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• Gabapentin is a reasonable first-choice for efficacy and tolerability
• If there is no pain relief or if it is insufficient at the maximum dose, adding a second drug, such as tramadol, is a reasonable choice, beginning at a low dose and raising the dose slowly.
• If the individual cannot tolerate gabapentin, the initial drug of choice is tramadol.
• If pain persists, adding a third drug, such as oxcarbazepine, which is as effective and better tolerated than tricyclic antidepressants, is a reasonable choice, starting at a low dose and then slowly increasing the dose.
• If a combination of three drugs is ineffective, one may wish to try the extended release formulation of a narcotic analgesic, preferably sustained release oral morphine.

Capsaicin can be used at any time since it has no systemic side effects. Some people have found it to be helpful when used in conjunction with prescribed medications.

Physical and Occupational Therapy for Peripheral Neuropathy

Physical Therapy

Regardless of the underlying cause of peripheral neuropathy, physical therapy may be helpful in maintaining strength, mobility, and function of the affected limb(s). Patients with diabetic neuropathy may also benefit from physical therapy, however, they must also rigorously control their blood sugar levels to prevent major fluctuations that can lead to further nerve damage. Some of the objectives of physical therapy include:

• Maintaining range of motion through progressive stretching.
• Strengthening muscles including exercising against increasing resistance, use of weights, and isometric exercise

Once a patient has reached a level where range of motion and muscle strength is at optimum function, it is important that they continue with the exercises independently in order to retain the benefit from therapy.

Physical therapists may also recommend:

• Braces - hand and/or foot braces can help with support if the patient suffers from muscle weakness. Braces also help with improving balance and posture.
• Splints - splinting temporarily immobilizes a limb or part of a limb and, by doing so, may reduce pain and dysfunction. It also prevents contracture of muscles which could further compress nerves and increase pain. Splints are often used in the treatment of compression mononeuropathies, such as carpal tunnel syndrome.
• Orthotics (customized foot supports) or orthopedic shoes may improve difficulties with gait as well as prevent foot injuries.

Occupational Therapy

Occupational therapy is instrumental in helping the patient cope with the functional, vocational, and social impact of peripheral neuropathy by:

• Improving sensory-motor skills
• Teaching the patient how to avoid exposure to environmental or industrial toxins
• Teaching self-care activities
• Teaching the patient safety issues, (e.g., paying more attention to the terrain when walking since falling or tripping may pose a risk for patients with peripheral neuropathy)
• Teaching the patient to pay attention to issues which involve automatic functions (e.g., learning how to change positions smoothly to avoid a sudden drop in blood pressure and the risk of falling)

Surgery for Peripheral Neuropathy

Surgery may be necessary for certain underlying conditions that may be associated with peripheral neuropathy. For example, if the neuropathy is caused by a condition such as carpal tunnel syndrome or the nerve compression is caused by a ruptured disk or a tumor, surgery may be necessary to resolve the underlying problem and relieve the neuropathic pain. Reconstructive surgery may be required for structural changes that may occur as neuropathy progresses (e.g., Achilles tendon lengthening).