and misconception often that they have some underlying malignancy, and informing them that the natural history might well be that the pain resolves in due course and that specific treatments are available for the pain in the short term, can be extremely helpful (23). Further evidence emphasizing the importance of comfort and support to improve painful symptomatology was provided in some preliminary observations of Kaye et al. (65) who also demonstrated that disappointment and failure of health care can result in intensification of painful symptomatology.


Several uncontrolled studies report significant benefits of acupuncture in the relief of painful symptomatology. In the most recent of these, a 10-week uncontrolled study of up to six courses of traditional Chinese acupuncture, resulted in 77% of patients experiencing significant pain relief and during a follow-up of up to 1 year, the majority of patients were able to stop or significantly reduce their other pain medication (66). Although, controlled trials are needed to confirm the benefits of acupuncture which appears to be free of side-effects, these are difficult to design because of the problems encountered with finding the correct site for "sham" acupuncture.

Other Physical Therapies

Many other physical therapies have been proposed, but most are supported by small single-center studies, thus, indicating the need for proper multicenter-controlled trials. The efficacy of pulsed-dose electrical stimulation through stocking electrodes in the treatment of painful diabetic neuropathy that was previously supported in an open-labelled study was not confirmed to be efficacious in a recent randomized cross-over trial (67).

A number of other physical therapies have been proposed and do have support from small-controlled trials: these include low-intensity laser therapy (68), monochromatic infrared light treatment (69), percutaneous electrical nerve stimulation (70), and static magnetic field therapy (71). For patients with the most severe painful neuropathy in unresponsive to conventional therapy, the use of electrical spinal cord stimulation was proposed in a small case series (72). However, although this cannot be generally recommended except in very resistant cases as it is invasive, expensive, and unproven in controlled studies, a recent follow-up of patients suggested that long-term symptomatic relief can be achieved (73).

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