Chronic non-freezing cold injury results in neuropathic pain due to a sensory neuropathy

Perhaps not a hot topic for NHS General Practice but as we approach another winter, this journal article is relevant for any healthcare professionals involved in the care of soldiers.

The original article is here  (I want to highlight the use of a DN4 neuropathic pain scoring chart if you are assessing a patient with suspected neuropathic pain).

My own experience with managing this very difficult condition is that it is frustrating for both the patient and doctor. Soldiers of Afro-Caribbean origin are far more likely to suffer from NFCI (30x by some estimates) and they are more prone to the side effects of neuropathic drugs, especially amitriptyline (totally anecdotal evidence).

In summary the article confirms this is a neuropathy confirmed by skin biopsy.  Quantitative sensory testing is also helpful.  Because the nerves are small sensory fibres, detection by nerve conduction studies is not always accurate.  It goes into quite some detail about the process (it is a PhD project).

For me the main message is this is a real phenomenon with physical changes.  In the study, 35% were medically discharged from the Forces and of these, over 50% were unemployed.  This is pretty horrendous and re-iterates that NFCI can be a chronic & disabling condition.

My own management involves adequate protection (motorcycling warmed gloves are useful as are silk liners), neuropathic agents, simple pain relief (opiates are occasionally helpful funnily enough) and a cognitive approach to pain.  The latter is especially important given that employment may be difficult if working outdoors is impossible for 4 months of the year.

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