|Micrograph showing a vasculitic peripheral neuropathy; plastic embedded; Toluidine blue stain|
Peripheral neuropathy, often shortened to neuropathy, is a general term describing disease affecting the peripheral nerves, meaning nerves beyond the brain and spinal cord. Damage to peripheral nerves may impair sensation, movement, gland or organ function depending on which nerves are affected; in other words, neuropathy affecting motor, sensory, or autonomic nerves result in different symptoms. More than one type of nerve may be affected simultaneously. Peripheral neuropathy may be acute (with sudden onset, rapid progress) or chronic (symptoms begin subtly and progress slowly), and may be reversible or permanent.
Common causes include systemic diseases (such as diabetes or leprosy), hyperglycemia-induced glycation, vitamin deficiency, medication (e.g., chemotherapy, or commonly prescribed antibiotics including metronidazole and the fluoroquinolone class of antibiotics (Ciprofloxacin, Levaquin, Avelox etc.)), traumatic injury, including ischemia, radiation therapy, excessive alcohol consumption, immune system disease, coeliac disease, non-celiac gluten sensitivity, or viral infection. It can also be genetic (present from birth) or idiopathic (no known cause). In conventional medical usage, the word neuropathy (neuro-, "nervous system" and -pathy, "disease of") without modifier usually means peripheral neuropathy.
Neuropathy affecting just one nerve is called "mononeuropathy" and neuropathy involving nerves in roughly the same areas on both sides of the body is called "symmetrical polyneuropathy" or simply "polyneuropathy". When two or more (typically just a few, but sometimes many) separate nerves in disparate areas of the body are affected it is called "mononeuritis multiplex", "multifocal mononeuropathy", or "multiple mononeuropathy".
Neuropathy may cause painful cramps, fasciculations (fine muscle twitching), muscle loss, bone degeneration, and changes in the skin, hair, and nails. Additionally, motor neuropathy may cause impaired balance and coordination or, most commonly, muscle weakness; sensory neuropathy may cause numbness to touch and vibration, reduced position sense causing poorer coordination and balance, reduced sensitivity to temperature change and pain, spontaneous tingling or burning pain, or skin allodynia (severe pain from normally nonpainful stimuli, such as light touch); and autonomic neuropathy may produce diverse symptoms, depending on the affected glands and organs, but common symptoms are poor bladder control, abnormal blood pressure or heart rate, and reduced ability to sweat normally.
- 1 Classification
- 2 Signs and symptoms
- 3 Causes
- 4 Diagnosis
- 5 Treatment
- 6 Research
- 7 See also
- 8 References
- 9 Further reading
- 10 External links
Peripheral neuropathy may be classified according to the number and distribution of nerves affected (mononeuropathy, mononeuritis multiplex, or polyneuropathy), the type of nerve fiber predominantly affected (motor, sensory, autonomic), or the process affecting the nerves; e.g., inflammation (neuritis), compression (compression neuropathy), chemotherapy (chemotherapy-induced peripheral neuropathy).
Mononeuropathy is a type of neuropathy that only affects a single nerve. Diagnostically, it is important to distinguish it from polyneuropathy because when a single nerve is affected, it is more likely to be due to localized trauma or infection.
The most common cause of mononeuropathy is physical compression of the nerve, known as compression neuropathy. Carpal tunnel syndrome and axillary nerve palsy are examples. Direct injury to a nerve, interruption of its blood supply resulting in (ischemia), or inflammation also may cause mononeuropathy.
"Polyneuropathy" is a pattern of nerve damage that is quite different from mononeuropathy, often more serious and affecting more areas of the body. The term "peripheral neuropathy" sometimes is used loosely to refer to polyneuropathy. In cases of polyneuropathy, many nerve cells in various parts of the body are affected, without regard to the nerve through which they pass; not all nerve cells are affected in any particular case. In distal axonopathy, one common pattern is that the cell bodies of neurons remain intact, but the axons are affected in proportion to their length; the longest axons are the most affected. Diabetic neuropathy is the most common cause of this pattern. In demyelinating polyneuropathies, the myelin sheath around axons is damaged, which affects the ability of the axons to conduct electrical impulses. The third and least common pattern affects the cell bodies of neurons directly. This usually picks out either the motor neurons (known as motor neuron disease) or the sensory neurons (known as sensory neuronopathy or dorsal root ganglionopathy).
The effect of this is to cause symptoms in more than one part of the body, often symmetrically on left and right sides. As for any neuropathy, the chief symptoms include motor symptoms such as weakness or clumsiness of movement; and sensory symptoms such as unusual or unpleasant sensations such as tingling or burning; reduced ability to feel sensations such as texture or temperature, and impaired balance when standing or walking. In many polyneuropathies, these symptoms occur first and most severely in the feet. Autonomic symptoms also may occur, such as dizziness on standing up, erectile dysfunction, and difficulty controlling urination.
Polyneuropathies usually are caused by processes that affect the body as a whole. Diabetes and impaired glucose tolerance are the most common causes. Hyperglycemia-induced formation of advanced glycation end products (AGEs) is related to diabetic neuropathy. Other causes relate to the particular type of polyneuropathy, and there are many different causes of each type, including inflammatory diseases such as Lyme disease, vitamin deficiencies, blood disorders, and toxins (including alcohol and certain prescribed drugs).
Most types of polyneuropathy progress fairly slowly, over months or years, but rapidly progressive polyneuropathy also occurs. It is important to recognize that at one time it was thought that many of the cases of small fiber peripheral neuropathy with typical symptoms of tingling, pain, and loss of sensation in the feet and hands were due to glucose intolerance before a diagnosis of diabetes or pre-diabetes. However, in August 2015, the Mayo Clinic published a scientific study in the Journal of the Neurological Sciences showing "no significant increase in...symptoms...in the prediabetes group", and stated that "A search for alternate neuropathy causes is needed in patients with prediabetes." 
The treatment of polyneuropathies is aimed firstly at eliminating or controlling the cause, secondly at maintaining muscle strength and physical function, and thirdly at controlling symptoms such as neuropathic pain.
Mononeuritis multiplex, occasionally termed polyneuritis multiplex, is simultaneous or sequential involvement of individual noncontiguous nerve trunks, either partially or completely, evolving over days to years and typically presenting with acute or subacute loss of sensory and motor function of individual nerves. The pattern of involvement is asymmetric, however, as the disease progresses, deficit(s) becomes more confluent and symmetrical, making it difficult to differentiate from polyneuropathy. Therefore, attention to the pattern of early symptoms is important.
Mononeuritis multiplex also may cause pain, which is characterized as deep, aching pain that is worse at night and frequently in the lower back, hip, or leg. In people with diabetes mellitus, mononeuritis multiplex typically is encountered as acute, unilateral, and severe thigh pain followed by anterior muscle weakness and loss of knee reflex.[medical citation needed]
It is caused by, or associated with, several medical conditions:
- diabetes mellitus
- vasculitides: polyarteritis nodosa, granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis
- immune-mediated diseases, such as rheumatoid arthritis, systemic lupus erythematosus (SLE)
- infections: leprosy, lyme disease, Parvovirus B19, HIV
- reactions to exposure to chemical agents, including trichloroethylene and dapsone[medical citation needed]
- rarely, following the sting of certain jellyfish, such as the sea nettle[medical citation needed]
Autonomic neuropathy is a form of polyneuropathy that affects the non-voluntary, non-sensory nervous system (i.e., the autonomic nervous system), affecting mostly the internal organs such as the bladder muscles, the cardiovascular system, the digestive tract, and the genital organs. These nerves are not under a person's conscious control and function automatically. Autonomic nerve fibers form large collections in the thorax, abdomen, and pelvis outside the spinal cord. They have connections with the spinal cord and ultimately the brain, however. Most commonly autonomic neuropathy is seen in persons with long-standing diabetes mellitus type 1 and 2. In most—but not all—cases, autonomic neuropathy occurs alongside other forms of neuropathy, such as sensory neuropathy.
Autonomic neuropathy is one cause of malfunction of the autonomic nervous system, but not the only one; some conditions affecting the brain or spinal cord also may cause autonomic dysfunction, such as multiple system atrophy, and therefore, may cause similar symptoms to autonomic neuropathy.
The signs and symptoms of autonomic neuropathy include the following:
- Urinary bladder conditions: bladder incontinence or urine retention
- Gastrointestinal tract: dysphagia, abdominal pain, nausea, vomiting, malabsorption, fecal incontinence, gastroparesis, diarrhoea, constipation
- Cardiovascular system: disturbances of heart rate (tachycardia, bradycardia), orthostatic hypotension, inadequate increase of heart rate on exertion
- Respiratory system: impairments in the signals associated with regulation of breathing and gas exchange (central sleep apnea, hypopnea, bradypnea).
- Other areas: hypoglycemia unawareness, genital impotence, sweat disturbances
Neuritis is a general term for inflammation of a nerve or the general inflammation of the peripheral nervous system. Symptoms depend on the nerves involved, but may include pain, paresthesia (pins-and-needles), paresis (weakness), hypoesthesia (numbness), anesthesia, paralysis, wasting, and disappearance of the reflexes.
Causes of neuritis include:
- Physical injury
- Chemical injury such as chemotherapy
- Radiation therapy
Types of neuritis include:
- Brachial neuritis
- Cranial neuritis such as Bell's palsy
- Optic neuritis
- Vestibular neuritis
- Wartenberg's migratory sensory neuropathy
- Underlying conditions including: :
Signs and symptoms
Those with diseases or dysfunctions of their nerves may present with problems in any of the normal nerve functions. Symptoms vary depending on the types of nerve fiber involved. In terms of sensory function, symptoms commonly include loss of function ("negative") symptoms, including numbness, tremor, impairment of balance, and gait abnormality. Gain of function (positive) symptoms include tingling, pain, itching, crawling, and pins-and-needles. Motor symptoms include loss of function ("negative") symptoms of weakness, tiredness, muscle atrophy, and gait abnormalities; and gain of function ("positive") symptoms of cramps, and muscle twitch (fasciculations).
In the most common form, length-dependent peripheral neuropathy, pain and parasthesia appears symmetrically and generally at the terminals of the longest nerves, which are in the lower legs and feet. Sensory symptoms generally develop before motor symptoms such as weakness. Length-dependent peripheral neuropathy symptoms make a slow ascent of leg, while symptoms may never appear in the upper limbs; if they do, it will be around the time that leg symptoms reach the knee. When the nerves of the autonomic nervous system are affected, symptoms may include constipation, dry mouth, difficulty urinating, and dizziness when standing.
The causes are grouped broadly as follows:
- Surgery: Lasik (corneal neuropathy - 20 to 55% of people). 
- Genetic diseases: Friedreich's ataxia, Fabry disease, Charcot-Marie-Tooth disease, hereditary neuropathy with liability to pressure palsy
- hyperglycemia-induced formation of advanced glycation end products (AGEs)
- Metabolic and endocrine diseases: diabetes mellitus, chronic kidney failure, porphyria, amyloidosis, liver failure, hypothyroidism
- Toxic causes: drugs (vincristine, metronidazole, phenytoin, nitrofurantoin, isoniazid, ethyl alcohol, statins),[medical citation needed] organic herbicides TCDD dioxin, organic metals, heavy metals, excess intake of vitamin B6 (pyridoxine). Peripheral neuropathies also may result from long term (more than 21 days) treatment with Linezolid (Zyvox).[medical citation needed]
- Adverse effects of fluoroquinolones: irreversible neuropathy is a serious adverse reaction of fluoroquinolone drugs[medical citation needed]
- Inflammatory diseases: Guillain–Barré syndrome, systemic lupus erythematosus, leprosy, multiple sclerosis, Sjögren's syndrome, Babesiosis, Lyme disease, vasculitis, sarcoidosis,
- Vitamin deficiency states: Vitamin B12 (Methylcobalamin), vitamin A, vitamin E, vitamin B1 (thiamin)
- Physical trauma: compression, automobile accident, sports injury, sports pinching, cutting, projectile injuries (for example, gunshot wound), strokes including prolonged occlusion of blood flow, electric discharge, including lightning strikes[medical citation needed]
- Effect of chemotherapy – see Chemotherapy-induced peripheral neuropathy
- Exposure to Agent Orange
- Others: electric shock, HIV, malignant disease, radiation, shingles, MGUS (Monoclonal gammopathy of undetermined significance).
Peripheral neuropathy may first be considered when an individual reports symptoms of numbness, tingling, and pain in feet. After ruling out a lesion in the central nervous system as a cause, diagnosis may be made on the basis of symptoms, laboratory and additional testing, clinical history, and a detailed examination.
During physical examination, specifically a neurological examination, those with generalized peripheral neuropathies most commonly have distal sensory or motor and sensory loss, although those with a pathology (problem) of the nerves may be perfectly normal; may show proximal weakness, as in some inflammatory neuropathies, such as Guillain–Barré syndrome; or may show focal sensory disturbance or weakness, such as in mononeuropathies. Classically, ankle jerk reflex is absent in peripheral neuropathy.
A physical examination will involve testing the deep ankle reflex as well as examining the feet for any ulceration. For large fiber neuropathy, an exam will usually show an abnormally decreased sensation to vibration, which is tested with a 128-Hz tuning fork, and decreased sensation of light touch when touched by a nylon monofilament.
Diagnostic tests include electromyography (EMG) and nerve conduction studies (NCSs), which assess large myelinated nerve fibers. Testing for small-fiber peripheral neuropathies often relates to the autonomic nervous system function of small thinly- and unmyelinated fibers. These tests include a sweat test and a tilt table test. Diagnosis of small fiber involvement in peripheral neuropathy may also involve a skin biopsy in which a 3 mm-thick section of skin is removed from the calf by a punch biopsy, and is used to measure the skin intraepidermal nerve fiber density (IENFD), the density of nerves in the outer layer of the skin. Reduced density of the small nerves in the epidermis supports a diagnosis of small-fiber peripheral neuropathy.
Laboratory tests include blood tests for vitamin B-12 levels, a complete blood count, measurement of thyroid stimulating hormone levels, a comprehensive metabolic panel screening for diabetes and pre-diabetes, and a serum immunofixation test, which tests for antibodies in the blood.
The treatment of peripheral neuropathy varies based on the cause of the condition, and treating the underlying condition can aid in the management of neuropathy. When peripheral neuropathy results from diabetes mellitus or prediabetes, blood sugar management is key to treatment. In prediabetes in particular, strict blood sugar control can significantly alter the course of neuropathy. In peripheral neuropathy that stems from immune-mediated diseases, the underlying condition is treated with intravenous immunoglobulin or steroids. When peripheral neuropathy results from vitamin deficiencies or other disorders, those are treated as well.
A range of medications that act on the central nervous system have been used to symptomatically treat neuropathic pain. Commonly used medications include tricyclic antidepressants (such as nortriptyline, amitriptyline, imapramine and desipramine), serotonin-norepinephrine reuptake inhibitor (SNRI) medications (duloxetine, venlafaxine and milnacipran), and antiepileptic medications (gabapentin, pregabalin, oxcarbazepine, zonisamide, levetiracetam, lamotrigine, topiramate and sodium valproate). Opioid and opiate medications (such as buprenorphine, morphine, methadone, fentanyl, hydromorphone and tramadol) are also often used to treat neuropathic pain. As is revealed in many of the reviews listed below, studies of these medications for the treatment of neuropathic pain are often methodologically flawed and potentially subject to major bias. In general, the evidence does not support the usage of antiepileptic and antidepressant medications for the treatment of neuropathic pain. Better designed clinical trials and further review from non-biased third parties are necessary to gauge just how useful for patients these medications truly are. It is also often the case that the aforementioned medications are prescribed for neuropathic pain conditions for which they had not been explicitly tested on.
In a 2015 Cochrane review of nortriptyline for the treatment of neuropathic pain, the authors note that, "We found little evidence to support the use of nortriptyline to treat the neuropathic pain conditions included in this review." In a 2015 Cochrane review of amitriptyline for the treatment of neuropathic pain, the authors note that, "The fact that there is no supportive unbiased evidence for a beneficial effect is disappointing".  A 2014 Cochrane review of imapramine concluded that, "This review found little evidence to support the use of imipramine to treat neuropathic pain. There was very low quality evidence of benefit but this came from studies that were methodologically flawed and potentially subject to major bias." In a 2014 Cochrane review of desipramine for the treatment of neuropathic pain, the authors conclude that, "This review found little evidence to support the use of desipramine to treat neuropathic pain."
In a 2014 Cochrane review of duloxetine the authors concluded that, "There is adequate amounts of moderate quality evidence from eight studies... that doses of 60 mg and 120 mg daily are efficacious for treating pain in diabetic peripheral neuropathy but lower daily doses are not." All eight studies were performed by the manufacturers of duloxetine. In a 2015 Cochrane review of venlafaxine for the treatment of neuropathic pain, the authors conclude that, "We found little compelling evidence to support the use of venlafaxine in neuropathic pain." In a 2015 Cochrane review of milnacipran for the treatment of neuropathic pain, the authors conclude that, "There was no evidence to support the use of milnacipran to treat neuropathic pain conditions".
For a more general outlook, a 2017 Cochrane review assessing the benefit of antidepressant medications for several types of chronic non-cancer pains (including neuropathic pain) in children and adolescents concluded that, "There is no evidence from randomised controlled trials to support or refute the use of antidepressants to treat chronic non-cancer pain in children or adolescents."
In a 2017 review of gabapentin for the treatment of neuropathic pain the authors note that, "Gabapentin at doses of 1800 mg to 3600 mg daily... can provide good levels of pain relief to some people with postherpetic neuralgia and peripheral diabetic neuropathy. Evidence for other types of neuropathic pain is very limited." This should be balanced with the outlook that, "3 or 4 out of 10 participants achieved... pain relief with gabapentin, compared with 1 or 2 out of 10 for placebo. Over half of those treated with gabapentin will not have worthwhile pain relief but may experience adverse events." It should also be noted that three of the seven authors have declared receiving many payments from pharmaceutical companies. In a 2019 Cochrane review of pregablin for the treatment of neuropathic pain, the authors conclude that there is some evidence for efficacy in the treatment of pain deriving from post-herpetic neuralgia, diabetic neuropathy and post-traumatic neuropathic pain. This should be balanced with the outlook that, "Some people will derive substantial benefit with pregabalin; more will have moderate benefit, but many will have no benefit or will discontinue treatment." It is also important to note that two of the five authors declared receiving payments from pharmaceutical companies.
In a 2017 review of oxcarbazepine for the treatment of neuropathic pain the authors concluded that, "This review found little evidence to support the effectiveness of oxcarbazepine in painful diabetic neuropathy, neuropathic pain from radiculopathy and a mixture of neuropathies... More well-designed, multicentre RCTs investigating oxcarbazepine for various types of neuropathic pain are needed, and selective publication of studies or data should be avoided." In a 2015 Cochrane review of zonisamide for the treatment of neuropathic pain, the authors conclude, "The review found a lack of evidence suggesting that zonisamide provides no pain relief in any neuropathic pain condition." A 2014 Cochrance review of levetiracetam for the treatment of neuropathic pain concluded that, "The amount of evidence for levetiracetam in neuropathic pain conditions was very small and potentially biased because of the methods of analysis used in the studies. There was no indication that levetiracetam was effective in reducing neuropathic pain, but it was associated with an increase in participants who experienced adverse events and who withdrew due to adverse events."
A 2013 Cochrane review of lamotrigine concluded,"Large, high-quality, long-duration studies reporting clinically useful levels of pain relief for individual participants provided no convincing evidence that lamotrigine is effective in treating neuropathic pain and fibromyalgia at doses of about 200 to 400 mg daily." A 2013 Cochrane review of Topimirate concluded, "Topiramate is without evidence of efficacy in diabetic neuropathic pain, the only neuropathic condition in which it has been adequately tested. The data we have includes the likelihood of major bias due to LOCF imputation, where adverse event withdrawals are much higher with active treatment than placebo control. Despite the strong potential for bias, no difference in efficacy between topiramate and placebo was apparent."
For a more general outlook, a 2017 Cochrane review aiming to assess the benefit of antiepileptic medications for several types of chronic non-cancer pains (including neuropathic pain) in children and adolescents concluded that, "We found no evidence to support or refute the use of antiepileptic drugs to treat chronic non-cancer pain in children and adolescents." Two of the ten authors of this study declared receiving payments from pharmaceutical companies.
Opioids and opiates
A 2015 Cochrane review of buprenorphine for the treatment of neuropathic pain concluded that, "There was insufficient evidence to support or refute the suggestion that buprenorphine has any efficacy in any neuropathic pain condition." A 2017 Cochrane review of morphine for the treatment of chronic neuropathic pain concluded that,"There was insufficient evidence to support or refute the suggestion that morphine has any efficacy in any neuropathic pain condition." The review also wrongfully refers to morphine as an opioid; it is an opiate. Conflicts of interest are also declared by the authors. A 2017 Cochrane review of methadone concluded, "The three studies provide very limited, very low quality evidence of the efficacy and safety of methadone for chronic neuropathic pain... No conclusions can be made regarding differences in efficacy or safety between methadone and placebo... " A 2016 Cochrane review of fentanyl concluded, "There is insufficient evidence to support or refute the suggestion that fentanyl works in any neuropathic pain condition." A 2016 Cochrane review of hydromorphone concluded, "There was insufficient evidence to support or refute the suggestion that hydromorphone has any efficacy in any neuropathic pain condition."
For tramadol, Cochrane found that there was only modest information about the benefits of it's usage for neuropathic pain. Studies were small, had potential risks of bias and apparent benefits increased with risk of bias. Overall the evidence was of low or very low quality and the authors state that it 'does not provide a reliable indication of the likely effect.'
More generally, a 2013 review examining the overall effectiveness of opioid therapy for the treatment of neuropathic pain found " Short-term studies provide only equivocal evidence regarding the efficacy of opioids in reducing the intensity of neuropathic pain. Intermediate-term studies demonstrated significant efficacy of opioids over placebo, but these results are likely to be subject to significant bias because of small size, short duration, and potentially inadequate handling of dropouts. Analgesic efficacy of opioids in chronic neuropathic pain is subject to considerable uncertainty." Also, a 2017 Cochrane review examining opioid therapy as a treatment for many non-cancer pain syndromes (including neuropathic pain) condluded, "There was no evidence from randomised controlled trials to support or refute the use of opioids to treat chronic non-cancer pain in children and adolescents."
A 2016 Cochrane review of paracetamol for the treatment of neuropathic pain concludes, "There is insufficient evidence to support or refute the suggestion that paracetamol alone, or in combination with codeine or dihydrocodeine, works in any neuropathic pain condition".
Symptomatic relief for the pain of peripheral neuropathy may be obtained by application of topical capsaicin. Capsaicin is the factor that causes heat in chili peppers. The evidence suggesting that capsaicin applied to the skin reduces pain for peripheral neuropathy is of moderate to low quality and should be interpreted carefully before using this treatment option.
Transcutaneous electrical nerve stimulation (TENS) therapy is often used to treat various types of neuropathy. A 2010 review of three trials, for the treatment of diabetic neuropathy explicitly, involving a total of 78 patients found some improvement in pain scores after 4 and 6, but not 12 weeks of treatment and an overall improvement in neuropathic symptoms at 12 weeks. Another 2010 review of four trials, for the treatment of diabetic neuropathy, found significant improvement in pain and overall symptoms, with 38% of patients in one trial becoming asymptomatic. The treatment remains effective even after prolonged use, but symptoms return to baseline within a month of cessation of treatment.
These older reviews can be balanced with a more recent 2017 review of TENS for neuropathic pain by Cochrane which concluded that, "This review is unable to state the effect of TENS versus sham TENS for pain relief due to the very low quality of the included evidence... The very low quality of evidence means we have very limited confidence in the effect estimate reported." A very low quality of evidence means, 'multiple sources of potential bias' with a 'small number and size of studies'. 
According to a single review (2019), strict gluten-free diet is an effective treatment when neuropathy is caused by gluten sensitivity, with or without the presence of digestive symptoms or intestinal injury.
A 2015 review on the treatment of neuropathic pain with psychological therapy concluded that, "There is insufficient evidence of the efficacy and safety of psychological interventions for chronic neuropathic pain. The two available studies show no benefit of treatment over either waiting list or placebo control groups."
Herbal Medicinal Products
A 2019 Cochrane review of the treatment of herbal medicinal products for patients suffering neuropathic pain for at least three months concluded that, "There was insufficient evidence to determine whether nutmeg or St John's wort has any meaningful efficacy in neuropathic pain conditions.The quality of the current evidence raises serious uncertainties about the estimates of effect observed, therefore, we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect." 
A 2017 Cochrane review on the usage of acupuncture as a treatment for neuropathic pain concludes, "Due to the limited data available, there is insufficient evidence to support or refute the use of acupuncture for neuropathic pain in general, or for any specific neuropathic pain condition when compared with sham acupuncture or other active therapies." It should be noted that "Most studies included a small sample size (fewer than 50 participants per treatment arm) and all studies were at high risk of bias for blinding of participants and personnel." Also, the authors state, "we did not identify any study comparing acupuncture with treatment as usual."
A 2018 Cochrane review on accupuncture and related interventions for the treatment of carpal tunnel syndrome concluded that, "Acupuncture and laser acupuncture may have little or no effect in the short term on symptoms of carpal tunnel syndrome (CTS) in comparison with placebo or sham acupuncture." It was also noted that all studies had an unclear or high overall risk of bias and that all evidence was of low or very low quality.
A 2008 literature review concluded that, "based on principles of evidence-based medicine and evaluations of methodology, there is only a 'possible' association [of celiac disease and peripheral neuropathy], due to lower levels of evidence and conflicting evidence. There is not yet convincing evidence of causality."
A 2019 review concluded that "gluten neuropathy is a slowly progressive condition. About 25% of the patients will have evidence of enteropathy on biopsy (CD [celiac disease]) but the presence or absence of an enteropathy does not influence the positive effect of a strict gluten-free diet."
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- Wiffen, Philip J.; Derry, Sheena; Bell, Rae F.; Rice, Andrew Sc; Tölle, Thomas Rudolf; Phillips, Tudor; Moore, R. Andrew (06 09, 2017). "Gabapentin for chronic neuropathic pain in adults". The Cochrane Database of Systematic Reviews. 6: CD007938. doi:10.1002/14651858.CD007938.pub4. ISSN 1469-493X. PMC PMCPMC6452908 Check
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- Zhou, Muke; Chen, Ning; He, Li; Yang, Mi; Zhu, Cairong; Wu, Fengbo (12 02, 2017). "Oxcarbazepine for neuropathic pain". The Cochrane Database of Systematic Reviews. 12: CD007963. doi:10.1002/14651858.CD007963.pub3. ISSN 1469-493X. PMC PMCPMC6486101 Check
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- Moore, R. Andrew; Wiffen, Philip J.; Derry, Sheena; Lunn, Michael P. T. (2015-01-22). "Zonisamide for neuropathic pain in adults". The Cochrane Database of Systematic Reviews. 1: CD011241. doi:10.1002/14651858.CD011241.pub2. ISSN 1469-493X. PMC PMCPMC6485502 Check
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- Cooper, Tess E.; Wiffen, Philip J.; Heathcote, Lauren C.; Clinch, Jacqui; Howard, Richard; Krane, Elliot; Lord, Susan M.; Sethna, Navil; Schechter, Neil (08 05, 2017). "Antiepileptic drugs for chronic non-cancer pain in children and adolescents". The Cochrane Database of Systematic Reviews. 8: CD012536. doi:10.1002/14651858.CD012536.pub2. ISSN 1469-493X. PMC PMCPMC6424379 Check
|pmc=value (help). PMID 28779491. Check date values in:
- Wiffen, Philip J.; Derry, Sheena; Moore, R. Andrew; Stannard, Cathy; Aldington, Dominic; Cole, Peter; Knaggs, Roger (2015-09-30). "Buprenorphine for neuropathic pain in adults". The Cochrane Database of Systematic Reviews (9): CD011603. doi:10.1002/14651858.CD011603.pub2. ISSN 1469-493X. PMC PMCPMC6481375 Check
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- Cooper, Tess E.; Chen, Junqiao; Wiffen, Philip J.; Derry, Sheena; Carr, Daniel B.; Aldington, Dominic; Cole, Peter; Moore, R. Andrew (05 22, 2017). "Morphine for chronic neuropathic pain in adults". The Cochrane Database of Systematic Reviews. 5: CD011669. doi:10.1002/14651858.CD011669.pub2. ISSN 1469-493X. PMC PMCPMC6481499 Check
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- Gaskell, Helen; Derry, Sheena; Stannard, Cathy; Moore, R. Andrew (2016-07-28). "Oxycodone for neuropathic pain in adults". The Cochrane Database of Systematic Reviews. 7: CD010692. doi:10.1002/14651858.CD010692.pub3. ISSN 1469-493X. PMC PMCPMC6457997 Check
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- Derry, Sheena; Stannard, Cathy; Cole, Peter; Wiffen, Philip J.; Knaggs, Roger; Aldington, Dominic; Moore, R. Andrew (2016-10-11). "Fentanyl for neuropathic pain in adults". The Cochrane Database of Systematic Reviews. 10: CD011605. doi:10.1002/14651858.CD011605.pub2. ISSN 1469-493X. PMC PMCPMC6457928 Check
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- Stannard, Cathy; Gaskell, Helen; Derry, Sheena; Aldington, Dominic; Cole, Peter; Cooper, Tess E.; Knaggs, Roger; Wiffen, Philip J.; Moore, R. Andrew (2016-05-24). "Hydromorphone for neuropathic pain in adults". The Cochrane Database of Systematic Reviews (5): CD011604. doi:10.1002/14651858.CD011604.pub2. ISSN 1469-493X. PMC PMCPMC6491092 Check
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- Duehmke, Rudolf Martin; Derry, Sheena; Wiffen, Philip J.; Bell, Rae F.; Aldington, Dominic; Moore, R. Andrew (06 15, 2017). "Tramadol for neuropathic pain in adults". The Cochrane Database of Systematic Reviews. 6: CD003726. doi:10.1002/14651858.CD003726.pub4. ISSN 1469-493X. PMC PMCPMC6481580 Check
|pmc=value (help). PMID 28616956. Check date values in:
- McNicol, Ewan D.; Midbari, Ayelet; Eisenberg, Elon (2013-08-29). "Opioids for neuropathic pain". The Cochrane Database of Systematic Reviews (8): CD006146. doi:10.1002/14651858.CD006146.pub2. ISSN 1469-493X. PMC PMCPMC6353125 Check
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- Wiffen, Philip J.; Knaggs, Roger; Derry, Sheena; Cole, Peter; Phillips, Tudor; Moore, R. Andrew (12 27, 2016). "Paracetamol (acetaminophen) with or without codeine or dihydrocodeine for neuropathic pain in adults". The Cochrane Database of Systematic Reviews. 12: CD012227. doi:10.1002/14651858.CD012227.pub2. ISSN 1469-493X. PMC PMCPMC6463878 Check
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- Moore RA, Chi CC, Wiffen PJ, Derry S, Rice AS (October 2015). "Oral nonsteroidal anti-inflammatory drugs for neuropathic pain". The Cochrane Database of Systematic Reviews. 10 (10): CD010902. doi:10.1002/14651858.CD010902.pub2. PMID 26436601.
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- Stem cell therapy for nerve injury
- Induced pluripotent stem cells for peripheral nerve regeneration.
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- Ju, Zi Yong; Wang, Ke; Cui, Hua Shun; Yao, Yibo; Liu, Shi Min; Zhou, Jia; Chen, Tong Yu; Xia, Jun (12 02, 2017). "Acupuncture for neuropathic pain in adults". The Cochrane Database of Systematic Reviews. 12: CD012057. doi:10.1002/14651858.CD012057.pub2. ISSN 1469-493X. PMC PMCPMC6486266 Check
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- Choi, Gwang-Ho; Wieland, L. Susan; Lee, Hyangsook; Sim, Hoseob; Lee, Myeong Soo; Shin, Byung-Cheul (12 02, 2018). "Acupuncture and related interventions for the treatment of symptoms associated with carpal tunnel syndrome". The Cochrane Database of Systematic Reviews. 12: CD011215. doi:10.1002/14651858.CD011215.pub2. ISSN 1469-493X. PMC PMCPMC6361189 Check
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