Neuropathic pain

What is neuropathic pain?

Neuropathic pain is pain caused by a lesion or disease of the somatosensory nervous system: the nerves and brain pathways that carry sensory signals from the body^1,2. It is one of three main categories of chronic pain, alongside nociceptive pain (from tissue damage) and nociplastic pain (from changes in central pain processing without identifiable injury), and it is estimated to affect roughly 7–10% of the general population^3,4. In Australia, where one in five adults lives with chronic pain, neuropathic features are present in a substantial fraction⁵.

Neuropathic pain often has a distinctive quality. People typically describe it as burning, shooting, electric, stabbing, or like pins and needles, and it may be accompanied by numbness or unusual sensitivity, where light touch or temperature changes feel painful (allodynia), or normal pain feels much worse than expected (hyperalgesia)³. These descriptive features are often the first clue that pain is neuropathic rather than coming from a muscle, joint or organ.

Many conditions can cause neuropathic pain. The most common include:

• Painful diabetic peripheral neuropathy. The most common cause globally, affecting up to half of people with long-standing diabetes³.
• Sciatica and lumbosacral radiculopathy. Pain radiating down the leg from compression or irritation of nerve roots in the lower back.
• Post-herpetic neuralgia. Persistent pain after a shingles episode.
• Trigeminal neuralgia. Severe facial pain from the trigeminal nerve.
• Chemotherapy-induced peripheral neuropathy. Nerve damage caused by neurotoxic chemotherapy agents.
• Post-surgical and post-traumatic neuropathic pain. Nerve damage occurring during surgery or injury.
• Central neuropathic pain. Pain from stroke, multiple sclerosis or spinal cord injury.

Neuropathic pain is real and treatable, though often only partially

Compared with conditions where pain has no visible cause, neuropathic pain usually has an identifiable mechanism that can be detected with the right examination, imaging or nerve studies. Pain medicine has formal diagnostic criteria for neuropathic pain (the NeuPSIG grading system distinguishes possible, probable and definite neuropathic pain) and an established treatment hierarchy with evidence behind each step^2,6.

Neuropathic pain also comes with its own difficult truth. Across the major drug classes used for neuropathic pain (tricyclic antidepressants, gabapentinoids, serotonin-noradrenaline reuptake inhibitors and topical agents), only around a third to a half of patients achieve clinically meaningful pain relief on any one drug, and the typical reduction is partial rather than complete^6,7. This is not a failing on anyone's part. It reflects how difficult it is to fully reverse changes in nerve function once they have set in.

In practice, the goal of treatment is usually meaningful improvement (better function, less interference with sleep, more participation in life) rather than complete pain elimination. Knowing this in advance changes how people experience treatment. Patients who go in expecting partial improvement and incremental progress tend to feel better served than those expecting a cure. The aim is to make the pain a smaller part of your day, not no part of it.

What current evidence says about neuropathic pain care

Current guidance from the International Association for the Study of Pain's Special Interest Group on Neuropathic Pain (NeuPSIG), the European Academy of Neurology, and Australian primary care guidance from the RACGP and Australian Pain Society recommends a stepped, multimodal approach^6,7,8,9.

First-line medications are tricyclic antidepressants (such as amitriptyline or nortriptyline), gabapentinoids (gabapentin and pregabalin) and serotonin-noradrenaline reuptake inhibitors (such as duloxetine)⁶. Second-line options include tramadol and topical agents such as lidocaine patches or high-dose capsaicin patches. Strong opioids (such as oxycodone or morphine) are generally a last resort, given limited long-term effectiveness in neuropathic pain and substantial harm potential⁶. Specific medication choice depends on the type of neuropathic pain, other conditions and tolerance of side effects, and is best made with a GP, neurologist or pain specialist.

Disease-specific treatments matter as much as symptom control. For diabetic neuropathy, glycaemic control slows progression and is part of pain management³. For acute herpes zoster (shingles), early antiviral treatment reduces the risk of post-herpetic neuralgia. For sciatica from a disc herniation, most cases improve substantially with conservative management over weeks to months; surgery is considered for severe or progressive neurological deficits.

Non-pharmacological treatments complement medication rather than replace it. Physiotherapy has a role for radicular pain (nerve gliding techniques and graded exercise), for diabetic neuropathy (balance training, gait and foot care) and for central neuropathic pain (graded motor imagery and mirror therapy in selected cases)¹⁰. Psychological support, particularly cognitive behavioural therapy, has consistent evidence for reducing the distress, fear and disability that often accompany neuropathic pain^11,12. Patient education about how the nervous system generates pain after nerve injury helps people make sense of their experience and approach treatment with realistic expectations¹⁰.

How Pain Coach is built for neuropathic pain

Pain Coach is a chronic pain tracking app designed to be used with your GP, neurologist, pain specialist or physiotherapist. For neuropathic pain, the daily check-in captures pain alongside the five lifestyle factors that influence chronic pain (sleep, exercise, nutrition, stress and social connection) in under two minutes a day.

Three things about neuropathic pain make tracking particularly useful. First, medication response takes weeks to evaluate, and many people need to try more than one agent before finding what works for them. Knowing exactly when a medication was started, at what dose, and what happened to pain and function over the following weeks is the only reliable way to judge effect; memory tends to compress this⁶. Second, side effects from neuropathic-pain medications are common (sedation, weight gain, dizziness, dry mouth), and tracking them daily makes it easier to tell side effects apart from underlying symptoms and from coincidental changes. Third, the gap between pain and function can be wide in neuropathic pain: many people remain in some pain but regain substantial function with the right combination of treatment, sleep and graded activity. Tracking function alongside pain is the only way to see this progress clearly¹⁰.

Pain Coach does not promise a cure. For most types of neuropathic pain, the realistic goal is meaningful improvement across months rather than elimination, and tracking is what lets you and your clinician see when meaningful improvement is happening⁶.

The five lifestyle factors and neuropathic pain

Each of the five factors Pain Coach tracks affects neuropathic pain, with some interactions specific to this category.

• Sleep. Neuropathic pain is particularly disruptive to sleep: the burning or electric quality often worsens at night, and sleep loss in turn amplifies central pain processing^13,14. Several first-line neuropathic pain medications (such as amitriptyline and gabapentinoids) are taken at night specifically to take advantage of sedative effects on sleep⁶. Tracking sleep alongside pain often reveals how much of the daytime symptom load is downstream of poor sleep.
• Exercise and movement. Graded movement supports nerve health and is recommended for most types of neuropathic pain, with the strongest evidence base in diabetic neuropathy, where regular exercise improves both glycaemic control and neuropathy outcomes^15,3. For radicular pain such as sciatica, gradual return to movement is usually more helpful than prolonged rest. The key word is graded: starting below current tolerance and building slowly. Pain Coach shows your clinician what you actually sustained.
• Nutrition. For diabetic neuropathy specifically, glycaemic control is part of pain management, and that depends substantially on what you eat³. For chronic musculoskeletal pain more broadly, regular, balanced eating supports energy, mood and recovery¹⁶. Pain Coach tracks plant intake, whole-food intake and added sugar so your clinician can see the pattern; it does not prescribe a specific diet.
• Stress. Persistent stress amplifies central pain processing, and in chronic neuropathic pain, central sensitisation often develops alongside the original nerve injury^17,18. Fear of activity and unhelpful beliefs about pain (particularly the belief that any pain means damage) can amplify the experience¹². Psychological support has consistent evidence for reducing distress and disability in chronic pain, including neuropathic pain¹¹.
• Social connection. Neuropathic pain is often invisible: there is no cast, no obvious scar to explain why someone is functioning poorly. Isolation and loneliness independently worsen chronic pain outcomes, and social pain shares neural pathways with physical pain^19,20. Small, regular contact with people who understand the condition tends to correlate with better days.

Find a neuropathic pain physiotherapist in Australia

Pain Coach Connect lists verified Australian physiotherapists who work with neuropathic pain, with telehealth and in-person consultations available. Different types of neuropathic pain benefit from different physiotherapy approaches: nerve gliding and graded exercise for radicular pain such as sciatica, balance and gait work for peripheral neuropathy, and graded motor imagery or mirror therapy for some central neuropathic pain presentations¹⁰. The listings are filtered to physiotherapists with specific experience in these areas.

Where neuropathic pain is moderate to severe, has been present for more than a few months, or is not responding to first-line treatment from your GP, referral to a pain specialist or neurologist is usually the appropriate next step. Pain medicine is a distinct specialty in Australia, with pain clinics in most major hospitals and a growing network of pain medicine physicians in private practice. Your GP can refer you.

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