แนวทางเวชปฏิบัติภาวะปวดเหตุพยาธิสภาพประสาท (2551) Neuropathic Pain สำนักงานหลักประกันสุขภาพแห่งชาติ แหล่งข้อมูล: http://www.nhso.go.th/FrontEnd/page-forhospital_cpg.aspx

1. ·π«Σ“߇«™ªØ‘∫—μ‘
¿“«–ª«¥‡Àμÿæ¬“Π‘ ¿“æª√– “Σ
(Clinical Practice Guideline for Neuropathic Pain)
æ.». 2551
®—¥Σ”‚¥¬
¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡Σ»‰Σ¬
‚¥¬§«“¡√à«¡¡◊Õ®“°
√“™«‘Σ¬“≈—¬Õ“¬ÿ√·æΣ¬å·Ààߪ√–‡Σ»‰Σ¬
√“™«‘Σ¬“≈—¬·æΣ¬åÕÕ√å‚Πªî¥‘° å·Ààߪ√–‡Σ»‰Σ¬
√“™«‘Σ¬“≈—¬·æΣ¬å‡«™»“ μ√åøóôπøŸ·Ààߪ√–‡Σ»‰Σ¬
√“™«‘Σ¬“≈—¬»—≈¬·æΣ¬å·Ààߪ√–‡Σ»‰Σ¬
√“™«‘Σ¬“≈—¬°ÿ¡“√·æΣ¬å·Ààߪ√–‡Σ»‰Σ¬
¡“§¡ª√– “Σ«‘Σ¬“·Ààߪ√–‡Σ»‰Σ¬
«‘Σ¬“≈—¬·æΣ¬å‡«™»“ μ√å§√Õ∫§√—«·Ààߪ√–‡Σ»‰Σ¬
°√¡æ—≤π“·æΣ¬å·ºπ‰Σ¬·≈–·æΣ¬åΣ“ß‡≈◊Õ° °√–Σ√«ß “Π“√≥ ÿ¢
π—∫ πÿπ‚¥¬ ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘

2. ·π«Σ“߇«™ªØ‘∫—μ‘
¿“«–ª«¥‡Àμÿæ¬“Π‘ ¿“æª√– “Σ
(Clinical Practice Guideline for Neuropathic Pain)
æ.». 2551
ISBN: 978-974-598-056-3
®—¥Σ”‚¥¬
¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡Σ»‰Σ¬
‚¥¬§«“¡√à«¡¡◊Õ®“°
“™«‘¬“—¬Õ“¬ÿ·æ¬å·Ààߪ–‡»‰¬
“™«‘¬“—¬·æ¬åÕÕ傪°å·Ààߪ–‡»‰¬
“™«‘¬“—¬·æ¬å‡«™»“μåøóôøŸ·Ààߪ–‡»‰¬
“™«‘¬“—¬»—¬·æ¬å·Ààߪ–‡»‰¬
“™«‘¬“—¬°ÿ¡“·æ¬å·Ààߪ–‡»‰¬
¡“§¡ª–“«‘¬“·Ààߪ–‡»‰¬
«‘¬“—¬·æ¬å‡«™»“μå§Õ§—«·Ààߪ–‡»‰¬
°¡æ—“·æ¬å·º‰¬·–·æ¬å“߇հ °–«ß““ÿ¢
π—∫ πÿπ‚¥¬ ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘

3. ·π«Σ“߇«™ªØ‘∫—μ‘
¿“«–ª«¥‡Àμÿæ¬“Π‘ ¿“æª√– “Σ
(Clinical Practice Guideline for Neuropathic Pain)
·π«Σ“߇«™ªØ‘∫—μ‘
¿“«–ª«¥‡Àμÿææ.»¬. “2551
Π‘ ¿“æª√– “Σ
(Clinical Practice ISBN: Guideline 978-974-598-for 056-Neuropathic 3
Pain)
æ.». 2551
ชื่อหนังสือ
®—¥Σ”‚¥¬
ISBN: 978-974-598-056-3
จัดทำโดย
®—¥Σ”‚¥¬
¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡Σ»‰Σ¬
‚¥¬§«“¡√à«¡¡◊Õ®“°
“™«‘¬“—¬Õ“¬ÿ·æ¬å·Ààߪ–‡»‰¬
“™«‘¬“—¬·æ¬åÕÕ傪°å·Ààߪ–‡»‰¬
“™«‘¬“—¬·æ¬å‡«™»“μåøóôøŸ·Ààߪ–‡»‰¬
“™«‘¬“—¬»—¬·æ¬å·Ààߪ–‡»‰¬
“™«‘¬“—¬°ÿ¡“·æ¬å·Ààߪ–‡»‰¬
¡“§¡ª–“«‘¬“·Ààߪ–‡»‰¬
¡“§¡°“√»÷°…“‡√◊ËÕߧ«“¡ª«¥·Ààߪ√–‡Σ»‰Σ¬
‚¥¬§«“¡√à«¡¡◊Õ®“°
“™«‘¬“—¬Õ“¬ÿ·æ¬å·Ààߪ–‡»‰¬
สบับสนุนโดย
«‘¬—¬·æ¬å‡«™»“μå§Õ§—«·Ààߪ–‡»‰¬
“™«‘¬“—¬·æ¬åÕÕ傪°å·Ààߪ–‡»‰¬
“™«‘¬“—¬·æ¬å‡«™»“μåøóôøŸ·Ààߪ–‡»‰¬
°¡æ—“·æ¬å·º‰¬·–·æ¬å“߇հ °–«ß““ÿ¢
“™«‘¬“—¬»—¬·æ¬å·Ààߪ–‡»‰¬
“™«‘¬“—¬°ÿ¡“·æ¬å·Ààߪ–‡»‰¬
¡“§¡ª–“«‘¬“·Ààߪ–‡»‰¬
π—∫ πÿπ‚¥¬ ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘
«‘¬“—¬·æ¬å‡«™»“μå§Õ§—«·Ààߪ–‡»‰¬
°¡æ—“·æ¬å·º‰¬·–·æ¬å“߇հ °–«ß““ÿ¢
ISBN: 978-974-598-056-3
พิมพ์ครั้งที่ 1
ธันวาคม 2551
π—∫ πÿπ‚¥¬ ”π—°ß“πÀ≈—°ª√–°—π ÿ¢¿“æ·Ààß™“μ‘
จำนวนพิมพ์
4,000 เล่ม
พิมพ์ที่
บียอนด์ เอ็นเทอร์ไพรซ์, กรุงเทพฯ

4. ÂœªšµŠ„µ¦¦´„¬µœ¸ÊÁž}œÁ‡¦ºÉ°Š¤º°­nŠÁ­¦·¤‡»–£µ¡…°Š„µ¦¦·„µ¦—oµœ­»…£µ¡
š¸ÉÁ®¤µ³­¤„´š¦´¡¥µ„¦ ¨³ÁŠºÉ°œÅ……°Š­´Š‡¤Åš¥ ×¥®ª´ŠŸ¨Äœ„µ¦­¦oµŠÁ­¦·¤
¨³Â„oÅ…ž{®µ­»…£µ¡…°Š‡œÅš¥°¥nµŠ¤¸ž¦³­·š›·£µ¡Â¨³‡»o¤‡nµ
…o°Âœ³œÎµ˜nµŠÇ ĜœªšµŠÁªž’·´˜·œ¸ÊŤnčn…o°´Š‡´…°Š„µ¦ž’·´˜·
Ÿ¼očo­µ¤µ¦™ž’·´˜·Â˜„˜nµŠÅž‹µ„…o°Âœ³œÎµœ¸ÊÅ—o
…¹Êœ°¥¼n„´„¦–¸®¦º°­™µœ„µ¦–rš¸É˜„˜nµŠ°°„Åž ®¦º°¤¸Á®˜»Ÿ¨š¸É­¤‡ª¦
ץčoª·‹µ¦–µ– ¨³„µ¦˜´—­·œÄ‹š¸ÉÁž}œš¸É¥°¤¦´Äœ­´Š‡¤

5. Neuropathic pain “
”
“
”
(general practitioners)
“ ”
. .
ก

6. ¦µ¥œµ¤‡–³Ÿ¼o‹´—šÎµ
1. ¦«.¡.¡Š«r£µ¦—¸Á‹µ”³Á„¬˜¦·œ š¸Éž¦¹„¬µ
­¤µ‡¤„µ¦«¹„¬µÁ¦ºÉ°Š‡ªµ¤žª—®nŠž¦³Áš«Åš¥
ž¦³›µœ
2. ¦«.œ¡.ž¦³—·¬“rž¦³š¸ž³ª–· ž¦³›µœ
­¤µ‡¤„µ¦«¹„¬µÁ¦ºÉ°Š‡ªµ¤žª—®nŠž¦³Áš«Åš¥
„¦¦¤„µ¦
3. ¦«.—¦.£.‹»”µ¤–¸­»š›·­¸­´Š…rž¦³›µœª·µ„µ¦
­¤µ‡¤„µ¦«¹„¬µÁ¦ºÉ°Š‡ªµ¤žª—®nŠž¦³Áš«Åš¥
„¦¦¤„µ¦
4. ¦«.¡.ª·¤¨¦´˜œr«¦¸¦µ ‡–³Â¡š¥«µ­˜¦r¤®µª·š¥µ¨´¥…°œÂ„nœ „¦¦¤„µ¦
5. «.œ¡.­µ¦Áœ˜¦ Ū‡„»¨ ¦µª·š¥µ¨´¥Â¡š¥r°°¦rÛžd—·„­r®nŠž¦³Áš«Åš¥ „¦¦¤„µ¦
6. Ÿ«.œ¡.ª·¬–»„´¤š¦š·¡¥r¦µª·š¥µ¨´¥Â¡š¥rÁª«µ­˜¦r¢gœ¢¼Â®nŠž¦³Áš«Åš¥ „¦¦¤„µ¦
7. œ¡.„»¨¡´•œrª¸¦­µ¦ ¦µª·š¥µ¨´¥«´¨¥Â¡š¥r®nŠž¦³Áš«Åš¥ „¦¦¤„µ¦
8. ¡š.œ¡.µ‡¦·œš¦r– µŠoµŠ ¦µª·š¥µ¨´¥„»¤µ¦Â¡š¥r®nŠž¦³Áš«Åš¥ „¦¦¤„µ¦
9. Ÿ«.¡.«·ªµ¡¦ ‹´œš¦r„¦³‹nµŠ ­¤µ‡¤ž¦³­µšª·š¥µÂ®nŠž¦³Áš«Åš¥ „¦¦¤„µ¦
10. ¦«.œ¡.°˜·Á¦„ ‹·ª³¡Š«rª·š¥µ¨´¥Â¡š¥rÁª«µ­˜¦r‡¦°‡¦´ªÂ®nŠž¦³Áš«Åš¥ „¦¦¤„µ¦
11. œ¡.›ª´ ¼¦–™µª¦­¤ „¦¤¡´•œµÂ¡š¥rŸœÅš¥Â¨³Â¡š¥ršµŠÁ¨º°„ „¦¦¤„µ¦
12. œ¡.­»¦‹·˜ ­»œš¦›¦¦¤ ¦µª·š¥µ¨´¥°µ¥»¦Â¡š¥r®nŠž¦³Áš«Åš¥ „¦¦¤„µ¦
13. ¦«.œ¡.„o°ŠÁ„¸¥¦˜·„¼–”r„´œš¦µ„¦ iµ¥ª·µ„µ¦
­¤µ‡¤„µ¦«¹„¬µÁ¦ºÉ°Š‡ªµ¤žª—®nŠž¦³Áš«Åš¥
„¦¦¤„µ¦Â¨³
Á¨…µœ»„µ¦
14. £„.›œ¦´˜œr­¦ª¨Á­œn®r‡–³Á£­´«µ­˜¦r¤®µª·š¥µ¨´¥«¦¸œ‡¦·œš¦ª·Ã¦• „¦¦¤„µ¦Â¨³
Ÿ¼onª¥Á¨…µœ»„µ¦
15. £„.¡Š«›¦ ¤¸­ª´­—·Í­¤ ‡–³Á£­´«µ­˜¦r¤®µª·š¥µ¨´¥«¦¸œ‡¦·œš¦ª·Ã¦• „¦¦¤„µ¦Â¨³
Ÿ¼onª¥Á¨…µœ»„µ¦
ข

7. สารบัญ
หน้า
คำนำ ก
รายนามคณะผู้จัดทำ ข
ข้อแนะนำการใช้CPG
วิธีการสืบค้นข้อมูล
ง
ฉ
บทที่ 1 บทนำ 1
1.1 ลักษณะอาการปวดเหตุพยาธิสภาพประสาท 1
1.2 ระบาดวิทยา 2
บทที่ 2 การวินิจฉัย เครื่องมือ และวิธีติดตามภาวะปวดเหตุพยาธิสภาพประสาท 3
บทที่ 3 การรักษาภาวะปวดเหตุพยาธิสภาพประสาท 7
3.1 การรักษาโดยการใช้ยา 7
3.2 การรักษาโดยการผ่าตัด 12
3.3 การรักษาโดยเวชศาสตร์ฟื้นฟูการแพทย์ผสมผสาน และ การแพทย์ทางเลือก 15
บทที่ 4 การวินิจฉัย และรักษาภาวะปวดเหตุพยาธิสภาพประสาทในโรคที่จำเพาะ 20
4.1 Diabetic peripheral neuropathy 20
4.2 Post herpetic neuralgia 22
4.3 Trigeminal neuralgia 23
4.4 Phantom limb pain 24
4.5 Central pain
4.6 อื่นๆ
25
26
บทที่ 5 เกณฑ์การส่งต่อผู้ป่วย 27
ภาคผนวก 1 คุณภาพหลักฐาน (Quality of evidence) 28
ภาคผนวก 2 หลักการกำหนดน้ำหนักคำแนะนำ 29
ภาคผนวก 3 แนวทางการใช้ระดับหลักฐานประกอบการกำหนดน้ำหนักคำแนะนำ 32
ภาคผนวก 4 ลักษณะของความปวดและการตรวจร่างกาย 33
ภาคผนวก 5 เครื่องมือที่ใช้ในการวินิจฉัยและคัดกรอง 35
ภาคผนวก 6 แบบสอบถาม Thai DN4 36
บรรณานุกรมและเอกสารแนะนำเพิ่มเติม 37
ค

8. …o°Âœ³œÎµ „µ¦Äo CPG
CPG Á®¤º°œÂŸœš¸É®¦º°‡¼n¤º°„µ¦Á—·œšµŠ Ážjµ®¤µ¥®¨´„…°Š CPG ‡º° „µ¦ª·œ·‹Œ´¥š¸É
™¼„˜o°ŠÂ¨³„µ¦—¼Â¨¦´„¬µ£µª³žª—Á®˜»¡¥µ›·­£µ¡ž¦³­µš „µ¦Äo CPG Á®¤º°œ„´„µ¦ÄoŸœš¸É
Á¤ºÉ°®¨ŠšµŠ®¦º°˜·—…´— – ‹»—Ä—„ÈÁžd——¼¦µ¥¨³Á°¸¥—¨³«¹„¬µ…o°¤¼¨ – ‹»—œ´Êœ Ž¹ÉŠ°µ‹Áž}œ˜µ¦µŠ
®¦º°¦µ¥¨³Á°¸¥—Äœ£µ‡Ÿœª„šoµ¥Á¨n¤
œÊε®œ´„‡ÎµÂœ³œÎµ (Strength of Recommendation)
œÊε®œ´„ ++ ®¤µ¥™¹Š ‡ªµ¤¤´ÉœÄ‹…°Š‡ÎµÂœ³œÎµÄ®ošÎµ°¥¼nÄœ¦³—´­¼Š Á¡¦µ³¤µ˜¦„µ¦
—´Š„¨nµª¤¸ž¦³Ã¥œr°¥nµŠ¥·ÉŠ˜n°Ÿ¼ožiª¥Â¨³‡»o¤‡nµ (cost effective) “‡ª¦šÎµ”
œÊε®œ´„ + ®¤µ¥™¹Š ‡ªµ¤¤´ÉœÄ‹…°Š‡ÎµÂœ³œÎµÄ®ošÎµ°¥¼nÄœ¦³—´žµœ„¨µŠ ÁœºÉ°Š‹µ„
¤µ˜¦„µ¦—´Š„¨nµª°µ‹¤¸ž¦³Ã¥œr˜n°Ÿ¼ožiª¥Â¨³°µ‹‡»o¤‡nµÄœ£µª³‹ÎµÁ¡µ³
“œnµšÎµ”
œÊε®œ´„ +/- ®¤µ¥™¹Š ‡ªµ¤¤´ÉœÄ‹¥´ŠÅ¤nÁ¡¸¥Š¡°Äœ„µ¦Ä®o‡ÎµÂœ³œÎµ ÁœºÉ°Š‹µ„¤µ˜¦„µ¦
—´Š„¨nµª¥´Š¤¸®¨´„“µœÅ¤nÁ¡¸¥Š¡°Äœ„µ¦­œ´­œ»œ®¦º°‡´—‡oµœªnµ °µ‹¤¸®¦º°
°µ‹Å¤n¤¸ž¦³Ã¥œr˜n°Ÿ¼ožiª¥ ¨³°µ‹Å¤n‡»o¤‡nµ ˜nŤn„n°Ä®oÁ„·—°´œ˜¦µ¥˜n°
Ÿ¼ožiª¥Á¡·É¤…¹Êœ —´Šœ´Êœ„µ¦˜´—­·œÄ‹„¦³šÎµ…¹Êœ°¥¼n„´ž{‹‹´¥°ºÉœÇ “°µ‹šÎµ
®¦º°Å¤nšÎµ”
œÊε®œ´„ - ®¤µ¥™¹Š ‡ªµ¤¤´ÉœÄ‹…°Š‡ÎµÂœ³œÎµ®oµ¤šÎµ°¥¼nÄœ¦³—´žµœ„¨µŠ ÁœºÉ°Š‹µ„
¤µ˜¦„µ¦—´Š„¨nµªÅ¤n¤¸ž¦³Ã¥œr˜n°Ÿ¼ožiª¥Â¨³Å¤n‡»o¤‡nµ ®µ„Ťn‹ÎµÁž}œ “Ťn
œnµšÎµ”
œÊε®œ´„ - - ®¤µ¥™¹Š ‡ªµ¤¤´ÉœÄ‹…°Š‡ÎµÂœ³œÎµ®oµ¤šÎµ°¥¼nÄœ¦³—´­¼Š Á¡¦µ³¤µ˜¦„µ¦
—´Š„¨nµª°µ‹Á„·—Ú¬®¦º°„n°Ä®oÁ„·—°´œ˜¦µ¥˜n°Ÿ¼ožiª¥ “Ťn‡ª¦šÎµ”
‡»–£µ¡…°Š®¨´„“µœšµŠª·µ„µ¦ (Classification of references)
Level of evidence A ®¤µ¥™¹Š ®¨´„“µœš¸ÉÅ—o‹µ„ systematic review …°Š randomized,
controlled clinical trials ®¦º°®¨´„“µœš¸ÉÅ—o‹µ„ randomized, controlled
clinical trials š¸É—εÁœ·œ„µ¦°¥nµŠÁ®¤µ³­¤
Level of evidence B ®¤µ¥™¹Š ®¨´„“µœš¸ÉÅ—o‹µ„ systematic review …°Š controlled clinical
study ®¦º° ®¨´„“µœš¸ÉÅ—o‹µ„ controlled clinical study (Ánœ
nonrandomized, controlled trial, cohort study, case-control study,
cross sectional study) š¸É—εÁœ·œ„µ¦°¥nµŠÁ®¤µ³­¤ ®¦º°®¨´„“µœš¸ÉÅ—o‹µ„
„µ¦ª·‹´¥šµŠ‡¨·œ·„š¸Éčo¦¼žÂ„µ¦ª·‹´¥°ºÉœ ¨³Ÿ¨„µ¦ª·‹´¥¡ž¦³Ã¥œr
ง
Š

9. ®¦º°Ãš¬‹µ„„µ¦ž’·´˜·¦´„¬µš¸ÉÁ—nœ´—¤µ„ ®¦º°Á¦ºÉ°Š—´Š„¨nµªÅ¤n¤¸Ÿ¨Šµœ
ª·‹´¥ž¦³Á£š randomized, controlled clinical trials ˜nÅ—oœÎµÁ°µ®¨´„“µœ
š¸ÉÅ—o‹µ„ randomized, controlled clinical trials Äœž¦³µ„¦„¨»n¤°ºÉœ®¦º°
Á¦ºÉ°Š°ºÉœš¸É‡¨oµ¥‡¨¹Š„´œ¤µÄoÁž}œ®¨´„“µœ ®¦º°®¨´„“µœš¸ÉÅ—o‹µ„
systematic review …°Š randomized, controlled clinical trials ®¦º°
randomized, controlled clinical trials š¸É—εÁœ·œ„µ¦Å¤nÁ®¤µ³­¤
Level of evidence C ®¤µ¥™¹Š ®¨´„“µœš¸ÉÅ—o‹µ„ systematic review …°Š descriptive study
®¦º° ®¨´„“µœš¸ÉÅ—o‹µ„ descriptive study Ž¹ÉŠ®¤µ¥™¹Š¦µ¥ŠµœŸ¼ožiª¥®œ¹ÉŠ
¦µ¥®¦º°¤µ„„ªnµ ®¦º°®¨´„“µœš¸ÉÅ—o‹µ„ systematic review …°Š
controlled clinical study ®¦º° controlled clinical study š¸É—εÁœ·œ„µ¦Å¤n
Á®¤µ³­¤ ®¦º°®¨´„“µœš¸ÉÅ—o‹µ„ controlled clinical trials Äœž¦³µ„¦„¨»n¤
°ºÉœ®¦º°Á¦ºÉ°Š°ºÉœš¸É‡¨oµ¥‡¨¹Š„´œ
Level of evidence D ¤µ¥™¹Š ®¨´„“µœš¸ÉÅ—o‹µ„‡ªµ¤Á®Èœ®¦º°Œ´œšµ¤˜· (consensus) …°Š‡–³
Ÿ¼oÁ¸É¥ªµ ÁœºÉ°Š‹µ„Ťn¤¸®¨´„“µœ‹µ„Ÿ¨Šµœª·‹´¥šµŠ‡¨·œ·„ ®¦º°
Ÿ¨Šµœª·‹´¥šµŠ‡¨·œ·„š¸É¤¸°¥¼nŤn­°—‡¨o°Š®¦º°Á®¤µ³­¤„´­™µœ„µ¦–r¨³
­™µœ£µ¡…°Š„µ¦ž¦³„°ª·µ¸¡Äœž¦³Áš«Åš¥ ®¦º°¤¸Á¡¸¥Š®¨´„“µœ
šµŠ®o°Šž’·´˜·„µ¦
®¤µ¥Á®˜»: Level of evidence (­µ¦¦µª·š¥µ¨´¥°µ¥»¦Â¡š¥r®nŠž¦³Áš«Åš¥ žeš¸É 18 Œ´š¸É 6
¡.¥.- ›.‡. 2544)
จ

10. ª·›¸„µ¦­º‡oœ…o°¤¼¨
‡–³Ÿ¼oœ·¡œ›r/Ÿ¼o‹´—šÎµÂœªšµŠ„µ¦¦´„¬µ£µª³žª—Á®˜»¡¥µ›·­£µ¡ž¦³­µšÅ—ošÎµ„µ¦­º‡oœ
…o°¤¼¨‹µ„“µœ…o°¤¼¨ Medline, Cochrane library, EMBASE ¨³“µœ…o°¤¼¨°ºÉœ ˜´ÊŠÂ˜nže 1966 ™¹Š
Á—º°œ¤„¦µ‡¤ 2008 ץčo‡Îµ­Îµ‡´—´Š˜n°Åžœ¸Ê neuropathic pain, epidemiology, assessment,
treatment, diagnosis, guideline, rehabilitation, complementary medicine, alternative
medicine, acupuncture, central pain, post herpetic neuralgia, trigeminal neuralgia, diabetic
peripheral neuropathy
Äœ­nªœ…°Š¦¦–µœ»„¦¤ ‹³¦³»ÁŒ¡µ³ key articles Ášnµœ´Êœ
ฉ

11. šœÎµ 1
1.1 ¨´„¬–³°µ„µ¦žª—Á®˜»¡¥µ›·­£µ¡ž¦³­µš
Neuropathic pain ®¤µ¥™¹Š ‡ªµ¤žª—Ž¹ÉŠÁž}œŸ¨Ã—¥˜¦Š‹µ„¡¥µ›·­£µ¡®¦º°Ã¦‡…°Š
somatosensory system ­nªœÄ®n¤´„‹³Á¦ºÊ°¦´Š ¨³¤¸°µ„µ¦žª—Á­¸¥ªÂž¨Á®¤º°œÅ¢o°˜
(lancinating) ­¦o°œ (burning) žª—Á¥ÈœÁ®¤º°œ™¼„œÊε…Ȋ ¦¼o­¹„¥·ÇŽnµÇ (tingling) ž¨ž¨µ
‡¨oµ¥Á…Ȥ˜Îµ (pins and needles) ‡´œ (itching) ®¦º°µ (paresthesia) ‡ªµ¤¦¼o­¹„š¸ÉŸ·—ž„˜·Á®¨nµœ¸Ê°µ‹
Á„·—…¹ÊœÁ°Š (stimulus- independent pain ®¦º° spontaneous pain) ®¦º°Á„·—£µ¥®¨´Š„µ¦„¦³˜»oœ
(stimulus- dependent pain ®¦º° stimulus-evoked pain) „ÈÅ—o ™oµ˜¦ª‹¡ªnµ ‡ªµ¤žª—Á„·—‹µ„
˜´ª„¦³˜»oœŽ¹ÉŠž„˜·Å¤nšÎµÄ®oÁ„·—‡ªµ¤žª— Á¦µÁ¦¸¥„„µ¦˜°­œ°Šš¸ÉŸ·—ž„˜·œ¸Êªnµ allodynia ®µ„Ÿ¼ožiª¥
¦¼o­¹„Å—o¤µ„„ªnµž„˜·„´„µ¦„¦³˜»oœŽ¹ÉŠž„˜·„ȚεĮoÁ„·—‡ªµ¤žª— Á¦µÁ¦¸¥„‡ªµ¤‡ªµ¤¦¼o­¹„š¸ÉŸ·—ž„˜·œ¸Êªnµ
hyperalgesia
Neuropathic pain ¡Å—on°¥ÄœŸ¼ožiª¥š¸É¤¸„µ¦µ—Á‹È®¦º°Áž}œÃ¦‡…°Š¦³ž¦³­µš Ž¹ÉŠ
¤oªnµ„µ¦µ—Á‹È®¦º°¦°¥Ã¦‡…°ŠŸ¼ožiª¥‹³Á®¤º°œ„´œ ˜n°µ„µ¦žª—°µ‹Â˜„˜nµŠ„´œ š´ÊŠ¨´„¬–³ Áª¨µ
¨³‡ªµ¤¦»œÂ¦Š …–³Á—¸¥ª„´œ Ÿ¼ožiª¥°µ‹¤¸°µ„µ¦žª—®¨µ¥¨´„¬–³ ÁœºÉ°Š‹µ„Á„·—‹µ„®¨µ¥„¨Å„ šÎµ
Ä®o„µ¦¦´„¬µš¸ÉÅ—o¦´Â˜„˜nµŠ„´œ neuropathic pain ¥´ŠÁž}œ­nªœž¦³„°Äœ„¨»n¤°µ„µ¦žª—°¸„®¨µ¥
œ·— Ánœ žª—‹µ„¤³Á¦ÈŠ žª—ÄœŸ¼ožiª¥˜·—ÁºÊ° HIV žª—®¨´ŠÁ¦ºÊ°¦´Š žª—„¨oµ¤ÁœºÊ° žª—£µ¥®¨´Š„µ¦
Ÿnµ˜´— ¨³ žª—°»oŠÁ·Š„¦µœ Äœ„¦–¸Ánœœ¸Ê¨´„¬–³…°Š neuropathic pain °µ‹Å¤n´—Á‹œÁšnµ„´Äœ
„¦–¸Â¦„ ÁœºÉ°Š‹µ„Áž}œ­nªœš¸ÉŸ­µœ°¥¼n„´‡ªµ¤žª—œ·—°ºÉœ ®¨´„„µ¦¦´„¬µ neuropathic pain Äœ
Ÿ¼ožiª¥š¸É¤¸‡ªµ¤žª—Ÿ­¤ (mixed pain) Ä®o¦´„¬µ˜µ¤°µ„µ¦žª—¨³¡¥µ›·­¦¸¦ª·š¥µš¸ÉÁž}œ­µÁ®˜»
Ž¹ÉŠ¤´„Ťn˜„˜nµŠ‹µ„Ÿ¼ožiª¥š¸É¤¸ neuropathic pain Á¡¸¥Š°¥nµŠÁ—¸¥ª
Äœ°—¸˜„µ¦ÂnŠ neuropathic pain Áž}œœ·—˜nµŠÇ ¥´ŠÅ¤n¤¸ÂÂŸœš¸ÉÂœnœ°œ Ánœ °µ‹ÂnŠ
˜µ¤Ã¦‡š¸ÉÁž}œ­µÁ®˜»Ánœ diabetic neuropathy, multiple sclerosis ®¦º°µŠš¸„ȝnŠ˜µ¤˜ÎµÂ®œnŠš¸É
¤¸¦°¥Ã¦‡Ánœ Á­oœž¦³­µš Å…­´œ®¨´Š ¨³oµŠ„ÈÁ…o¤Šª—ªnµ˜o°Š¤¸°µ„µ¦Â­—Šš¸ÉÁ®ÈœÅ—o´—ªnµ¤¸¡¥µ›·
…°Š¦³ž¦³­µš‹¹Š‹³ª·œ·‹Œ´¥ªnµÁž}œ neuropathic pain Äœže‡.«. 1994 International
Association for the Study of Pain ‹¹ŠÄ®oœ·¥µ¤ neuropathic pain Ä®oœ·¥µ¤…°Š neuropathic pain
Ūo°¥nµŠ„ªoµŠÇªnµ “‡ªµ¤žª—Ž¹ÉŠÁ„·—‹µ„¦°¥Ã¦‡®¦º°„µ¦šÎµŠµœš¸ÉŸ·—ž„˜·…°Š¦³ž¦³­µš”1
˜n°¤µ¡ªnµœ·¥µ¤œ¸Ê¤¸‹»—„¡¦n°Š®¨µ¥ž¦³„µ¦ Ánœ Ťn¤¸„µ¦¦³»ªnµ‹³˜o°ŠÁž}œ¦°¥Ã¦‡˜ÎµÂ®œnŠÄ—
Äœ¦³ž¦³­µš ˜n„ÈÁž}œš¸ÉÁ…oµÄ‹ªnµ‹³˜o°ŠÁ„¸É¥ª…o°Š„´­nªœ…°Š somatosensory pathways ¤¸„µ¦
šÎµ¨µ¥ž¨µ¥ž¦³­µš š¸ÉÄ¥ž¦³­µš…œµ—Á¨È„ ®¦º° spino-thalamocortical system …°Š¦³
1

12. ž¦³­µš­nªœ„¨µŠ „µ¦Äo‡Îµ°›·µ¥ªnµ “Áž}œ„µ¦šÎµŠµœš¸ÉŸ·—ž„˜·” „Ȥ¸‡ªµ¤®¤µ¥š¸É„ªoµŠ¤µ„
œ°„‹µ„œ¸Ê°µ„µ¦µŠ°¥nµŠš¸É¡Äœ neuropathic pain „È¡Äœ£µª³žª—Á¦ºÊ°¦´ŠÅ—o—oª¥2 —´Šœ´Êœ „µ¦
čoœ·¥µ¤œ¸Ê°µ‹šÎµÄ®o¤¸„µ¦ª·œ·‹Œ´¥ neuropathic pain ¤µ„„ªnµ‡ªµ¤Áž}œ‹¦·Š
Äœže‡.«. 2007 Äœ„µ¦ž¦³»¤ 2nd Congress of Neuropathic Pain š¸É„¦»ŠÁ°¦r¨·œ Å—o¤¸„µ¦
Ä®o‡Îµœ·¥µ¤Ä®¤nªnµ “‡ªµ¤žª—š¸ÉÁž}œŸ¨Ã—¥˜¦Š‹µ„懚¸É¤¸Ÿ¨„¦³š˜n° somatosensory system”
(Pain arising as a direct consequences of disease affecting the somatosensory system)3
œ·¥µ¤Ä®¤nœ¸ÊÁ…oµÄ‹Å—oŠnµ¥„ªnµÁ¡¦µ³Áœoœ˜ÎµÂ®œnŠ…°Š¡¥µ›·­£µ¡ šÎµÄ®oš¦µ„¨Å„„µ¦Á„·— —´Šœ´Êœ
‡ªµ¤žª—Á¦ºÊ°¦´Š‹µ„­µÁ®˜»°ºÉœŽ¹ÉŠ¦³ž¦³­µš¤¸‡ªµ¤Åª„ªnµž„˜· (hyperexcitability) ¨³¤¸„µ¦
Áž¨¸É¥œÂž¨ŠÅž (plasticity) ‹¹ŠÅ¤nčn neuropathic pain „µ¦¦´„¬µ neuropathic pain š¸ÉÅ—oŸ¨
‹³˜o°Š¦´„¬µ˜µ¤„¨Å„„µ¦Á„·— Ťnčnš¸É­µÁ®˜»…°Š‡ªµ¤žª—4
1.2 ¦³µ—ª·š¥µ
ÄœÁªž’·´˜·‹³¡ neuropathic pain ¦nª¤„´Ã¦‡šµŠ°µ¥»¦„¦¦¤š¸É¤¸Ÿ¨˜n°¦³ž¦³­µšš´ÊŠ
­nªœ„¨µŠ®¦º°­nªœž¨µ¥ Ánœ multiple sclerosis Áµ®ªµœ °µ‹¡®¨´Š„µ¦Á„·—懚¸É¤¸„µ¦®µ¥…°Š
¦°¥Ã¦‡Â¨oª Ánœ post herpetic neuralgia °µ‹¡®¨´Š„µ¦µ—Á‹È˜n°¦³ž¦³­µš‹µ„°»´˜·Á®˜»
Ánœ spinal cord injury ®¦º°®¨´Š„µ¦Ÿnµ˜´—Ánœ post mastectomy syndrome ®¦º° phantom pain
®¨´Š amputation œ°„‹µ„œ¸Ê¥´Š°µ‹¡¦nª¤„´Ã¦‡Á¦ºÊ°¦´Š°ºÉœš¸É¤¸Ÿ¨˜n°¦³ž¦³­µšÁnœ low back
pain š¸É¤¸ sciatica ®¦º° ¤³Á¦ÈŠ Áž}œ˜oœ
‡ªµ¤»„…°Š neuropathic pain ¤¸¦µ¥ŠµœÂ˜„˜nµŠ„´œÅž˜µ¤ª·›¸„µ¦Â¨³­™µœš¸Éš¸ÉšÎµ„µ¦«¹„¬µ
­µÁ®˜»…°Š°µ„µ¦žª—®¦º°Ã¦‡š¸É¡¦nª¤ ¦³¥³Áª¨µš¸ÉÁ„·—°µ„µ¦ ˜¨°—‹œ°µ¥»…°ŠŸ¼ožiª¥š¸ÉšÎµ„µ¦«¹„¬µ
×¥„µ¦­Îµ¦ª‹Äœž¦³µ„¦š´ÉªÅž¡Å—o¦o°¥¨³ 6.8-8.25, 6 ¡‡ªµ¤»„Á¡·É¤…¹ÊœÁž}œ¦o°¥¨³ 37.8-48 Äœ
Ÿ¼ožiª¥š¸É¤µ¦´„µ¦¦´„¬µš¸É抡¥µµ¨®¦º°‡¨·œ·„¦³Š´žª—7, 8 Ÿ¼ožiª¥¤´„Áž}œÁ¡«®·Š¤µ„„ªnµµ¥
­nªœÄ®n°¥¼nÄœª´¥„¨µŠ‡œ ÄœŸ¼ožiª¥¤³Á¦ÈŠ¡Å—o¦o°¥¨³ 369 ­nªœ‡ªµ¤»„Ĝ懘nµŠÇš¸É‹ÎµÁ¡µ³¤¸
¦µ¥ŠµœÂ˜„˜nµŠ„´œÅž˜µ¤œ·—…°ŠÃ¦‡ Ánœ 懚¸ÉÁ„¸É¥ª„´¦³ž¦³­µš­nªœž¨µ¥ ¡ post
herpetic neuralgia Å—o¦o°¥¨³ 10-1510 ÄœŸ¼ožiª¥Áµ®ªµœ¡Å—o¦o°¥¨³ 16-2611 ¨³Äœ low back
pain ¡Å—o¦o°¥¨³ 54.712 Áž}œ˜oœ ­nªœ‡ªµ¤»„Ĝ懚¸ÉÁ„¸É¥ª„´¦³ž¦³­µš­nªœ„¨µŠœ´Êœ ¡ post
stroke pain Å—o¦o°¥¨³ 813 Äœ multiple sclerosis ¡Å—o¦o°¥¨³ 27.514 ¨³Äœ£µª³µ—Á‹ÈÅ…­´œ
®¨´Š¡Å—o¦o°¥¨³ 13- 38 15, 16, 17 ­nªœ neuropathic pain ®¨´Š„µ¦Ÿnµ˜´— Ánœ post mastectomy
syndrome ¡Å—o¦o°¥¨³ 2018
Neuropathic pain Áž}œ‡ªµ¤žª—Á¦ºÊ°¦´Šš¸É¤¸Ÿ¨„¦³š˜n°‡»–£µ¡¸ª·˜Ÿ¼ožiª¥19 ¤¸°µ„µ¦š¸É
¡¦nª¤—oª¥Å—o„nœ°œÅ¤n®¨´ ­¼Á­¸¥­¤µ›·Ž¹¤Á«¦oµ „´Šª¨ ÁºÉ°°µ®µ¦20 ¨³¤¸„µ¦­¼Á­¸¥‡nµÄo‹nµ¥
Äœ„µ¦¦´„¬µ¡¥µµ¨¤µ„„ªnµŸ¼ožiª¥š¸ÉŤn¤¸ neuropathic pain21, 22
2

13. „µ¦ª·œ·‹Œ´¥ Á‡¦ºÉ°Š¤º°
¨³ª·›¸˜·—˜µ¤£µª³žª—Á®˜»¡¥µ›·­£µ¡ž¦³­µš 2
„µ¦ª·œ·‹Œ´¥Áž}œ­·ÉŠš¸É‹ÎµÁž}œ¤µ„­Îµ®¦´‡ªµ¤žª—š»„œ·— ×¥„µ¦Ž´„ž¦³ª´˜·Â¨³˜¦ª‹¦nµŠ„µ¥
Ž¹ÉŠÄ®o¦µ¥¨³Á°¸¥—Á„¸É¥ª„´ ˜ÎµÂ®œnŠ ¦³¥³Áª¨µš¸Éžª— ‡ªµ¤¦»œÂ¦Š ¨´„¬–³ ÂŸœ…°Š‡ªµ¤žª—
¥´ŠÁž}œ­·ÉŠš¸É‹ÎµÁž}œš¸É­»—Äœ…–³œ¸ÊÁ¡¦µ³…o°¤¼¨š¸ÉÅ—o‹³­µ¤µ¦™Ä®o„µ¦ª·œ·‹Œ´¥Äœ…´Êœ˜oœ ¨³Á¦·É¤Ä®o„µ¦
¦´„¬µÅ—o
×¥„µ¦Ž´„ž¦³ª´˜·Â¨³˜¦ª‹¦nµŠ„µ¥Ÿ¼ožiª¥ ¤¸‹»—ž¦³­Š‡rÁ¡ºÉ°‡oœ®µÃ¦‡š¸ÉÁž}œ­µÁ®˜»…°Š
°µ„µ¦ ¨³Á¡ºÉ°ª·œ·‹Œ´¥ªnµ ‡ªµ¤žª—œ´ÊœÁž}œœ·— nociceptive, neuropathic, psychogenic ®¦º°
Áž}œÂŸ­¤ ×¥ÁŒ¡µ³ neuropathic pain ÁœºÉ°Š‹µ„‡ªµ¤žª—œ·—œ¸Ê¤´„Ťn˜°­œ°Š˜n°„µ¦¦´„¬µ
—oª¥¥µÂ„ožª—¡ºÊœ“µœ ¡š¥r‹¹Š‹ÎµÁž}œ˜o°Šª·œ·‹Œ´¥Â¥„œ·—‡ªµ¤žª—¨³¦´„¬µÅž˜µ¤­µÁ®˜» ˜n
ÁœºÉ°Š‹µ„¥´ŠÅ¤n¤¸°µ„µ¦®¦º°°µ„µ¦Â­—ŠÄ—Çš¸ÉÁž}œ¨´„¬–³‹ÎµÁ¡µ³ (pathognomonic sign) …°Š
neuropathic pain ‹¹Š˜o°Š°µ«´¥…o°¤¼¨šµŠ‡¨·œ·„Ž¹ÉŠÅ—o„n°µ„µ¦žª—Äœ¦·Áª–ž¦³­µš„µ¥ª·£µ‡
(neuroanatomy) š¸ÉÁ„¸É¥ª…o°Š ž¦³ª´˜·„µ¦Á‹Èžiª¥®¦º°„µ¦¤¸¡¥µ›·­£µ¡…°Š¦³ž¦³­µš °µ„µ¦µ
®¦º°¦´¦¼oœo°¥„ªnµž„˜·Äœ¦·Áª–žª— ¨³®¨´„“µœªnµ¤¸¦°¥Ã¦‡š¸ÉÁ­oœž¦³­µš —´Šœ´Êœ ¦³—´‡ªµ¤
ÁºÉ°¤´ÉœÄœ„µ¦ª·œ·‹Œ´¥ neuropathic pain ÄœšµŠ‡¨·œ·„‹¹ŠÂ˜„˜nµŠ„´œ …¹Êœ„´ž¦·¤µ–…o°¤¼¨š¸É­œ´­œ»œ
(Ÿœ£¼¤·š¸É 2.1 ¨³¦¼žš¸É 2.1)
3

14. Ÿœ£¼¤·š¸É 2.1 …´Êœ˜°œÄœ„µ¦ª·œ·‹Œ´¥ (—¼¦µ¥¨³Á°¸¥—Äœ£µ‡Ÿœª„š¸É 4, 5 ¨³ 6)
°µ„µ¦žª—
„µ¦Ž´„ž¦³ª´˜·Â¨³„µ¦˜¦ª‹¦nµŠ„µ¥ (—¼£µ‡Ÿœª„š¸É 4) œÊε®œ´„‡ÎµÂœ³œÎµ
Ä®očo­°™µ¤ DN4 Œ´£µ¬µÅš¥Äœ„µ¦˜¦ª‹‡´—„¦°Š (—¼¦µ¥¨³Á°¸¥—…°Š Thai
DN4 Äœ£µ‡Ÿœª„š¸É 6)
+
®¦º° Ž´„ž¦³ª´˜·Äœ®´ª…o°˜n°Åžœ¸Ê
1. ¤¸ž¦³ª´˜·Ã¦‡ ®¦º°¦°¥Ã¦‡š¸ÉÁ„¸É¥ª…o°Š„´¦³ž¦³­µš ++
2. ˜ÎµÂ®œnŠš¸Éžª—Á„·—Äœ¦·Áª–š¸ÉÁ¨¸Ê¥Š—oª¥Á­oœž¦³­µšš¸Éµ—Á‹È Ž¹ÉŠÁ„¸É¥ª…o°Š„´
ž¦³­µš„µ¥ª·£µ‡°¥nµŠ´—Á‹œ
++
3. ¤¸¨´„¬–³ ÂŸœ…°Š‡ªµ¤žª— ‡º° žª—­¦o°œ žª—Á¥ÈœÁ®¤º°œ™¼„œÊε…Ȋ žª—
Á®¤º°œ™¼„Å¢o°˜
++
4. ¤¸°µ„µ¦˜n°Åžœ¸Ê¡¦o°¤„´°µ„µ¦žª— ‡º° Ž¼nŽnµÁ®¤º°œÁž}œÁ®œÈ, ž¨ž¨µ‡¨oµ¥
Á…Ȥ˜Îµ, µÅ¦o‡ªµ¤¦¼o­¹„, ‡´œ
++
5. ¤¸„µ¦¦´¦¼oÁ¤ºÉ°™¼„­´¤Ÿ´­ ®¦º°™¼„Á…Ȥ˜ÎµÅ—oœo°¥„ªnµž„˜·+
6. ¤¸°µ„µ¦žª—Á„·—…¹Êœ ®¦º°Á¡·É¤…¹ÊœÁ¤ºÉ°™¼„¨¼—oª¥Âž¦Š…œ +
¤¸…o° 1 ¨³ 2
+ …o° 3-6 °¸„ 1 …o°
Ťn¤¸
®¦º°¤¸Å¤n‡¦
Neuropathic pain °µ‹Å¤nčn
neuropathic pain
Ä®ošÎµ„µ¦ž¦³Á¤·œŽÊε°¸„‡¦´ÊŠ
ž¦³Á¤·œ‡ªµ¤žª—Á·Šž¦·¤µ– (‡ªµ¤¦»œÂ¦Š) œÊε®œ´„‡ÎµÂœ³œÎµ
x ץčo visual analog scale ®¦º° numerical rating scale ++
x ˜o°Šž¦³Á¤·œ„´‡ªµ¤žª—š»„¨´„¬–³ +/-
x šÎµ„µ¦´œš¹„‡ªµ¤žª—Á·Šž¦·¤µ–ŪoÁ¤ºÉ°¤¸„µ¦ª·œ·‹Œ´¥ÁºÊ°Š˜oœš»„‡¦´ÊŠ ¨³
¦³®ªnµŠšÎµ„µ¦¦´„¬µ
+
4

15. NEUROPATHIC PAIN
Definite
Probable
x Document of nerve
lesion
Possible
x Decreased sensibility in
painful area
x Decreased sensibility
in painful area
x History of relevant
disease or lesion in
the nervous system
x History of relevant
disease or lesion in the
nervous system
x History of relevant
disease or lesion in
the nervous system
x Pain in neuro-anatomical
area
x Pain in neuro-anatomical
area
x Pain in neuro-anatomical
area
¦¼žš¸É 2.1 ¦³—´‡ªµ¤ÁºÉ°¤´ÉœÄœ„µ¦ª·œ·‹Œ´¥ neuropathic pain1
°µ„µ¦žª—Áž}œ­µÁ®˜»œÎµš¸ÉšÎµÄ®oŸ¼ožiª¥¤µ¡Â¡š¥r—´Šœ´Êœ„µ¦‡´—„¦°Š neuropathic pain
°°„‹µ„‡ªµ¤žª—Á¦ºÊ°¦´Š°ºÉœÇ ‹¹ŠÄo‡Îµ¦¦¥µ¥Â¨³¨´„¬–³…°Š‡ªµ¤žª—Áž}œ­nªœ­Îµ‡´ Á‡¦ºÉ°Š¤º°
‡´—„¦°Š­nªœÄ®n‹¹ŠÁž}œÂ­°™µ¤š¸É¡´•œµÂ¨³Ÿnµœ„µ¦š—­°‡ªµ¤Áš¸É¥Š˜¦Š ¨³Å—oš—¨°ŠÄo
„´Ÿ¼ožiª¥ªnµÅ—oŸ¨Â¨oª ž{‹‹»´œÁ‡¦ºÉ°Š¤º°‡´—„¦°Š neuropathic pain ¤¸°¥¼n®¨µ¥ÂÄ®oÁ¨º°„čo˜µ¤
‹»—ž¦³­Š‡r (˜µ¦µŠš¸É 2.1) š¸ÉÂœ³œÎµÅ—o„n Neuropathic Pain Scale (NPS)2, Neuropathic Pain
Questionnaire (NPQ)3, NPQ short form4, Neuropathic Pain Symptom Inventory (NPSI)5, ID
Pain6, DN47, PainDetect8 ¨³ LANSS Pain Scale9 (—¼£µ‡Ÿœª„š¸É 5) Á‡¦ºÉ°Š¤º°Á®¨nµœ¸ÊčoŠnµ¥Ã—¥
¡š¥r®¦º°Ÿ¼onª¥ µŠÂŸ¼ožiª¥­µ¤µ¦™˜°Â­°™µ¤Å—oÁ°Š ˜nµŠÂ˜o°Š¤¸„µ¦˜¦ª‹®¦º°
š—­°‡ªµ¤¦¼o­¹„ץ¡š¥r¦nª¤—oª¥ °¥nµŠÅ¦„È—¸„µ¦œÎµÁ‡¦ºÉ°Š¤º°—´Š„¨nµª¤µÄo„´Ÿ¼ožiª¥˜nµŠµ˜·˜nµŠ
£µ¬µ ‹³˜o°Š¤¸„µ¦Âž¨—oª¥ª·›¸„µ¦°¥nµŠ™¼„˜o°Š ¨³˜o°Š¤¸„µ¦¡·­¼‹œr‡ªµ¤Áš¸É¥Š˜¦ŠÂ¨³ž¦³­·š›·£µ¡
„n°œ„µ¦Äoš»„‡¦´ÊŠ ­°™µ¤š¸É¤¸„µ¦Âž¨Áž}œ£µ¬µÅš¥°¥nµŠ™¼„˜o°ŠÂ¨oª‡º° DN410 (—¼Thai DN4
£µ‡Ÿœª„š¸É 6)
„µ¦˜¦ª‹®µ…o°¤¼¨Á·Šž¦·¤µ– (quantitative) …°Š‡ªµ¤žª— ‹³Å¤n¤¸ž¦³Ã¥œr˜n°„µ¦ª·œ·‹Œ´¥
neuropathic pain Ášnµ„´ „µ¦˜¦ª‹®µ…o°¤¼¨Á·Š‡»–£µ¡ (qualitative) ˜n„Èœ´ªnµ¤¸‡ªµ¤‹ÎµÁž}œ ™oµ‹³
˜·—˜µ¤Ÿ¨„µ¦¦´„¬µ —´Šœ´Êœ‹¹Š‡ª¦´œš¹„…o°¤¼¨Á·Šž¦·¤µ–ŪoÁ¤ºÉ°¤¸„µ¦ª·œ·‹Œ´¥…´Êœ˜oœš»„‡¦´ÊŠ
×¥š´ÉªÅž„µ¦ª´—ž¦·¤µ–‡ªµ¤žª—­µ¤µ¦™„¦³šÎµ—oª¥ª·›¸Šnµ¥Ç ‡º° čo¤µ˜¦ª´— Ž¹ÉŠ˜o°ŠÄo„´‡ªµ¤
žª—Ä®o‡¦š»„¨´„¬–³ Å—o„n spontaneous ongoing pain, spontaneous paroxysmal pain,
dysesthesia ¨³ paresthesia ®¦º° žª—Áª¨µ¤¸­·ÉŠ„¦³˜»oœ (evoked pains) °µ‹‹³Áž}œ allodynia
®¦º° hyperalgesia °µ„µ¦žª—š¸É¤µ„…¹ÊœÁª¨µÁž¨¸É¥œ°·¦·¥µš ¤µ˜¦ª´—š¸ÉÂœ³œÎµ Å—o„n
1. Visual analogue scale (VAS) Áž}œª·›¸ª´—ž¦·¤µ–‡ªµ¤žª—š¸Éčo¤µœµœ œnµÁºÉ°™º°Â¨³
Šnµ¥˜n°„µ¦ž’·´˜·11ÁœºÉ°Š‹µ„ VAS Áž}œÁ­oœ˜¦Š¥µª 10 ÁŽœ˜·Á¤˜¦ Ťn¤¸˜´ªÁ¨…Ä®oÁ®Èœ
5

16. ¥„Áªoœ­nªœ˜oœÂ¨³ž¨µ¥ ‹¹ŠÁ®¤µ³­Îµ®¦´Äoª´—ž¦·¤µ–‡ªµ¤¦»œÂ¦ŠÁž¦¸¥Áš¸¥Äœ
„µ¦«¹„¬µª·‹´¥ (¦¼žš¸É 2.2 A)
2. Numerical rating scale (NRS) ­nªœÄ®nčo 11-point Likert scale (0 = no pain, 10 =
worst possible pain) (¦¼žš¸É 2.2 B)
3. Verbal rating scales (VRS) čo‡Îµ°›·µ¥ ¦³—´‡ªµ¤¦»œÂ¦Š˜nµŠÇ Ä®oŸ¼ožiª¥Á¨º°„ (¦¼ž
š¸É 2.2 C)
4. Wong-Baker faces pain rating scale ¤µ˜¦ª´—œ¸ÊÁ®¤µ³­Îµ®¦´ž¦³Á¤·œ‡ªµ¤žª—ÄœÁ—È„
°µ¥»˜´ÊŠÂ˜n 3 že…¹ÊœÅžš¸É¥´ŠÅ¤n­µ¤µ¦™Äoª·›¸°ºÉœ Ánœ numerical rating scale Å—o ª·›¸„µ¦
‡º° ¸ÊÄ®oÁ—È„Á¨º°„¦¼ž®œoµš¸É°„™¹Š¦³—´‡ªµ¤žª— ¨oª´œš¹„˜´ªÁ¨…š¸É‡ªµ¤®¤µ¥˜¦Š„´œ
„´¦¼ž®œoµœ´Êœ (¦¼žš¸É 2.2 D)
Ťnžª—Á¨¥ žª—¤µ„š¸É­»—š¸É‡·—Å—o
Ťnžª—Á¨¥
0
žª—Á¨È„œo°¥
1-3
žª—žµœ„¨µŠ
4-6
žª—¤µ„
7-10
0 1 2 3 4 5 6 7 8 9 10
Ťnžª—Á¨¥ žª—¤µ„š¸É­»—š¸É‡·—Å—o
A
B
C
D
¦¼žš¸É 2.2 ¤µ˜¦ª´—‡ªµ¤žª— A: Visual analogue scale (VAS), B: Numerical rating scale
(NRS), C: Verbal rating scales (VRS), D: Wong-Baker faces pain rating scale
6

17. Äœ„µ¦ª´—‡ªµ¤¦»œÂ¦Š…°Š°µ„µ¦žª—˜n¨³Â ‡ª¦Äo¤µ˜¦ª´—œ·—Á—¸¥ª„´œ ¨³´œš¹„
Â¥„Ūo®µ„¤¸°µ„µ¦žª—š¸ÉÁ®¤º°œ„´œÄœ®¨µ¥˜ÎµÂ®œnŠ °µ‹ÄoŸœ£µ¡¦nµŠ„µ¥Á¡ºÉ°Â­—Š¨´„¬–³
¨³ž¦·¤µ–‡ªµ¤žª—˜n¨³œ·— (¦¼žš¸É 2.3)
¦¼žš¸É 2.3 ˜´ª°¥nµŠÂŸœ£µ¡¦nµŠ„µ¥š¸Éčo´œš¹„°µ„µ¦žª—
„µ¦ª´—ž¦·¤µ– ¥´Š­µ¤µ¦™šÎµÅ—o°¸„ª·›¸Ã—¥„µ¦˜¦ª‹®µž¦·¤µ–‡ªµ¤Ÿ·—ž„˜·Äœ„µ¦¦´¦¼o®¦º°
Quantitative Sensory Testing (QST) ª·›¸œ¸ÊŤnÂœ³œÎµÄ®očoÁ¡ºÉ°„µ¦ª·œ·‹Œ´¥…´Êœ˜oœ ÁœºÉ°Š‹µ„…o°¤¼¨š¸ÉÅ—o
Ťn¤¸‡ªµ¤­Îµ‡´˜n°„µ¦ª·œ·‹Œ´¥ œ°„‹µ„œ¸Ê¥´ŠšÎµ¥µ„ čoÁª¨µœµœÄœ„µ¦˜¦ª‹ ¨³˜o°ŠÄoÁ‡¦ºÉ°Š¤º°Ž¹ÉŠ¤¸
¦µ‡µ‡n°œ…oµŠÂ¡Š …o°—¸…°Š„µ¦˜¦ª‹®µž¦·¤µ–‡ªµ¤Ÿ·—ž„˜·Äœ„µ¦¦´¦¼o‡º°„µ¦˜·—˜µ¤ ¨³Á¤ºÉ°¤¸…o°
­Š­´¥Äœž¦³­·š›·£µ¡…°Š„µ¦¦´„¬µ „µ¦˜¦ª‹®µž¦·¤µ–‡ªµ¤Ÿ·—ž„˜·Áž}œ˜´ªÁ¨…‹¹ŠÁž¦¸¥Áš¸¥Å—o
Áš¸É¥Š˜¦Š„ªnµ …o°—¸°¸„ž¦³„µ¦‡º°­µ¤µ¦™šÎµŽÊεŗo°¸„Äœš»„„¦–¸Ã—¥ÁŒ¡µ³„µ¦˜·—˜µ¤Ÿ¨„µ¦¦´„¬µ
£µª³ allodynia ¨³ hyperalgesia
7

19. ž¦³Á¤·œ‡ªµ¤žª—¨³‡»–£µ¡¸ª·˜…°ŠŸ¼ožiª¥ *
‡ªµ¤žª—¨—¨Š¤µ„?A
čn
Ťnčn
¦´„¬µ—oª¥¥µ…œµ—Á—·¤˜n°Åž
¨³˜·—˜µ¤Ÿ¼ožiª¥Áž}œ¦³¥³ ­·Êœ­»—
‡ªµ¤žª—¨—¨ŠoµŠ?B čn
Ťnčn
‡ªµ¤žª—Å ¤n¨—¨Š®¦º°
¨ —¨ŠÁ¨È„œo°¥?C
Áž¨¸É¥œÅžÄo¥µ first-line drug ˜´ª°ºÉœ
Áž¨¸É¥œÁž}œ first-line drug œ·—°ºÉœ
Á¡·É¤¥µ first-line drug °¸„
1 œ·— Ž¹ÉŠ ‡ª¦¤¸„¨Å„
„µ¦°°„§š›·Í˜„˜nµŠ„´œ
(—¼¦µ¥¨³Á°¸¥—Äœ ˜µ¦µŠš¸É 1)
Á¡·É¤…œµ—¥µÁ—·¤
™oµÄo¥ µ first-line ˜´ªÁ—¸¥ª®¦º°
¦nª¤„´œ®¨µ¥˜´ªÂ¨oªÅ¤nÅ—oŸ¨
Ä®oÁž¨¸É¥œÅžÄo second -line
(—¼¦µ¥¨³Á°¸¥—Äœ˜µ¦µŠš¸É 3.1)
®¦º°
­nŠ˜n°Ÿ¼ožiª¥Åž¥´ŠŸ¼oÁ¸É¥ªµ
* šÎµ„µ¦ž¦ ³Á¤·œ‡n°œ…oµŠ™¸É×¥ÁŒ¡µ³ÄœnªŠÂ¦„…°Š„µ¦Äo¥µ
A Average p ain score ‹µ„ VAS ®¦º° NRS ¨—¨Š™¹Š 3/10 ¨³Ÿ¼ožiª¥šœ°µ„µ¦…oµŠÁ‡¸¥ŠÅ—o
B Average p ain score ‹µ„ VAS ®¦º° NRS ¥´Š‡Š 4/10 ®¨´Š‹µ„Å—očo¥µÄœ…œµ—š¸ÉÄ®oŸ¨Äœ„µ¦¦´„¬µ¤µÂ¨oª 4-8 ­´ž—µ®r
C Average pain score ‹µ„ VAS ®¦º° NRS ¨—¨Šœo°¥„ªnµ 30% ‹µ„Á—·¤ ×¥š¸Éčo…œµ—¥µš¸ÉÅ—oŸ¨Äœ„µ¦¦´„¬µÂ¨³Äo¥µ¤µ˜n°ÁœºÉ°Š
4-8 ­´ž—µ®r¨oª

20. ˜µ¦µŠš¸É 3.1 ­¦»ž…o°¤¼¨…°Š¥µ„¨»n¤˜nµŠÇ š¸ÉčoÄœ„µ¦¦´„¬µ neuropathic pain ¨³œÊε®œ´„ ‡ÎµÂœ³œÎµ
10
¥µ „¨Å„
„µ¦°°„§š›·Í
…œµ—¥µ °µ„µ¦…oµŠÁ‡¸¥Š
š¸É­Îµ‡´
…o°‡ª¦¦³ª´Š œÊε®œ´„‡ÎµÂœ³œÎµ
1. First-line medications Ÿ¼ožiª¥
š´ÉªÅž
Ÿ¼ožiª¥¤¸Ã¦‡¦nª¤
1.1 Tricyclic antidepressants
- Amitriptyline + + - -
Ťn‡ª¦ÄoÄœ
Ÿ¼ožiª¥­¤°Š
Á­ºÉ°¤ Ÿ¼ožiª¥
懮´ªÄ‹ æ‡
˜n°¤¨¼„®¤µ„Ø
˜o°®·œ¤»¤žd—
懨¤´„
- Nortriptyline +
(…œµ—¥µ
ŤnÁ„·œ 75
¤„./ª´œ)
-
- Imipramine
Enhance
descending
inhibitory
pain pathway
10-75 ¤„./
ª´œ
Á¦·É¤‹µ„
10-25 ¤„.
„n°œœ°œ
¨³ž¦´
…œµ—¥µ…¹Êœ
‡¦´ÊŠ¨³ 10-
25 ¤„. š»„
1-2 ­´ž—µ®r
ŠnªŠœ°œ, ®´ª
Ä‹Á˜oœÁ¦Èª,
anticholinergic,
°µ„µ¦…oµŠÁ‡¸¥Š
œÊε®œ´„˜´ªÁ¡·É¤
¦³ª´Š„µ¦ÄoÄœ
Ÿ¼o­¼Š°µ¥»Ÿ¼ožiª¥
­¤°ŠÁ­ºÉ°¤ Ÿ¼ožiª¥
懮´ªÄ‹ ¨³Ÿ¼ožiª¥
š¸É˜o°Š¦³ª´Š°µ„µ¦
…oµŠÁ‡¸¥Š
anticholinergic*
- - -
1.2 Calcium channel D2G1 ligands
- Gabapentin Block D2G1
subunit of
calcium
channel
300-3600
¤„./ª´œ
Á¦·É¤—oª¥ 100-
300 ¤„. „n°œ
œ°œ ¨³ž¦´
…œµ—¥µ…¹Êœ
‡¦´ÊŠ¨³ 100-
300 ¤„. š»„
3-7 ª´œ ×¥
nŠÄ®oª´œ¨³
2-4 ‡¦´ÊŠ
ŠnªŠœ°œ, ª·ŠÁª¸¥œ
ª¤š¸É¦¥µŠ‡r­nªœ
ž¨µ¥
˜o°Š¨—…œµ—¥µ
ÄœŸ¼ožiª¥š¸É¤¸„µ¦
šÎµŠµœ…°ŠÅ˜
„¡¦n°Š Á¡¦µ³
¥µ…´°°„šµŠÅ˜
Äœ¦¼žÁ—·¤
+ + +
Âœ³œÎµÄ®očoÄœ
Ÿ¼o­¼Š°µ¥»Ÿ¼ožiª¥
­¤°ŠÁ­ºÉ°¤
Ÿ¼ožiª¥Ã¦‡®´ªÄ‹
懘n°¤
¨¼„®¤µ„Ø ˜o°
®·œ¤»¤žd—
1.3 Sodium channel blockers
- Carbamazepine 200-1200
¤„./ª´œ
+ -
Ťn‡ª¦ÄoÄœ
Ÿ¼ožiª¥Ã¦‡˜´
æ‡Å…„¦³—¼„
- Oxcarbazepine
Block sodium
channel
300-1800
¤„./ª´œ
‡¨ºÉœÅ­o°µÁ‹¸¥œ
Áª¸¥œ«¸¦¬³
Á®Èœ£µ¡Žo°œ
šÎµÄ®oÃŽÁ—¸¥¤Äœ
Á¨º°—˜Éε
×¥ÁŒ¡µ³Ÿ¼oš¸É
Å—o¦´¥µ…´
ž{­­µª³ + -
Ťn‡ª¦ÄoÄœ
Ÿ¼ožiª¥Ã¦‡˜´
æ‡Å…„¦³—¼„
˜n° Æ
*°µ„µ¦…oµŠÁ‡¸¥Š anticholinergic Ánœ žµ„®oŠ ‡°Â®oŠ ˜µ¡¦nµ šo°ŠŸ¼„ ž{­­µª³‡´ÉŠ ŠnªŠŽ¹¤ ®´ªÄ‹Á˜oœÁ¦Èª
10

21. 11
˜µ¦µŠš¸É 3.1 ­¦»ž…o°¤¼¨…°Š¥µ„¨»n¤˜nµŠÇš¸ÉčoÄœ„µ¦¦´„¬µ neuropathic pain ¨³œÊε®œ´„ ‡ÎµÂœ³œÎµ (˜n°)
¥µ „¨Å„
„µ¦°°„§š›·Í
…œµ—¥µ °µ„µ¦…oµŠÁ‡¸¥Š
š¸É­Îµ‡´
…o°‡ª¦¦³ª´Š œÊε®œ´„‡ÎµÂœ³œÎµ
2. Second-line medications Ÿ¼ožiª¥š´ÉªÅž Ÿ¼ožiª¥¤¸Ã¦‡¦nª¤
2.1 Tramadol -Weak P
agonist
-Enhance
descending
inhibitory pain
pathway
50-400 ¤„./
ª´œ
‡¨ºÉœÅ­o°µÁ‹¸¥œ
šo°ŠŸ¼„ ª·ŠÁª¸¥œ
ŠnªŠŽ¹¤ šÎµÄ®o´„
Å—oŠnµ¥…¹Êœ
- ‡ª¦®¨¸„Á¨¸É¥Š
„µ¦ÄoÄœŸ¼ožiª¥
¨¤´„¨³„µ¦Äo
¦nª¤„´ SSRIs
¨³ SNRIs
- ‡ª¦¨—…œµ—¥µ
ÄœŸ¼ožiª¥š¸ÉŘ
šÎµŠµœ„¡¦n°Š
+ +/-
¦³¤´—¦³ª´Š„µ¦Äo
ÄœŸ¼ožiª¥Ã¦‡
¨¤´„ Ÿ¼ožiª¥š¸Éčo
¥µ SSRIs ¨³
SNRIs ¨³
TCAs
2.2 Oral morphine P agonist ž¦´…œµ—˜µ¤
„µ¦˜°­œ°Š
…°ŠŸ¼ožiª¥
‡¨ºÉœÅ­o°µÁ‹¸¥œ
šo°ŠŸ¼„ ª·ŠÁª¸¥œ
ŠnªŠŽ¹¤
- ‡ª¦¦³ª´Š„µ¦Äo
ÄœŸ¼ožiª¥š¸É˜·—¥µ
- ‡ª¦¨—…œµ—¥µ
ÄœŸ¼ožiª¥š¸ÉŘ
šÎµŠµœ„¡¦n°Š
+
„¦–¸š¸ÉŤn
˜°­œ°Š—¸
˜n°
tramadol
+/-
¦³¤´—¦³ª´Š„µ¦Äo
ÄœŸ¼ožiª¥˜·—
­µ¦Á­¡˜·—
°¨„°±°¨r
2.3 Methadone P agonist
NMDA
antagonist
ž¦´…œµ—˜µ¤
„µ¦˜°­œ°Š
…°ŠŸ¼ožiª¥
‡¨ºÉœÅ­o°µÁ‹¸¥œ
šo°ŠŸ¼„ ª·ŠÁª¸¥œ
ŠnªŠŽ¹¤
- ‡nµ‡¦¹ÉŠ¸ª·˜Äœ
¦nµŠ„µ¥¥µªœµœ
Á„·—„µ¦­³­¤…°Š
¥µÅ—oŠnµ¥ ¨³¤¸
°´œ˜¦„·¦·¥µ„´¥µ
°ºÉœÅ—on°¥ ‹¹Š˜o°Š
˜·—˜µ¤Ÿ¼ožiª¥
°¥nµŠÄ„¨o·—
+
„¦–¸š¸ÉŤn
˜°­œ°Š—¸
˜n°
tramadol
®¦º°
morphine
+/-
¦³¤´—¦³ª´Š„µ¦Äo
ÄœŸ¼ožiª¥Ã¦‡˜´
2.4 Pethidine P agonist Ťn‡ª¦Äo¦´„¬µ neuropathic pain ÁœºÉ°Š‹µ„¤¸Ÿ¨…oµŠÁ‡¸¥Š
¤µ„¨³Á„·—„µ¦˜·—¥µÅ—oŠnµ¥
- -
2.4 Selective serotonin and norepinephrine reuptake inhibitors (SNRIs)
- Venlafaxine 75-150 ¤„./
ª´œ
+ +/-
¦³¤´—¦³ª´Š„µ¦Äo
ÄœŸ¼ožiª¥š¸É¤¸‡ªµ¤
—´œÃ¨®·˜­¼ŠÂ¨³
‡ª‡»¤Å¤nÅ—o
- Duloxetine*
Enhance
descending
Inhibitory pain
pathway
30-60 ¤„./ª´œ
‡¨ºÉœÅ­oÄ‹­´Éœ
‡ªµ¤—´œÃ¨®·˜
Á¡·É¤ šo°ŠŸ¼„
¦³ª´Š„µ¦ÄoÄœ
Ÿ¼ožiª¥Ã¦‡®´ªÄ‹
Ťn‡ª¦Äo¦nª¤„´
tramadol Á¡¦µ³
Á¡·É¤‡ªµ¤Á­¸É¥Š˜n°
„µ¦Á„·—
serotonin
syndrome
+ +/-
¦³¤´—¦³ª´Š„µ¦Äo
ÄœŸ¼ožiª¥š¸É¤¸‡ªµ¤
—´œÃ¨®·˜­¼ŠÂ¨³
‡ª‡»¤Å¤nÅ—o
2.5 Calcium channel D2G1 ligands
- Pregabalin Block D2 G1
subunit of
calcium
channel
75-600 ¤„./
ª´œ
ŠnªŠœ°œ, ª·ŠÁª¸¥œ
,ª¤š¸É¦¥µŠ‡r­nªœ
ž¨µ¥
˜o°Š¨—…œµ—¥µ
ÄœŸ¼ožiª¥š¸É¤¸„µ¦
šÎµŠµœ…°ŠÅ˜
„¡¦n°ŠÁ¡¦µ³¥µ
…´°°„šµŠÅ˜Äœ
¦¼žÁ—·¤
+ ++
Âœ³œÎµÄ®očoÄœ
Ÿ¼o­¼Š°µ¥»Ÿ¼ožiª¥
­¤°ŠÁ­ºÉ°¤ Ÿ¼ožiª¥
懮´ªÄ‹ 懘n°¤
¨¼„®¤µ„Ø ˜o°
®·œ¤»¤žd—
2.6 Paracetamol, NSAIDs,
COX-2 inhibitors
Ťn‡ª¦ÄoÄœ„µ¦¦´„¬µ chronic neuropathic pain Á¡¦µ³Å¤n
¤¸ž¦³­·š›·£µ¡Â¨³°µ‹¤¸Ÿ¨…oµŠÁ‡¸¥Š
- -
*¥µ¥´Š°¥¼nÄœ¦³®ªnµŠ„µ¦˜·—˜µ¤‡ªµ¤ž¨°—£´¥ : Duloxetine ˜´ÊŠÂ˜n 31 ­·Š®µ‡¤ 2549
11

22. ˜µ¦µŠš¸É 3.2 ­¦»žœÊε®œ´„‡ÎµÂœ³œÎµ…°Š„µ¦Äo¥µÁ¤ºÉ°¡·‹µ¦–µ˜µ¤¨´„¬–³°µ„µ¦…°Š neuropathic pain
12
¥µ ¨´„¬–³°µ„µ¦…°Š neuropathic pain
Burning Lancinating Hyperalgesia Allodynia Paresthesia,
dysesthesia
TCA Amitriptyline + + +/- + + + + +
SNRI Venlafaxine + +/- + + +/-
Duloxetine + + +/- + + + +/-
Sodium channel Carbamazepine +/- + + + + +
blockers Oxcarbazepine +/- + + + + +
Calcium channel Gabapentin + + +/- + + + + +
D2G1 ligands Pregabalin + + +/- + + + + +
Opioids Tramadol + +/- + + +
Morphine +/- +/- +/- +/- +/-
˜µ¦µŠš¸É 3.3 ­¦»žœÊε®œ´„‡ÎµÂœ³œÎµ…°Š„µ¦Äo¥µÁ¤ºÉ°¡·‹µ¦–µ˜µ¤Ã¦‡š¸ÉÁž}œ­µÁ®˜»…°Š neuropathic pain
¥µ 懚¸ÉÁž}œ­µÁ®˜»…°Š neuropathic pain
DPN PHN TGN Phantom
limb pain
Central pain
TCA Amitriptyline + + + + +/- + + +
SNRI Venlafaxine + + - - +/-
Duloxetine + + + - - +/-
Sodium channel Carbamazepine +/- +/- + + + +
blockers Oxcarbazepine +/- +/- + + + +
Calcium channel Gabapentin + + + + +/- + +
D2G1 ligands Pregabalin + + + + +/- + +
Opioids Tramadol + + - +/- +/-
Morphine +/- +/- - +/- +/-
DPN: diabetic peripheral neuropathy, PHN: post herpetic neuralgia, TGN: trigeminal neuralgia

23. 13
3.2 „µ¦¦´„¬µÃ—¥„µ¦Ÿnµ˜´—
˜µ¦µŠš¸É 3.4 ­¦»ž…o°¤¼¨„µ¦¦´„¬µ neuropathic pain ×¥„µ¦Ÿnµ˜´— ¨³ œÊε®œ´„‡ÎµÂœ³œÎµ
æ‡ …o°nŠ¸Ê­Îµ®¦´„µ¦Ÿnµ˜´— ª·›¸„µ¦Ÿnµ˜´— œÊε®œ´„
‡ÎµÂœ³œÎµ
®¤µ¥Á®˜»
1. Ťn˜°­œ°Š˜n°„µ¦
¦´„¬µ—oª¥¥µ
2. Ťn­µ¤µ¦™šœ°µ„µ¦
…oµŠÁ‡¸¥Š‹µ„¥µÅ—o
3. ¤¸ vascular loop
compression
Microvascular decompression
(MVD)
+ + x 68-95% —¸…¹Êœ
x 70 – 95% Ťn¤¸°µ„µ¦žª—®¨´Š‹µ„
Ÿnµ˜´—
x 72 – 73% Ťn¤¸°µ„µ¦žª—®¨´Š‹µ„
˜·—˜µ¤Åž 5-6 že
x 0.1% Á­¸¥¸ª·˜
x 1 % ­¼Á­¸¥„µ¦Å—o¥·œ
Gamma knife +/- x 47 – 88 % Ťn¤¸°µ„µ¦žª—š¸ÉÁª¨µ 1
že (75 – 92.9 % —¸…¹Êœš¸ÉÁª¨µ 1 že)
x 24 – 74 % Ťn¤¸°µ„µ¦žª—š¸ÉÁª¨µš¸É
Áª¨µ 18 Á—º°œ ¨³ 3 že ( 48 –
90% —¸…¹Êœ)
x 10% Ťn˜°­œ°Š˜n°„µ¦¦´„¬µ—oª¥
SRS
x £µª³Âš¦„Žo°œš¸É¡Å—on°¥š¸É­»—‡º°
persistent paresthesia ( ¡
15.8% ÄœŸ¼oš¸ÉŤnÁ‡¥Å—o¦´„µ¦Ÿnµ˜´—
¤µ„n°œÂ¨³ 16.3% ÄœŸ¼oš¸ÉÁ‡¥¦´
„µ¦Ÿnµ˜´—¤µ„n°œ
Radiofrequency
thermoregulation
+ x 83 – 97% Ťn¤¸°µ„µ¦žª—š´œš¸®¨´Š
Ÿnµ˜´—
x 49 – 70% Ťn¤¸°µ„µ¦žª—š¸ÉÁª¨µš¸É
Áª¨µ 5-7 že
x °´˜¦µ„µ¦„¨´Áž}œŽÊε­¼Š
Trigeminal neuralgia
1. Ťn˜°­œ°Š˜n°„µ¦
¦´„¬µ—oª¥¥µ
2. Ťn­µ¤µ¦™šœ°µ„µ¦
…oµŠÁ‡¸¥Š‹µ„¥µÅ—o
Motor cortex stimulation +/- x 10% ‡ª‡»¤°µ„µ¦žª—Å—o—¸Á¥¸É¥¤,
42% ‡ª‡»¤°µ„µ¦žª—Å—o—¸, 35%
‡ª‡»¤°µ„µ¦žª—Å—oŤn—¸, 13%
°µ„µ¦žª—Ťn˜nµŠ‹µ„Á—·¤
x 36% ­µ¤µ¦™®¥»—¥µÂ„ožª—Å—o
Dorsal root entry zone
(DREZ) dressing
+/-
Spinal cord stimulation +/-
Post herpetic neuralgia 1. Ťn˜°­œ°Š˜n°„µ¦
¦´„¬µ—oª¥¥µ
2. Ťn­µ¤µ¦™šœ°µ„µ¦
…oµŠÁ‡¸¥Š‹µ„¥µÅ—oMotor cortex stimulation +/-
x ¤¸¦µ¥Šµœªnµ DREZ ¨³ spinal
cord stimulation (60-70% for
DREZ) ¤¸„µ¦˜°­œ°Š˜n°„µ¦
¦´„¬µ—¸
x ŤnÂœ³œÎµÄ®oŸnµ˜´—Ÿ·ª®œ´Š
˜n° Æ

24. ˜µ¦µŠš¸É 3.4 ­¦»ž…o°¤¼¨„µ¦¦´„¬µ neuropathic pain ×¥„µ¦Ÿnµ˜´— ¨³ œÊε®œ´„‡ÎµÂœ³œÎµ (˜n°)
14
æ‡ …o°nŠ¸Ê­Îµ®¦´„µ¦Ÿnµ˜´— ª·›¸„µ¦Ÿnµ˜´— œÊε®œ´„
‡ÎµÂœ³œÎµ
®¤µ¥Á®˜»
+/-
For general
x Ä®oŸ¨„µ¦¦´„¬µ—¸Äœ traumatic
amputations associated with root
avulsion
Dorsal root entry zone
(DREZ) lesion
- -
Stump pain
x Ä®oŸ¨„µ¦¦´„¬µÅ¤n—¸Äœ phantom
¨³ stump pain ®¦º° stump pain
°¥nµŠÁ—¸¥ª
Phantom limb pain 1. Ťn˜°­œ°Š˜n°„µ¦
¦´„¬µ—oª¥¥µ
2. Ťn­µ¤µ¦™šœ°µ„µ¦
…oµŠÁ‡¸¥Š‹µ„¥µÅ—o
Deep brain stimulation (DBS) +/- x °´˜˜¦µ¨—žª—Äœ¦³¥³¥µª­¼Šš¸É­»—
‡º° DBS š¸É PVG/PAG grey matter
(79%) ®¦º° PVG/PAG plus
sensory thalamus/internal
capsule (87%)
x „µ¦„¦³˜»oœ sensory thalamus
°¥nµŠÁ—¸¥ªÄ®oŸ¨œo°¥„ªnµ (58%
long-term success) (p 0.05)
x DBS Ä®oŸ¨„µ¦¦´„¬µ nociceptive
pain —¸„ªnµ deafferentation pain
(63% vs 47% long-term success;
p 0.01)
3. Ÿ¼ožiª¥š¸ÉÇœ¦¥µŠ‡rŸ·—
¦¼žÅ¤n­µ¤µ¦™Ä­nÂ…œ
…µÁš¸¥¤Å—o—¸¤¸„¦³—¼„
Š°„°°„¤µŸ·—ž„˜·¤¸
Ÿ¨Áž}œÄœ˜ÎµÂ®œnŠš¸É
„—„´Â…œ…µÁš¸¥¤¤¸
ÁœºÊ°Á¥ºÉ°°n°œš¸Éž¨µ¥
„¦³—¼„®œµ®¦º°µŠ
Á„·œÅž ®¦º°¤¸ÂŸ¨„—
š´
x „µ¦Ÿnµ˜´—œÎµ neuroma š¸É
°¥¼n˜ºÊœÂ¨³Áž}œ­nªœ­Îµ‡´
Äœ„µ¦Áž}œ‹»—„εÁœ·—‡ªµ¤
žª—°°„Åž
x „µ¦Ÿnµ˜´—¥oµ¥œ·ÊªÁšoµ¤µ¥´Š
Çœ¦¥µŠ‡rœš¸É…µ—¦³—´
…o°¤º°
+
+/-
Deep brain stimulation +/- x Trial stimulation ž¦³­
‡ªµ¤­ÎµÁ¦È‹ž¦³¤µ– 50% Äœ
Ÿ¼ožiª¥ post-stroke pain ¨³
58% …°ŠŸ¼ožiª¥š¸É {ŠÁ‡¦ºÉ°Š¤º°™µª¦
¥´Š­µ¤µ¦™¨—°µ„µ¦žª—Å—o
Thalamic pain 1. Ťn˜°­œ°Š˜n°„µ¦
¦´„¬µ—oª¥¥µ
2. Ťn­µ¤µ¦™šœ°µ„µ¦
…oµŠÁ‡¸¥Š‹µ„¥µÅ—o
Motor cortex stimulation +/- x 10% ‡ª‡»¤°µ„µ¦žª—Å—o¥°—
Á¥¸É¥¤, 42% ‡ª‡»¤°µ„µ¦žª—Å—o
—¸, 35% ‡ª‡»¤°µ„µ¦žª—Å—oŤn—¸
, 13% °µ„µ¦žª—Ťn˜nµŠ‹µ„Á—·¤
x 36% ­µ¤µ¦™®¥»—¥µÂ„ožª—Å—o
Causalgia, Sympathetic
mediated pain
1. Ťn˜°­œ°Š˜n°„µ¦
¦´„¬µ—oª¥¥µ
2. Ťn­µ¤µ¦™šœ°µ„µ¦
…oµŠÁ‡¸¥Š‹µ„¥µÅ—o
Sympathectomy +
ÁŒ¡µ³„¦–¸š¸É
šÎµ
sympathetic
block ¨oª
Å—oŸ¨
x ‡ªµ¤¡¹Š¡°Ä‹…°ŠŸ¼ožiª¥Äœ
£µ¡¦ª¤Â¨³‡ªµ¤ž¦µ¦™œµÄœ
„µ¦¦´„µ¦Ÿnµ˜´—‡¦´ÊŠ˜n°Åž°¥¼n
ÄœnªŠ 66-96%
x Ÿ¼ožiª¥ 94% š¸ÉšÎµ sympathectomy
®µ¥‹µ„°µ„µ¦žª—

25. 15
3.3 „µ¦¦´„¬µÃ—¥Áª«µ­˜¦r¢gœ¢¼„µ¦Â¡š¥rŸ­¤Ÿ­µœ
¨³„µ¦Â¡š¥ršµŠÁ¨º°„
Neuropathic pain Áž}œ£µª³žª—Á¦ºÊ°¦´Šš¸É¤¸Á®˜»Á„·—‹µ„‡ªµ¤Ÿ·—ž„˜·…°Š¦³ž¦³­µšš´ÊŠ
­nªœ„¨µŠÂ¨³­nªœž¨µ¥ ¤¸Ÿ¨˜n°¦nµŠ„µ¥ ‹·˜Ä‹ ¨³­´Š‡¤…°ŠŸ¼ožiª¥ šÎµÄ®oŸ¼ožiª¥šœš»„…rš¦¤µœ
Á‡¦¸¥— ª·˜„„´Šª¨ …µ—‡ªµ¤ÁºÉ°¤´ÉœÂ¨³£µ‡£¼¤·Ä‹Äœ˜œÁ°Š ‹·˜Ä‹Á«¦oµ®¤°Š Ž¹¤Á«¦oµ ­¼Á­¸¥
‡ªµ¤­µ¤µ¦™Äœ„µ¦Á‡¨ºÉ°œÅ®ª¦nµŠ„µ¥ ­¼Á­¸¥­¤¦¦™£µ¡Äœ„µ¦šÎµŠµœÂ¨³ž¦³„°°µ¸¡
­¼Á­¸¥¦µ¥Å—oŤn­µ¤µ¦™Á…oµ­´Š‡¤Å—oÁ®¤º°œž„˜·…µ—­´¤¡´œ›£µ¡š¸É—¸„´‡œÄœ‡¦°‡¦´ªÂ¨³Ÿ¼o°ºÉœ
šÎµÄ®oŸ¼ožiª¥…µ—‡ªµ¤­»…­Îµ¦µÄœ¸ª·˜ ¨³‡»–£µ¡¸ª·˜Â¥n¨Š —´Šœ´Êœ „µ¦—¼Â¨¦´„¬µŸ¼ožiª¥š¸É¤¸£µª³
neuropathic pain ‹¹Š¤¸Ážjµ®¤µ¥­Îµ‡´ 2 ž¦³„µ¦1 Å—o„n
1. ¨—žª—
2. Á¡·É¤‡ªµ¤­µ¤µ¦™Äœ„µ¦Á‡¨ºÉ°œÅ®ªÂ¨³­¤¦¦™£µ¡Äœ„µ¦šÎµŠµœ…°ŠŸ¼ožiª¥
Ážjµ®¤µ¥„µ¦¦´„¬µ˜o°ŠÁ®¤µ³­¤„´Ÿ¼ožiª¥Â˜n¨³¦µ¥ ¨³Áž}œÁžjµ®¤µ¥š¸ÉÁž}œÅžÅ—o¨³
­µ¤µ¦™ž’·´˜·Å—o‹¦·Š ×¥¡¥µ¥µ¤¨—žª—Ä®oŸ¼ožiª¥¤µ„š¸É­»—Ášnµš¸É‹³šÎµÅ—o¨³Á¡·É¤‡ªµ¤­µ¤µ¦™
Äœ„µ¦Á‡¨ºÉ°œÅ®ªÂ¨³­¤¦¦™£µ¡Äœ„µ¦šÎµŠµœ…°ŠŸ¼ožiª¥ Á¡ºÉ°šÎµÄ®o‡»–£µ¡¸ª·˜…°ŠŸ¼ožiª¥—¸…¹Êœ
×¥„µ¦¦´„¬µ—oª¥¥µ ¦nª¤„´„µ¦¦´„¬µÃ—¥Å¤nčo¥µ Å—o„n„µ¦—¼Â¨­£µ¡‹·˜Ä‹ „µ¦¢gœ¢¼
­¤¦¦™£µ¡Ÿ¼ožiª¥ „µ¦Â¡š¥rŸ­¤Ÿ­µœ ¨³„µ¦Â¡š¥ršµŠÁ¨º°„°ºÉœÇ Áž}œ˜oœ Ž¹ÉŠ…¹Êœ°¥¼n„´
­£µª³…°ŠŸ¼ožiª¥Â˜n¨³¦µ¥ ‡ªµ¤¦»œÂ¦Š…°ŠÃ¦‡Â¨³‡ªµ¤Á‹Èžª— ­£µ¡­´Š‡¤Á«¦¬“„·‹ ‡ªµ¤ÁºÉ°
‡ªµ¤«¦´š›µÂ¨³‡ªµ¤˜o°Š„µ¦…°ŠŸ¼ožiª¥ ˜µ¤®¨´„“µœšµŠ„µ¦Â¡š¥rš¸É¤¸°¥¼nš¸ÉšÎµÄ®oÁºÉ°Å—oªnµ°µ‹
Á„·—ž¦³Ã¥œr„nŸ¼ožiª¥ ¨³¤¸‡ªµ¤Á­¸É¥Šœo°¥š¸É­»— ×¥Áœoœ‡ªµ¤ž¨°—£´¥…°ŠŸ¼ožiª¥Áž}œ­Îµ‡´ „µ¦
¦´„¬µ­µ¤µ¦™Á…oµ™¹ŠÅ—oŠnµ¥®¦º°­µ¤µ¦™ž’·´˜·Å—oÁ°Š ¨³¦µ‡µÅ¤n¡Š
„µ¦¦´„¬µ£µª³ neuropathic pain ×¥ª·›¸š¸ÉŤnčo¥µ ×¥ÁŒ¡µ³„µ¦¢gœ¢¼­¤¦¦™£µ¡Ÿ¼ožiª¥
­nªœÄ®nŤn‡n°¥¤¸®¨´„“µœ­œ´­œ»œšµŠ„µ¦Â¡š¥rš¸É—¸œ´„ ®¦º°®¨´„“µœÅ¤n‡n°¥´—Á‹œ ¨³¥´Š¤¸
…o°‹Îµ„´—…°Š¦³Á¸¥ª·›¸„µ¦ª·‹´¥ Ánœ Ťn‡n°¥¤¸„µ¦ª·‹´¥Â RCT ‹ÎµœªœŸ¼ožiª¥ÄœŠµœª·‹´¥œo°¥
Á„·œÅž Áž}œ˜oœ —´Šœ´Êœ„µ¦¦´„¬µ­nªœÄ®n‹¹ŠÁž}œ¨´„¬–³¦´„¬µ˜µ¤°µ„µ¦ ¨³˜µ¤‡ªµ¤Á®Èœ
Ÿ¼oÁ¸É¥ªµ ×¥‹³Áž}œ„µ¦¦´„¬µÁ­¦·¤ (adjunctive therapy) ¦nª¤„´„µ¦¦´„¬µ°ºÉœÇ ץœªšµŠ
„µ¦ž’·´˜·Äœ„µ¦—¼Â¨¦´„¬µ‹³‡¦°‡¨»¤„µ¦¦´„¬µš¸É¤¸Äœž¦³Áš«Â¨³­µ¤µ¦™Á…oµ™¹ŠÅ—oŠnµ¥ Ž¹ÉŠ
­µ¤µ¦™ÄoÅ—o˜´ÊŠÂ˜nÁ¦·É¤Â¦„ ž¨°—£´¥ Ÿ¨…oµŠÁ‡¸¥Šœo°¥ ¨³¦µ‡µÅ¤n¡Š
„µ¦¦´„¬µ—oª¥ª·›¸š¸ÉŤnčo¥µ °µ«´¥ª·›¸„µ¦Â¨³°»ž„¦–r„µ¦¦´„¬µšµŠÁª«µ­˜¦r¢gœ¢¼Á¡ºÉ°
¦¦Ášµ°µ„µ¦žª— ¨³Áœoœ„µ¦¢gœ¢¼­¤¦¦™£µ¡¦nµŠ„µ¥Â¨³„µ¥£µ¡Îµ´—Á¡ºÉ°žj°Š„´œ
£µª³Âš¦„Žo°œ‹µ„„µ¦œ°œœµœ®¦º°…µ—„µ¦Á‡¨ºÉ°œÅ®ª Ž¹ÉŠ‹³šÎµÄ®oŸ¼ožiª¥Á„·—‡ªµ¤¡·„µ¦š»¡¡¨
£µ¡ŽÊεŽo°œ Ánœ „¨oµ¤ÁœºÊ°¨¸ °n°œÂ¦Š …o°˜n°˜·—¥¹— ¨³­¼Á­¸¥‡ªµ¤­µ¤µ¦™Äœ„µ¦šÎµŠµœÂ¨³
ž¦³„°°µ¸¡ Áž}œ˜oœ œ°„‹µ„œ¸Ê¥´Š˜o°ŠÄ®o„µ¦—¼Â¨­£µ¡‹·˜Ä‹ Ánœ‡ªµ¤ª·˜„„´Šª¨ Ž¹¤Á«¦oµ ¨³
15

26. Ä®o„ε¨´ŠÄ‹Ÿ¼ožiª¥Â¨³‡¦°‡¦´ª2,3 Á¡ºÉ°Ä®o­µ¤µ¦™ž¦´˜´ªš´ÊŠ¦nµŠ„µ¥Â¨³‹·˜Ä‹ Ä®o­µ¤µ¦™ÁŸ·„´
ž{®µ‡ªµ¤Á‹Èžª—š¸É¦»œÂ¦ŠÂ¨³Á¦ºÊ°¦´ŠÅ—o
16
3.3.1 „µ¦¦´„¬µÃ—¥Áª«µ­˜¦r¢gœ¢¼
‹µ„„µ¦ššªœŠµœª·‹´¥ neuropathic pain ¡ªnµ¤¸…o°¤¼¨š´ÊŠ®¤— 40 ·Êœ š¸ÉÁ„¸É¥ª…o°Š„´
Áª«µ­˜¦r¢gœ¢¼Â¨³ 5 ·Êœ š¸ÉÁ„¸É¥ª„´ alternative medicine ¨³ 36 ·Êœ š¸ÉÁ„¸É¥ª…o°Š„´ „µ¦
{ŠÁ…Ȥ (acupuncture) Ž¹ÉŠ¡°‹³­¦»žÁœºÊ°®µ­µ¦³­Îµ®¦´Áž}œÂœªšµŠÄœÁªž’·´˜·—´Š˜µ¦µŠš¸É 3.5
˜µ¦µŠš¸É 3.5 ­¦»ž„µ¦¦´„¬µšµŠÁª«µ­˜¦r¢gœ¢¼Â¨³ œÊε®œ´„‡ÎµÂœ³œÎµ
ª·›¸…o°nŠ¸Ê…o°‡ª¦¦³ª´Š/…o°®oµ¤ ‡ªµ¤Á®ÈœÁ¡·É¤Á˜·¤ Á°„­µ¦°oµŠ°·Š œÊε®œ´„‡ÎµÂœ³œÎµ
Patient education Á¦ºÉ°Š
­µÁ®˜»°µ„µ¦žª—
ž{‹‹´¥š¸ÉšÎµÄ®ožª—¤µ„…¹Êœ
®¦º°¨—¨Š
„µ¦ž’·´˜·˜´ª
++
TENS (Transcutaneous
Electrical Nerve
Stimulation)
- Hi-TENS (conventional)
ŗo„n Hi frequency, low
intensity
- Lo-TENS (acupuncture-like)
ŗo„n Lo frequency,
Hi intensity
Chronic neuropathic
pain
-°µ‹¦„ªœ„µ¦
šÎµŠµœ…°Š cardiac
pacemaker
-¦³ª´ŠÄœŸ¼ožiª¥µŠ
¦µ¥š¸É¤¸£µª³
allodynia °µ‹Å¤n
­µ¤µ¦™šœžª—‹µ„
„µ¦¦´„¬µÅ—oץčo
TENS „¦³˜»oœ8
-„µ¦«¹„¬µ 9 ¦µ¥Šµœ
‹Îµœªœ 200 ‡œ
-¨—žª—Å—o—¸­´¤¡´œ›r
„´ž¦·¤µ–„µ¦¦´„¬µ
Å—o„n‹Îµœªœ‡¦´ÊŠ
‡ªµ¤™¸É¨³¦³¥³Áª¨µ
Äœ„µ¦¦´„¬µÂ˜n¨³‡¦´ÊŠ
-Hi-TENS ¨—žª—Å—o
—¸„ªnµ¥µ®¨°„, ˜n
—o°¥„ªnµ Lo-TENS
- ¤¸Ÿ¨¦³Š´žª—
¦ª—Á¦Èª ˜n¤¸Ÿ¨
Á¡¸¥Š´Éª‡¦µª
- ­µ¤µ¦™ÄoÅ—oš»„ª´œ
…¹Êœ„´°µ„µ¦žª—
×¥š´ÉªÅžÄoÁª¨µ
¦´„¬µž¦³¤µ– 30
œµš¸/‡¦´ÊŠ ¨³
­µ¤µ¦™ŽÊε Å—oÁ¤ºÉ°¤¸
°µ„µ¦žª—
- ×¥š´ÉªÅž„µ¦
Á¨º°„čo Hi-TENS
®¦º° Lo-TENS ¤¸
…o°¤¼¨­œ´­œ»œÁ¡¸¥Š
µŠ­nªœ ˜nÄœšµŠ
ž’·´˜·„µ¦Á¨º°„čo
‡n°œ…oµŠÁž}œÂ trial
error µŠš¸˜o°Š¤¸
„µ¦­¨´„´œ ÁœºÉ°Š‹µ„
¤¸ accommodation
effects of nerve ¨³
nerve fiber
4,5,6,7 +
(Ÿ¼ožiª¥˜o°Š¤µÃ¦Š¡¥µµ¨
š»„ª´œ ¨³°µ‹Å¤n¤¸»‡¨µ„¦
Á¡¸¥Š¡°š¸É‹³¤µšÎµÄ®o˜¨°—)
+/-
­Îµ®¦´„¦–¸š¸ÉŸ¼ožiª¥ÅžŽºÊ°
œÎµ¤µÄoÁ°Š
- -
Ťn‡ª¦Äo Hi-TENS Äœ
Ÿ¼ožiª¥š¸Éčo cardiac
pacemaker
˜n° Æ
16

27. 17
˜µ¦µŠš¸É 3.5 ­¦»ž„µ¦¦´„¬µšµŠÁª«µ­˜¦r¢gœ¢¼Â¨³ œÊε®œ´„‡ÎµÂœ³œÎµ (˜n°)
ª·›¸…o°nŠ¸Ê…o°‡ª¦¦³ª´Š/…o°®oµ¤ ‡ªµ¤Á®ÈœÁ¡·É¤Á˜·¤ Á°„­µ¦°oµŠ°·Š œÊε®œ´„‡ÎµÂœ³œÎµ
Relaxation techniques
Ánœ „µ¦œ´ÉŠ­¤µ›·„µ¦­³„—
‹·˜ Ã¥‡³
Neuropathic pain:
Postherpetic neuralgia
¨³ peripheral
neuropathy
- - ­µ¤µ¦™¨—žª—Å—o
¨³°µ‹nª¥Á¡·É¤
‡»–£µ¡¸ª·˜…°Š
Ÿ¼ožiª¥
7,8,17 +
General Exercise Á¡ºÉ°
improve general condition
-­µ¤µ¦™¨—žª— ¨³
Å—ož¦³Ã¥œršµŠ°o°¤
‹µ„„µ¦š¸É„¨oµ¤ÁœºÊ°
…Ȋ¦Ššœšµœ ¨³
¥º—®¥»nœ—¸…¹Êœ ¨³¤¸
Ÿ¨—¸˜n°¦³®¨°—
Á¨º°—¨³®´ªÄ‹ ŤnÁ„·—
£µª³Âš¦„Žo°œ‹µ„
„µ¦œ°œœµœ®¦º°…µ—
„µ¦Á‡¨ºÉ°œÅ®ª
(immobilization
syndrome) šÎµÄ®o
Ÿ¼ožiª¥Å¤n­¼Á­¸¥
‡ªµ¤­µ¤µ¦™®¦º°
­¤¦¦™£µ¡Äœ„µ¦
Á‡¨ºÉ°œÅ®ª šÎµÄ®o­—
ºÉœ„¦³ž¦¸Ê„¦³Áž¦nµ
°µ¦¤–r—¸¤¸­»… ¨³
nª¥‡ª‡»¤œÊε®œ´„
-ž’·´˜·Å—oŠnµ¥
ž¨°—£´¥ ¦µ‡µ™¼„
6,7 ++
Specific exercise Á¡ºÉ°¨—
°µ„µ¦žª—
+/-
Heat Cold Ánœ hot
pack, warm bath, ice Áž}œ
˜oœ
Neuropathic pain -¦³ª´Š burn ™oµŸ¼ožiª¥
¤¸ sensory impaired
-­µ¤µ¦™nª¥¨—žª—
Å—oץčoÁž}œ„µ¦
¦´„¬µÁ­¦·¤
7 +/-
ÄœŸ¼ožiª¥š´ÉªÅž
- -
Ťn‡ª¦ÄoÄœŸ¼ožiª¥š¸É¤¸
sensory deficit
×¥ÁŒ¡µ³Ÿ¼ožiª¥ DM
Desensitization Å—o„n„µ¦
¨¼Å¨o„µ¦Á‡µ³ œª—‡¨¹Š
®¦º°„µ¦­´Éœ­³Ášº°œÁµÇ
¦·Áª–š¸É¤¸°µ„µ¦žª—
Neuropathic pain -¦³ª´ŠÄœŸ¼ožiª¥µŠ¦µ¥
š¸É¤¸£µª³ allodynia
°µ‹Å¤n­µ¤µ¦™šœ
žª—‹µ„„µ¦¦´„¬µÅ—o
-Áž}œ„µ¦¦´„¬µÁ­¦·¤
čoÅ—oš»„­£µª³ čoÅ—o
Šnµ¥ ­µ¤µ¦™šÎµÁ°ŠÅ—o
¦µ‡µ™¼„
9 +/-
- -
™oµŸ¼ožiª¥¤¸ allodynia ¨³
Ťn­µ¤µ¦™šœžª—Å—o‹µ„
„µ¦šÎµ (˜n°µ‹¡·‹µ¦–µ
ÄœŸ¼ožiª¥ÁŒ¡µ³¦µ¥)

28. 18
3.3.2 „µ¦¦´„¬µÃ—¥„µ¦Â¡š¥rŸ­¤Ÿ­µœ ¨³ „µ¦Â¡š¥ršµŠÁ¨º°„
„µ¦«¹„¬µ™¹Š„µ¦Äo„µ¦Â¡š¥ršµŠÁ¨º°„¨³„µ¦Â¡š¥rŸ­¤Ÿ­µœ (Complementary
Alternative Medicine: CAM) Äœ„µ¦¦´„¬µ peripheral neuropathy ¡ªnµ¦o°¥¨³ 43 ¤¸„µ¦Äo CAM
Å—o„nª·˜µ¤·œ (mega-vitamins ¦o°¥¨³ 35) ¤nÁ®¨È„ (magnet ¦o°¥¨³ 30) „µ¦ {ŠÁ…Ȥ (¦o°¥¨³ 30)
­¤»œÅ¡¦ (¦o°¥¨³ 22) ¨³ chiropractor (¦o°¥¨³ 21)10 ×¥¡ªnµÁ„º°‡¦¹ÉŠ®œ¹ÉŠ…°ŠŸ¼ožiª¥Äo¦·„µ¦
„µ¦Â¡š¥ršµŠÁ¨º°„¨³„µ¦Â¡š¥rŸ­¤Ÿ­µœ¤µ„„ªnµ®œ¹ÉŠœ·—…¹ÊœÅž ×¥Á®˜»Ÿ¨š¸É­Îµ‡´š¸É­»—š¸ÉšÎµ
Ä®oŸ¼ožiª¥ÅžÄo¦·„µ¦ ÁœºÉ°Š‹µ„ªnµ„µ¦¦´„¬µš¸ÉÅ—o¦´°¥¼nŤn­µ¤µ¦™¨—žª—Å—oŽ¹ÉŠÄœ¦¦—µŸ¼ožiª¥š¸Éčo
¦·„µ¦„µ¦Â¡š¥ršµŠÁ¨º°„¨³„µ¦Â¡š¥rŸ­¤Ÿ­µœ ž¦³¤µ–¦o°¥¨³ 27 ¦µ¥ŠµœªnµÅ—oŸ¨—¸
×¥š´ÉªÅž„µ¦¦´„¬µ—oª¥ª·›¸„µ¦Á®¨nµœ¸Ê¤´„Ťn‡n°¥¤¸®¨´„“µœšµŠ„µ¦Â¡š¥rš¸É¤¸„µ¦ª·‹´¥Áž}œ¦³Â¨³
¦³Á¸¥ª·›¸„µ¦ª·‹´¥¤¸…o°„¡¦n°Š ÄœšµŠž’·´˜·‹¹Š¡·‹µ¦–µÁž}œ¦µ¥Ç ץčoÁž}œ„µ¦¦´„¬µÁ­¦·¤‹µ„
„µ¦¦´„¬µÂ¤µ˜¦“µœ ×¥‡Îµœ¹Š™¹Š‡ªµ¤ž¨°—£´¥ Ÿ¨…oµŠÁ‡¸¥Š ¨³‡nµÄo‹nµ¥Äœ„µ¦¦´„¬µ¦nª¤
—oª¥ œÊε®œ´„‡ÎµÂœ³œÎµ…°Š„µ¦Äo CAM Äœ„µ¦¦´„¬µ°µ„µ¦žª—Äœ neuropathic pain —´Š­¦»žÄœ
˜µ¦µŠš¸É 3.6
18

29. 19
˜µ¦µŠš¸É 3.6 ­¦»ž„µ¦Â¡š¥rŸ­¤Ÿ­µœ ¨³„µ¦Â¡š¥ršµŠÁ¨º°„ ¨³ œÊε®œ´„‡ÎµÂœ³œÎµ
ª·›¸…o°nŠ¸Ê…o°‡ª¦¦³ª´Š/…o°®oµ¤ ‡ªµ¤Á®ÈœÁ¡·É¤Á˜·¤ Á°„­µ¦°oµŠ°·Š œÊε®œ´„‡ÎµÂœ³œÎµ
„µ¦ {ŠÁ…Ȥ
(Acupuncture)
Painful diabetic
neuropathy, central
neuropathic pain in
spinal cord injury
(SCI)
…o°‡ª¦¦³ª´Š
-„¦³šÎµÃ—¥Ÿ¼oÁ¸É¥ªµÁšnµœ´Êœ
-Ÿ¼oš¸É¤¸ÂœªÃœo¤Á¨º°—°°„Šnµ¥
Ánœ Å—o¦´¥µ˜oµœÁ„¦È—Á¨º°—®¦º°
¥µ˜oµœ„µ¦Â…ÈŠ˜´ª…°ŠÁ¨º°—
Ÿ¼ožiª¥Ã¦‡˜´Â…ÈŠ ¤¸¦°¥Á…¸¥ª‹Êε
¡¦µ¥¥Êε Á¨º°—°°„ Á¨º°—‡´ÉŠ
¦·Áª–‹»— {ŠÁ…Ȥ ®¦º°¤¸‡ªµ¤
Ÿ·—ž„˜·…°Š¦³„µ¦Â…ÈŠ˜´ª
…°ŠÁ¨º°—
-¤¸ÂŸ¨˜·—ÁºÊ°¦·Áª–‹»— {ŠÁ…Ȥ
-Ÿ¼ožiª¥š¸ÉÁž}œÃ¦‡˜·—ÁºÊ°š¸É˜·—˜n°
ŸnµœšµŠÁ¨º°—Ánœ HIV,
hepatitis B
-RCT Äœ£µª³žª—‹µ„¦°¥Ã¦‡
Š¼­ª´— (postherpetic neuralgia)
Ÿ¨Å¤n˜„˜nµŠ‹µ„ placebo,
sham, ®¦º°Å¤nÄ®o„µ¦¦´„¬µ
-Å—oŸ¨—¸ÄœŸ¼ožiª¥ painful
diabetic neuropathy, central
neuropathic pain in SCI
-ž¨°—£´¥ ˜n¤¸…o°‹Îµ„´— Á¦ºÉ°Š
¦³Á¸¥ª·›¸„µ¦ª·‹´¥ Ánœ ‹Îµœªœ
Ÿ¼ožiª¥œo°¥ ¨³Å¤n¤¸„¨»n¤‡ª‡»¤
-°µ‹¡·‹µ¦–µÁž}œ„µ¦¦´„¬µ
¦nª¤„´„µ¦¦´„¬µ°ºÉœ Á¡ºÉ°Äo¨—
žª—®¦º°¨—ž¦·¤µ–¥µš¸É˜o°Š
čoÅ—o‡ªµ¤Á­¸É¥ŠÂ¨³£µª³Âš¦„
Žo°œœo°¥ ™oµÅ—o¦´„µ¦¦´„¬µÃ—¥
Ÿ¼oš¸ÉÅ—o¦´„µ¦ f„ œ˜µ¤
¤µ˜¦“µœ
-×¥š´ÉªÅž {ŠÁ…Ȥ 1-3 ‡¦´ÊŠ ˜n°
­´ž—µ®r (10 ‡¦´ÊŠ/‡°¦r­) ™oµÅ¤n
Å—oŸ¨Äœ 4-5 ‡¦´ÊŠ ¡·‹µ¦–µ®¥»—
„µ¦¦´„¬µ
5,8,11
1,6,12,13
10,14
+/-
­Îµ®¦´„µ¦ÄoÄœ
radiculopathy ¨³
trigeminal neuralgia
‹³Ä®oŸ¨¨—°µ„µ¦žª—
Å—o´Éª‡¦µª ¨³¥´Š¤¸
®¨´„“µœ­œ´­œ»œ
œo°¥
+/-
Ĝ Central NeP
(SCI) ¨³ painful
diabetic neuropathy
-
Ĝ post-herpetic
neuralgia
°µ®µ¦Â¨³ª·˜µ¤·œ Painful peripheral
neuropathy
-Ťn¤¸Ÿ¨Ã—¥˜¦Š„´°µ„µ¦žª—
neuropathic pain ˜n°µ‹¤¸Ÿ¨
˜n°Ã¦‡š¸ÉÁž}œ­µÁ®˜»…°Š°µ„µ¦
žª— neuropathic pain
-Âœ³œÎµ°µ®µ¦­¤—»¨ (balanced
diet)
-®¨¸„Á¨¸É¥ŠÁ‡¦ºÉ°Š—ºÉ¤š¸É¤¸
°¨„°±°¨rŸ­¤‹œ¤µ„Á„·œÅž
(ŤnÁ„·œª´œ¨³ 1 —ºÉ¤)
-¡·‹µ¦–µÄ®oª·˜µ¤·œÁ­¦·¤
×¥ÁŒ¡µ³Ÿ¼ožiª¥š¸É—ºÉ¤­»¦µ‹´—
¨³…µ—ª·˜µ¤·œ
-ž¨°—£´¥ ˜n˜o°Š¦³ª´ŠŸ¨Á­¸¥
‹µ„„µ¦Äo¤µ„Á„·œÅž‹œÁ„·œ
…œµ— ×¥ÁŒ¡µ³ B6 Ž¹ÉŠ°µ‹šÎµ
Ä®oÁ„·— neuropathy Å—o
6,10 +
Balanced diet
+ +
Avoid alcohol
+/-
MTV, B complex, 3B
- -
Ťn‡ª¦Äo B6 …œµ—
¤µ„„ªnµ 100 ¤„./ª´œ)
- -
Vitamin E 400
U/day ¥„ÁªoœÄœ„µ¦
¦´„¬µ Parkinson’
disease ¨³
Alzheimer’s disease
„µ¦œª—ŸœÅš¥
(Ťn¦ª¤„µ¦œª—
Á¡ºÉ°Ÿn°œ‡¨µ¥)
Mild degree
neuropathic pain
ÁnœÁ—¸¥ª„´„µ¦œª—×¥š´ÉªÅž -°µ‹nª¥¨— peripheral
sensitization ÄœµŠ¦µ¥
-‡ª¦Äo¦nª¤„´„µ¦¦´„¬µ—oª¥¥µ
Äœ¦µ¥š¸É¤¸°µ„µ¦žª—žµœ„¨µŠ
™¹Š¦»œÂ¦Š
+/-
19

30. 20
„µ¦ª·œ·‹Œ´¥ ¨³¦´„¬µ
£µª³žª—Á®˜»¡¥µ›·­£µ¡ž¦³­µšÄœÃ¦‡š¸É‹ÎµÁ¡µ³ 4
4.1 Diabetic neuropathy
æ‡Áµ®ªµœÁž}œÃ¦‡Á¦ºÊ°¦´Šš¸É¡Å—on°¥Â¨³„n°Ä®oÁ„·—£µª³Âš¦„Žo°œ˜nµŠÇÅ—o¤µ„
æ‡Á­oœž¦³­µš„ÈÁž}œ­µÁ®˜»®œ¹ÉŠš¸É„n°Ä®oÁ„·—‡ªµ¤¡·„µ¦Â¨³­nŠŸ¨˜n°‡»–£µ¡¸ª·˜…°ŠŸ¼ožiª¥
Áµ®ªµœÁnœ„´œ ×¥ÁŒ¡µ³ÄœŸ¼ožiª¥š¸ÉÁž}œÁµ®ªµœ¤µœµœÂ¨³‡ª‡»¤Ã¦‡Å—oŤn—¸š´ÊŠÄœÁµ®ªµœ
œ·—š¸É 1 ¨³œ·—š¸É 2 ÄœµŠ¦µ¥°µ‹¡Ã¦‡Á­oœž¦³­µšÄœ…–³š¸ÉÁ¡·ÉŠÅ—o¦´„µ¦ª·œ·‹Œ´¥Áµ®ªµœ
œ·—š¸É 2 „ÈÅ—oÁœºÉ°Š‹µ„Ÿ¼ožiª¥°µ‹Å¤n¤¸°µ„µ¦Áµ®ªµœ¤µ„œ´„˜nÁž}œÃ¦‡¤µœµœ °µ„µ¦žª—Áž}œ
°µ„µ¦­Îµ‡´…°ŠÃ¦‡Á­oœž¦³­µšœ¸Ê˜n°µ‹Å¤n¡ÄœŸ¼ožiª¥š»„¦µ¥Ž¹ÉŠ„¨Å„—´Š„¨nµª¥´ŠÅ¤nÁž}œš¸É
´—Á‹œœ´„ Ÿ¼ožiª¥­nªœÄ®nš¸É¤¸°µ„µ¦žª— ¤´„‹³¤¸°µ„µ¦žª—Á¦ºÊ°¦´Š ¦´„¬µÅ—o¥µ„ ¨³­nŠŸ¨˜n°
‡»–£µ¡¸ª·˜…°ŠŸ¼ožiª¥ °µ‹„n°Ä®oÁ„·—£µª³Âš¦„Žo°œ°ºÉœ˜µ¤¤µ ¨³Á„·—‡ªµ¤­¼Á­¸¥šµŠÁ«¦¬“„·‹
Äœš¸É­»—1
‡ªµ¤»„…°Š£µª³Á­oœž¦³­µšÁ­ºÉ°¤œ¸Ê‡n°œ…oµŠ®¨µ„®¨µ¥˜µ¤„¨»n¤ž¦³µ„¦Â¨³ž¦³Áš«š¸É
«¹„¬µ ¦µ¥Šµœ…œµ—Ä®n‹µ„ž¦³Áš«°°­Á˜¦Á¨¸¥¡£µª³œ¸Ê¦o°¥¨³ 13.12 ÄœŸ¼ožiª¥Áµ®ªµœš´ÊŠÁ„nµ
¨³Ä®¤n­nªœÄœ°·˜µ¨¸¡¦o°¥¨³ 32.33 °¥nµŠÅ¦„Șµ¤Ÿ¼ožiª¥­nªœ®œ¹ÉŠÁšnµœ´Êœš¸É¤¸°µ„µ¦žª—¦nª¤—oª¥
Ž¹ÉŠ‹³¤µ„…¹Êœ˜µ¤¦³¥³Áª¨µš¸Éžiª¥Áž}œÁµ®ªµœ Ánœ ¦o°¥¨³ 7-13 Á¤ºÉ°Å—o¦´„µ¦ª·œ·‹Œ´¥4 ¨³Á¡·É¤
Áž}œ¦o°¥¨³ 20-33% ®¨´ŠÁž}œÁµ®ªµœ¤µ 10 že4 Ž¹ÉŠ¤¸‡ªµ¤­´¤¡´œ›r„´„µ¦Á„·—Ÿ¨Á¦ºÊ°¦´Šš¸ÉÁšoµÄœ
Ÿ¼ožiª¥Åš¥5
¨´„¬–³šµŠ‡¨·œ·„š¸É­Îµ‡´
„¨»n¤°µ„µ¦š¸É­Îµ‡´­µ¤µ¦™ÂnŠÅ—o 3 „¨»n¤‡º°
1. Distal symmetric diabetic polyneuropathy (DSDP)
Áž}œ„¨»n¤°µ„µ¦š¸É¡Å—on°¥š¸É­»— ×¥Ÿ¼ožiª¥­nªœÄ®n¤´„¤¸°µ„µ¦šµŠž¦³­µš¦´‡ªµ¤¦¼o­¹„š¸É
Ÿ·—ž„˜·„n°œ Ánœ ¤¸°µ„µ¦µ žª—­¦o°œ ¦¼o­¹„®œµ/®œ´„ ²¨² š¸ÉÁšoµš´ÊŠ 2 …oµŠÁšnµÇ„´œ ×¥¤¸
°µ„µ¦¤µ„˜°œ„¨µŠ‡ºœ ¨³°µ‹šÎµÄ®oŸ¼ožiª¥Á„·—°»´˜·Á®˜»®¦º°ÂŸ¨Á¦ºÊ°¦´Šš¸É¦¥µŠ‡rÅ—o®µ„Áž}œ¤µ„
…¹Êœ‹³¤¸°µ„µ¦ÁnœÁ—¸¥ª„´œš¸É¤º° ‹œÄœš¸É­»—‹³Á„·—„µ¦Áž¨¸É¥œÂž¨Š…°ŠŸ·ª®œ´Š ®¦º°…o° Äœ¦·Áª–
œ´Êœ µŠ¦µ¥°µ‹Á„·—¦nª¤„´„¨»n¤°µ„µ¦Ã¦‡Á­oœž¦³­µš°ºÉœÇÅ—o
2. Autonomic neuropathy
‡ªµ¤Ÿ·—ž„˜·…°Š¦³ž¦³­µšÁ­¦¸ (autonomic neuropathy) °µ‹¡Å—o™¹Š‡¦¹ÉŠ®œ¹ÉŠ…°Š
Ÿ¼ožiª¥Áµ®ªµœÂ¨³ ¤´„¡¦nª¤„´ DSDP šÎµÄ®oŸ¼ožiª¥¤¸°µ„µ¦˜nµŠÇ Ánœ šo°ŠŸ¼„ šo°ŠÁ­¸¥
ž{­­µª³Ÿ·—ž„˜·Áž}œ¨¤ ®¦º°‡ªµ¤—´œÃ¨®·˜˜Éε´Éª‡¦µªÁ¤ºÉ°Áž¨¸É¥œšnµšµŠ ­¤¦¦™£µ¡šµŠÁ¡«
20

31. ¨—¨Š Á®ŠºÉ°°°„¤µ„®¦º°œo°¥„ªnµž„˜·Áž}œ˜oœ ‡ªµ¤Ÿ·—ž„˜·˜n°„µ¦Á˜oœ®´ªÄ‹‹µ„£µª³œ¸Ê‹³šÎµÄ®o
Á„·—nªŠ QT ¥µª…¹Êœ ¨³Á„·—®´ªÄ‹Á˜oœŸ·—‹´Š®ª³®¦º°Á­¸¥¸ª·˜„³š´œ®´œÅ—o
3. Focal and multifocal neuropathy
Áž}œ„¨»n¤…°ŠÃ¦‡Á­oœž¦³­µšÁŒ¡µ³š¸É‡º°¤¸‡ªµ¤Ÿ·—ž„˜·…°ŠÁ­oœž¦³­µš…œµ—Ä®nÁŒ¡µ³
µŠÁ­oœ Ž¹ÉŠÁ„·—Å—oš´ÊŠÁ­oœž¦³­µš­¤°ŠÂ¨³Á­oœž¦³­µš˜µ¤¦nµŠ„µ¥ œ°„‹µ„œ´Êœ Á­oœž¦³­µš°ºÉœ
š¸ÉÅžÁ¨¸Ê¥Š˜µ¤¦¥µŠ‡r°µ‹‹³Á„·—‡ªµ¤Ÿ·—ž„˜·Å—oÁnœÁ—¸¥ª„´œ Ánœ truncal radiculoneuropathy,
median, radial, ulnar ®¦º° peroneal nerve Ž¹ÉŠ°µ‹Á„·—‹µ„„µ¦„—š´ (entrapment) …°Š
Á­oœž¦³­µš®¦º°‹µ„˜´ªÁµ®ªµœÁ°Šš¸ÉšÎµÄ®o®¨°—Á¨º°—…œµ—Á¨È„š¸ÉÁ¨¸Ê¥ŠÁ­oœž¦³­µšÁ„·—°»—˜´œÂ¨oª
Á­oœž¦³­µš‹¹ŠšÎµŠµœÅ¤nÅ—o˜µ¤ž„˜·
œ°„‹µ„œ´ÊœÂ¨oªŸ¼ožiª¥Áµ®ªµœÁ°Š¥´Š¤¸Ã°„µ­Á­¸É¥Š˜n°Ã¦‡šµŠ„µ¥Ánœ Řªµ¥, ¡·¬‹µ„¥µ
21
š»¡Ã£œµ„µ¦Â¨³£µª³°ºÉœÇ Ž¹ÉŠ„n°Ä®oÁ„·—æ‡Á­oœž¦³­µš Å—oÁnœ„´œ
¡¥µ›·„εÁœ·—
£µª³œÊε˜µ¨ÄœÁ¨º°—­¼Š (hyperglycemia) Áž}œ­µÁ®˜»®¨´„š¸É„n°Ä®oÁ„·—‡ªµ¤Ÿ·—ž„˜·°ºÉœÇ
˜µ¤¤µ ÁœºÉ°Š‹µ„£µª³œ¸Ê‹³šÎµÄ®o„µ¦šÎµŠµœ…°ŠÁŽ¨¨r˜nµŠÇŸ·—ž„˜·Ã—¥ÁŒ¡µ³ÁŽ¨¨rž¦³­µš Äœ
¦³—´ÁŽ¨¨rœÊε˜µ¨š¸É¤µ„Á„·œÅž‹³„¦³˜»oœ„µ¦­¦oµŠ°œ»¤¼¨°·­¦³…°Š°°„Ž·Á‹œ (reactive oxygen
species) šÎµÄ®oÁŽ¨¨rž¦³­µšÅ¤n­µ¤µ¦™ž¦´˜´ªÁ…oµ„´£µª³Ä®¤nœ¸ÊÅ—oÁ„·—„µ¦­³­¤…°Š
­µ¦ž¦³„°œÊε˜µ¨ (advanced glycation endproducts ®¦º° AGEs) ¤¸­µ¦ž¦³„°š¸ÉŸ·—ž„˜·‹µ„
polyol pathway Á„·—…¹Êœ ¨³„µ¦šÎµŠµœ…°Š protein kinase C Ÿ·—ž„˜·œ°„‹µ„œ´Êœ­µ¦š¸É‹ÎµÁž}œ˜n°
„µ¦Á‹¦·…°ŠÁŽ¨¨rž¦³­µš„Ȩ—¨Š¦nª¤„´„µ¦Å®¨Áª¸¥œÁ¨º°—š¸ÉŸ·—ž„˜·¥·ÉŠÁ¦nŠ¡¥µ›·„εÁœ·—Ä®oÁ¦Èª
¨³¦»œÂ¦Š…¹Êœ Äœš¸É­»—ÁŽ¨¨rž¦³­µšÂ¨³Äž¦³­µš‹³Á­ºÉ°¤Â¨³˜µ¥¨ŠÁ¦ºÉ°¥ÇÄœš¸É­»—6
„µ¦˜¦ª‹ª·œ·‹Œ´¥Â¨³„µ¦˜¦ª‹¡·Á«¬
ÄœŸ¼ožiª¥Áµ®ªµœš¸É¤¸°µ„µ¦žª——´Š„¨nµª ¤´„Ťn˜o°Š„µ¦„µ¦˜¦ª‹ª·œ·‹Œ´¥Á¡·É¤Á˜·¤ ­nªœŸ¼oš¸É
ŤnÁ‡¥¤¸ž¦³ª´˜·¤µ„n°œ‡ª¦Å—o¦´„µ¦˜¦ª‹¦³—´œÊε˜µ¨ÄœÁ¨º°—„n°œ°µ®µ¦ ®¦º° 2 ´ÉªÃ¤Š®¨´Š°µ®µ¦
®µ„ž„˜·‡ª¦¡·‹µ¦–µ˜¦ª‹ glucose tolerance test ˜n°Åž ­nªœ„µ¦˜¦ª‹Á¡·É¤Á˜·¤Á¡ºÉ°Â¥„懰ºÉœ
Ç š¸É°µ‹¤¸°µ„µ¦‡¨oµ¥„´œ°°„Åž Å—o„n serum electrophoresis, TSH, BUN, Creatinine ²¨² ˜µ¤
‡ªµ¤Á®¤µ³­¤…°ŠŸ¼ožiª¥Â˜n¨³¦µ¥
ž{‹‹»´œ¤¸„µ¦ÄoÁš‡œ·‡Äœ„µ¦˜´—·ÊœÁœºÊ°š¸ÉŸ·ª®œ´Š (skin biopsy) ¨oª¥o°¤¡·Á«¬ Á¡ºÉ°˜¦ª‹
œ´ž¦·¤µ–¨³¨´„¬–³…°Šž¨µ¥ž¦³­µš¦·Áª–œ´Êœ ×¥Áš¸¥„´Ÿ·ª®œ´Š¦·Áª–°ºÉœ®¦º°„´‡œž„˜·
Ž¹ÉŠnª¥Ä®o„µ¦ª·œ·‹Œ´¥Â¨³˜·—˜µ¤°µ„µ¦Áž}œÅžÅ—o°¥nµŠÂ¤nœ¥Îµ¥·ÉŠ…¹Êœ7 ¦nª¤„´„µ¦ÄoÁ‡¦ºÉ°Š¤º°¡·Á«¬
‡º° Quantitative sensory testing (QST) Ž¹ÉŠ‹³ª´—„µ¦¦´‡ªµ¤¦¼o­¹„Ä®o°°„¤µÁž}œ˜´ªÁ¨…Á¡ºÉ°
Áž¦¸¥Áš¸¥„´‡nµ¤µ˜¦“µœÄœ ‡œž„˜·
21

32. 2
„µ¦¦´„¬µ
„µ¦žj°Š„´œ : ­·ÉŠš¸É­Îµ‡´š¸É­»— ‡º° „µ¦‡ª‡»¤Áµ®ªµœÂ¨³£µª³Âš¦„Žo°œ°ºÉœÄ®o°¥¼nÄœ
¦³—´ž„˜·¤µ„š¸É­»— Á¡ºÉ°žj°Š„´œ„µ¦—εÁœ·œÃ¦‡ ¨³£µª³Âš¦„Žo°œÄ®¤n­nªœ„µ¦Äo¥µ„¨»n¤ aldose
reductase inhibitors ®¦º° nerve growth factor Ťn¡ªnµ¤¸ž¦³Ã¥œr´—Á‹œ ¨³¥´ŠÅ¤n¤¸š¸ÉčoÄœšµŠ
‡¨·œ·„8,9
„µ¦¦´„¬µ˜µ¤°µ„µ¦ : Äœ„¨»n¤Ã¦‡Á­oœž¦³­µšÁŒ¡µ³š¸É (focal or multifocal neuropathy)
Ÿ¼ožiª¥¤´„‹³—¸…¹Êœ®¦º°®µ¥Å—oÁ°Š ­nªœ„µ¦Äo¥µ°ºÉœÇ Á¡ºÉ°‡ª‡»¤°µ„µ¦žª—‹µ„Á­oœž¦³­µšš¸É
Å—oŸ¨ Ánœ ¥µ„¨»n¤¥µ„´œ´„ (carbamazepine, gabapentin, pregabalin), ¥µ„¨»n¤ antidepressant
(amitryptyline, nortryptyline, duloxetine)10 ÄœµŠ„¦–¸°µ‹¡·‹µ¦–µÄo¥µÂ„ožª—„¨»n¤ opioid Ánœ
tramadol ®¦º° strong opioid Äœ¦µ¥š¸Éčo¥µ°ºÉœÅ¤nÅ—oŸ¨ ®¦º° Áž}œ¥µÁ­¦·¤Äœ„¦–¸š¸Éžª—¤µ„Ž¹ÉŠ ‡ª¦
¡·‹µ¦–µÁž}œ¦µ¥Ç Åž ¨³¦³ª´ŠŸ¨…oµŠÁ‡¸¥Š—oª¥11 ¤¸®¨´„“µœªnµ topical capsaicin ‡ªµ¤Á…o¤…oœ
0.075% ­µ¤µ¦™¦¦Ášµ°µ„µ¦žª— neuropathic pain Å—o12 ®µ„Ÿ¼ožiª¥¤¸°µ„µ¦®œoµ¤º— ‡ªµ¤
—´œÃ¨®·˜˜Éε°µ‹ čo fludrocortisone ®¦º° midodrine ¦nª¤—oª¥Á¡ºÉ°Á¡·É¤‡ªµ¤—´œÃ¨®·˜ œ°„‹µ„œ´Êœ
„µ¦žj°Š„´œ£µª³Âš¦„Žo°œ‹µ„„µ¦­¼Á­¸¥‡ªµ¤¦¼o­¹„ Ánœ Ÿ¨Á¦ºÊ°¦´Š„µ¦˜·—ÁºÊ° °»´˜·Á®˜»²¨² „Ȥ¸
­nªœ­Îµ‡´Ánœ„´œ13
4.2 žª—˜µ¤®¨´ŠŠ¼­ª´— (Post herpetic neuralgia, PHN)
Š¼­ª´—Áž}œÃ¦‡š¸ÉÁ„·œ‹µ„„µ¦„εÁ¦·…°Š„µ¦˜·—ÁºÊ°Åª¦´­ varicella-zoster š¸ÉšÎµÄ®oÁ„·—æ‡
­»„Ä­„n°œ®œoµœ¸Ê×¥¤¸°»´˜·„µ¦–r¦µª 2.2-3.4 ¦µ¥˜n°ž¦³µ„¦ 1,000 ¦µ¥˜n°že„µ¦„εÁ¦·œ¸Ê¤¸
‡ªµ¤­´¤¡´œ›r„´¦³—´£¼¤·‡»o¤„´œš¸É¨—¨Š˜µ¤ª´œš¸ÉÁ¡·É¤…¹Êœ ‹¹Š¤¸ž¦³¤µ–„µ¦ªnµž¦³µ„µ¦¦µª¦o°¥¨³
20 ‹³Á„·—Š¼­ª´—…¹Êœ‡¦´ÊŠ®œ¹ÉŠÄœ¸ª·˜1 ×¥¤´„¤¸‡ªµ¤¦»œÂ¦Š­¼ŠÄœŸ¼ožiª¥­¼Š°µ¥»Â¨³Ÿ¼oš¸É¤¸£¼¤·‡»o¤„´œ
„¡¦n°Š °µ„µ¦¤´„Á¦·É¤‹µ„ŸºÉœ®¦º°˜»n¤Ä­ ¦nª¤„´°µ„µ¦žª—Äœ¦·Áª–Â…œŠ…°Š¦µ„ž¦³­µš
(dermatome) °µ„µ¦žª—¤¸‡ªµ¤¦»œÂ¦Š˜nµŠ„´œ Ánœ žª—ž¨ žª—­¦o°œ žª—˜ºÊ° ‡´œ ²¨²
®¨´Š‹µ„œ´Êœ °µ„µ¦—´Š„¨nµª‹³¨—¨ŠÂ¨³Äœš¸É­»—ŸºÉœ‹³®µ¥ÅžÄœÁª¨µ®¨µ¥­´ž—µ®r
Ÿ¼ožiª¥µŠ¦µ¥‹³¥´Š‡Š¤¸°µ„µ¦žª—˜n°ÁœºÉ°ŠÂ¤oªnµ°µ„µ¦šµŠŸ·ª®œ´Š„¨´¤µÁž}œž„˜·Â¨oª
Ž¹ÉŠ¤´„¤¸°µ„µ¦žª—˜n°ÁœºÉ°Š¦nª¤„´¤¸°µ„µ¦žª—Áž}œ¡´„Ç ®µ„°µ„µ¦žª—¥´ŠÅ¤n®µ¥Åž ÄœÁª¨µ 1-3
Á—º°œ ‹³™º°ªnµŸ¼ožiª¥Áž}œÃ¦‡žª—˜µ¤®¨´ŠŠ¼­ª´— (post herpetic neuralgia) Ÿ¼oš¸É¤¸‡ªµ¤Á­¸É¥Š˜n° PHN
¤´„Áž}œŸ¼o­¼Š°µ¥»¤¸°µ„µ¦žª—¦»œÂ¦ŠÄœnªŠÂ¦„ ¤¸°µ„µ¦žª—¦»œÂ¦ŠÂ¨³Á„·—…¹ÊœÁ¦Èª Ÿ¼ožiª¥Á®¨nµœ¸Ê
¤´„¤¸‡ªµ¤š»„…rš¦¤µœ‹µ„°µ„µ¦žª—Á®¨nµœ¸Ê¤µ„ ¨³¤´„‹³‡Š°¥¼nÁž}œÁª¨µœµœ„¨µ¥Áž}œ°µ„µ¦
žª—Á¦ºÊ°¦´ŠÄœš¸É­»—2
„µ¦Äo¥µ˜oµœÅª¦´­ Ánœ acyclovir, valacyclovir ¨³ famciclovir ­µ¤µ¦™¨—‡ªµ¤¦»œÂ¦Š
…°ŠÃ¦‡Å—o®µ„Ä®o£µ¥Äœ 72 ´ÉªÃ¤ŠÂ¦„š¸ÉÁ„·—ŸºÉœŠ¼­ª´— ×¥¨—°µ„µ¦žª—ÁŒ¸¥¡¨´œ ¨—„µ¦
„¦³‹µ¥…°ŠÅª¦´­ ¨—‡ªµ¤¦»œÂ¦Š…°ŠŸºÉœÂ¨³£µª³Âš¦„Žo°œÄœnªŠ¦³¥³Â¦„Å—o˜n…o°¤¼¨¥´ŠÅ¤n
22

33. ´—Á‹œœ´„Äœ„µ¦žj°Š„´œ PHN1,2 ­nªœ„µ¦Ä®o¥µ­Á˜¸¥¦°¥—r°µ‹nª¥¦¦Ášµžª—Äœ¦³¥³ÁŒ¸¥¡¨´œ
Å—o®µ„Ä®o¦nª¤„´¥µ˜oµœÅª¦´­ ˜n¥´ŠÅ¤n¤¸®¨´„“µœÁ¡¸¥Š¡°Äœ„µ¦žj°Š„´œ PHN3 ¤¸„µ¦«¹„¬µ…œµ—
Á¨È„¦µ¥Šµœ™¹Š„µ¦Äo¥µ amitryptyline ¨³„µ¦Äo®´˜™„µ¦Á¡ºÉ°¥´¥´ÊŠ„µ¦šÎµŠµœ…°ŠÁ­oœž¦³­µšªnµ
Å—oŸ¨oµŠ ˜n„ÈŤn¤¸¦µ¥Šµœ¥ºœ¥´œ¤µ„œ´„2
—´Šœ´Êœ„µ¦žj°Š„´œ PHN š¸ÉÅ—oŸ¨—¸œnµ‹³Á¦·É¤‹µ„„µ¦žj°Š„´œŠ¼­ª´— ץčoª´‡Ž¸œÄœ„¨»n¤Á­¸É¥Š
Ž¹ÉŠ¡ªnµÅ—oŸ¨—¸Äœ„µ¦žj°Š„´œŠ¼­ª´—¨³ PHN ˜n˜o°ŠÄ®oª´‡Ž¸œ‡¦°‡¨»¤ž¦³µ„¦‹Îµœªœ¤µ„4
®µ„Á„·—Š¼­ª´—…¹Êœ „µ¦Å—o¦´„µ¦¦´„¬µ°¥nµŠÁ˜È¤š¸ÉÁ¡ºÉ°žj°Š„´œ£µª³Âš¦„Žo°œ ¨³¡·‹µ¦–µÄo¥µÂ„o
žª—Á¡ºÉ°¦¦Ášµžª—Ä®o¤µ„š¸É­»—Ťnªnµ‹³Áž}œ„¨»n¤¥µ„´œ´„Ánœ gabapentin ¨³ pregabalin ¥µ
˜oµœÁ«¦oµ„¨»n¤ TCAs ¨³ tramadol Ž¹ÉŠÅ—o¦´„µ¦¡·­¼‹œr¤µÂ¨oªªnµÅ—oŸ¨ ×¥­µ¤µ¦™Äo¥µÁ®¨nµœ¸Ê
¦nª¤„´œÅ—oÄœ„¦–¸š¸Éčo¥µÁ—¸É¥ªÂ¨oªÅ¤nÅ—oŸ¨1,5
4.3 žª—ž¦³­µšÅš¦Á‹¤·œ´¨ (Trigeminal neuralgia or Tic douloureux)
°µ„µ¦žª—š¸Éĝ®œoµ˜µ¤Â…œŠ…°ŠÁ­oœž¦³­µš­¤°Šš¸É 5 œ¸Ê‹³¡n°¥ÄœŸ¼ožiª¥­¼Š°µ¥»Á¡«
®·Š¤µ„„ªnµÁ¡«µ¥ ×¥¤¸°»´˜·„µ¦–r¦µª 5.9 ¦µ¥Â¨³ 3.4 ¦µ¥˜n°ž¦³µ„¦ 100,000 ¦µ¥˜n°že
¨´„¬–³°µ„µ¦žª—‹³¤¸°µ„µ¦žª—¦»œÂ¦ŠÁž}œ¡´„ Ç Á®¤º°œÅ¢¢jµÈ°˜ Á­¸¥ªÂž¨Åž˜µ¤Ä®œoµ
Á¡¸¥ŠÅ¤n„¸Éª·œµš¸Â¨oªÁž}œŽÊε°¸„˜n° Ç „´œ µŠ‡¦´ÊŠ„µ¦­´¤Ÿ´­š¸Éĝ®œoµ „¦³¡»oŠÂ„o¤ ¢{œ®¦º°„µ¦„¨ºœ
š¸É¤¸ž¦³­µš­´¤Ÿ´­‹µ„Á­oœž¦³­µš­¤°Š‡¼nš¸É 5 Â…œŠÁ—¸¥ª„´œ „ȚεĮoÁ„·—°µ„µ¦žª—…¹ÊœÅ—ošÎµÄ®o¤¸
Ÿ¨˜n°‡»–£µ¡¸ª·˜…°ŠŸ¼ožiª¥°¥nµŠ¤µ„
„µ¦˜¦ª‹¦nµŠ„µ¥¤´„‹³ž„˜·Â˜nŸ¼ožiª¥¤´„‹³¦³ª´ŠÅ¤nÄ®oŸ¼o˜¦ª‹­´¤Ÿ´­Ä®œoµÁ¡¦µ³Á„¦Š‹³šÎµ
Ä®oÁ„·—°µ„µ¦ŽÊε°¸„ ®µ„°µ„µ¦œ¸ÊÁ„·—‹µ„¦°¥Ã¦‡®¦º°¡¥µ›·­£µ¡´—Á‹œš¸É trigeminal ganglion
°µ‹¡‡ªµ¤Ÿ·—ž„˜·…°Š„µ¦¦´­´¤Ÿ´­ (sensory function) Äœ˜ÎµÂ®œnŠœ´ÊœÅ—o×¥š´ÉªÅž°µ„µ¦…°Š
懤´„‹³Áž}œ˜µ¤Â…œŠš¸É 2 ¨³ 3 (V2,V3) ¤µ„„ªnµÂ…œŠš¸É 1 (V1) Ÿ¼ožiª¥¤´„‹³¤¸‹»—„¦³˜»oœ°µ„µ¦
(trigger point) ®¦º°ž{‹‹´¥„¦³˜»oœ´—Á‹œ Ánœ ¨¤¡´—ĝ®œoµ ž¦Š¢{œ Äœ®œª— ²¨² Ÿ¼ožiª¥µŠ
¦µ¥°µ‹¤¸°µ„µ¦Áž}œnªŠÇ ­¨´„´ž„˜·Â˜n­nªœÄ®n¤´„¤¸°µ„µ¦™¸É…¹ÊœÂ¨³¦»œÂ¦Š…¹ÊœÁ¦ºÉ°¥ Ç Ž¹ÉŠ
Ÿ¼ožiª¥Á®¨nµœ¸Ê‹³¤¸°µ„µ¦žª—˜¨°—Áª¨µÂ˜ºÊ°Ç˜»Ç¦nª¤„´°µ„µ¦žª—ž¨Áž}œ¡´„Ç1
­µÁ®˜»…°ŠÃ¦‡œ¸ÊŤnÂœn´—œ´„˜nÁºÉ°ªnµ Ÿ¼ožiª¥­nªœÄ®n¤´„‹³Á„·—‹µ„ arterial ®¦º° venous
loop Åž„—¦´ÊŠÂ…œŠž¦³­µš­¤°Š‡¼nš¸É 5 šÎµÄ®oÁ„·—°µ„µ¦¦³‡µ¥Á‡º°ŠÂ¨³„µ¦­nŠ„¦³Â­ž¦³­µšš¸É
Ÿ·—ž„˜·µŠ‡¦´ÊŠ„µ¦šÎµ MRI brain °µ‹nª¥nŠ™¹Š¡¥µ›·­£µ¡š¸É‹ÎµÁ¡µ³Á¡ºÉ°nª¥‹ÎµÂœ„æ‡ Ánœ
demyelination ‹µ„ multiple sclerosis ÄœŸ¼ožiª¥°µ¥»œo°¥ ®¦º° meningioma ÄœŸ¼ožiª¥­¼Š°µ¥»
„µ¦¦´„¬µ­nªœÄ®n‹³Äo¥µÁ¡ºÉ°¦¦Ášµ°µ„µ¦ ¥µš¸Éčon°¥Â¨³Å—oŸ¨—¸‡º° carbamazepine
×¥™º°ªnµÁž}œ¥µ¤µ˜¦“µœš¸ÉčoĜ懜¸Ê×¥Á¦·É¤Äœ…œµ—˜É뵂 ž¦³¤µ– 100 ¤„. ª´œ¨³ 2-3 ‡¦´ÊŠ ¨³
‡n°¥ Ç Á¡·É¤Áž}œ 600-1,200 ¤„.˜n°ª´œ®µ„‹ÎµÁž}œ Á¤ºÉ°°µ„µ¦—¸…¹Êœ°µ‹¨—…œµ—¥µ¨Š Á¡ºÉ°Ä®o‡ª‡»¤
°µ„µ¦Å—oŸ¼ožiª¥‡ª¦Å—o¦´„µ¦Á jµ¦³ª´ŠŸ¨…oµŠÁ‡¸¥Š‹µ„¥µœ¸ÊÁnœ Á¤È—Á¨º°—…µª˜Éε ®¦º°¡·¬˜n°˜´
23
23

34. ®µ„ŤnÅ—oŸ¨®¦º°¤¸Ÿ¨…oµŠÁ‡¸¥Š ‡ª¦¡·‹µ¦–µÄ®o oxcarbazepine ®¦º°¡·‹µ¦–µÄo¥µ°ºÉœ¦nª¤—oª¥š¸É¤¸
ž¦³­·š›·£µ¡¦°Š¨ŠÅž Ánœ baclofen, phenytoin, gabapentin, lamotrigine Áž}œ˜oœ1-3
24
ÄœŸ¼ožiª¥­nªœ®œ¹ÉŠš¸Éčo¥µÂ¨oªÅ¤nÅ—oŸ¨‡ª¦¡·‹µ¦–µ­nŠ˜n°Ÿ¼ožiª¥Á®¨nµœ¸ÊÁ¡ºÉ°šÎµ„µ¦Ÿnµ˜´—˜n
Áœ·ÉœÇ ×¥ÁŒ¡µ³¦µ¥š¸É˜¦ª‹¡ªnµ¤¸„µ¦„—š´…°ŠÁ­oœž¦³­µš‹µ„®¨°—Á¨º°—­¤°Š(2) „µ¦¦´„¬µ
×¥„µ¦Å¤nčo¥µœ´Êœ °µ‹Äo„µ¦Œ¸— alcohol ÁŒ¡µ³š¸É®¦º°Äo‡¨ºÉœª·š¥»Á¡ºÉ°­¦oµŠ‡ªµ¤¦o°œÅžšÎµ¨µ¥
Â…œŠž¦³­µš®¦º° ganglion š¸ÉŸ·—ž„˜·Ÿ¼ožiª¥‹³¤¸°µ„µ¦—¸…¹Êœ ˜n¤´„‹³¤¸£µª³Âš¦„Žo°œ‹µ„
°µ„µ¦µš¸Éĝ®œoµÂšœ ­nªœ„µ¦¦´„¬µÃ—¥„µ¦Ÿnµ˜´— micro vascular loop decompression (MVD)
œ´Êœ ¡ªnµÅ—oŸ¨—¸Â¨³¥´Š‡Š¤¸ž¦³­·š›·£µ¡Äœ¦³¥³¥µªÃ—¥¤¸£µª³Âš¦„Žo°œœo°¥ ¤¸„µ¦Äo Gamma
knife radiosurgery Äœ„µ¦¦´„¬µÃ¦‡œ¸ÊÁœºÉ°Š‹µ„¤¸‡ªµ¤Á­¸É¥Š˜Éε ˜n‡ª¦¤¸„µ¦«¹„¬µ¦³¥³¥µª˜n°Åž4
Áš‡œ·‡Äœ„µ¦Ÿnµ˜´—Á®¨nµœ¸Ê¤´„¤¸…o°—¸Â¨³…o°Á­¸¥Â˜„˜nµŠ„´œÅž ˜n…o°¤¼¨¦³¥³¥µª¡ªnµ„µ¦Ÿnµ˜´—
MVD ¤¸°´˜¦µ„µ¦Áž}œŽÊεœo°¥š¸É­»—¨³Ÿ¼ožiª¥¤¸‡ªµ¤¡¹Š¡°Ä‹­¼Š­»—5
4.4 „¨»n¤°µ„µ¦žª—Á¦ºÊ°¦´ŠÄœ¦¥µŠ‡rš¸É™¼„˜´—°°„ (Phantom limb pain)
„¨»n¤°µ„µ¦žª—Á¦ºÊ°¦´ŠÄœ¦¥µŠ‡rš¸É™¼„˜´—°°„¨oª ®¤µ¥™¹Š‡ªµ¤¦¼o­¹„žª—…°ŠŸ¼ožiª¥š¸ÉÁ„·—…¹Êœ
Äœ­nªœ¦¥µŠ‡rš¸ÉÅ—o™¼„˜´—°°„ިoª ×¥š¸É¤¸°µ„µ¦žª—Á­¤º°œ¦¥µŠ‡rÄœ¥´Š˜·—°¥¼n„´¦nµŠ„µ¥1, 2 ­nªœ
Ÿ¼ožiª¥š¸ÉÅ—o¦´„µ¦˜´—¦¥µŠ‡r°°„¨oª ˜n¥´Š¤¸‡ªµ¤¦¼o­¹„ªnµ¦¥µŠ‡r…oµŠœ´Êœ˜·—°¥¼nš¸ÉÁ—·¤ ‡ªµ¤¦¼o­¹„œ¸Ê
Á¦¸¥„ªnµ phantom sensation °µ„µ¦žª—š¸ÉÁ„·—…¹ÊœÄœ¦³¥³®¨´ŠŸnµ˜´—Áž}œ„µ¦žª—œ·—ÁŒ¸¥¡¨´œ
®¦º° acute just post amputation pain ­nªœ°µ„µ¦žª—š¸ÉŸ¼ožiª¥¥´Š¤¸°¥¼n®¨´ŠŸnµ˜´—˜nŤn¤¸°µ„µ¦Â¨³
°µ„µ¦Â­—Š…°Š„µ¦žª—ž¦³­µš¦¸¥„ªnµ chronic residual limb pain
‡ªµ¤¦¼o­¹„š¸ÉŸ¼ožiª¥¥´Š¤¸Äœ¦¥µŠ‡rš¸ÉÅ—o¦´„µ¦Ÿnµ˜´—œÎµ¦¥µŠ‡r…oµŠœ´Êœ°°„ިoª ®¦º°
phantom phenomena ¤´„Á„·—…¹Êœ„´Ÿ¼ožiª¥š»„¦µ¥š¸ÉÅ—o¦´„µ¦Ÿnµ˜´—¦¥µŠ‡r°°„ÁœºÉ°Š¤µ‹µ„懮¦º°
„µ¦µ—Á‹ÈÄœ¦³¥³Â¦„Ÿ¼ožiª¥¤´„¤¸‡ªµ¤¦¼o­¹„ªnµ¦¼ž¦nµŠ…°Š¦¥µŠ‡rš¸É™¼„˜´—°°„¨oª¥´Š¤¸Á®¤º°œÁ—·¤
¨³­µ¤µ¦™Á‡¨ºÉ°œÅ®ªÅ—o—´ŠÁ—·¤ ˜n°¤µ‡ªµ¤¦¼o­¹„™¹Š¦¼ž¦nµŠ¤´„Ÿ·—ž„˜·Åž Ÿ¼ožiª¥¤´„¦¼o­¹„ªnµ¦¥µŠ‡rš¸É
Å—o¦´„µ¦˜´—°°„ިoª­´Êœ¨Š °µ„µ¦Á®¨nµœ¸Ê¤´„ŤnÁž}œž{®µšµŠ‡¨·œ·„¨³¤´„®µ¥ÅžÁ°Š®¨´Š„µ¦
Ÿnµ˜´—Äœ¦³¥³®œ¹ÉŠ Ÿ¼ožiª¥¦o°¥¨³ 60-80 š¸ÉÅ—o¦´„µ¦Ÿnµ˜´—œÎµÂ…œ…µ°°„Á„·—„¨»n¤°µ„µ¦žª—Á¦ºÊ°¦´ŠÄœ
¦¥µŠ‡rš¸É™¼„˜´—°°„ (phantom pain) Ž¹ÉŠŸ¼ožiª¥­nªœÄ®n¤¸°µ„µ¦žª—Áž}œ‡¦´ÊŠ‡¦µª¦³¥³®œ¹ÉŠÂ¨oª
®µ¥ÅžÁ°Š ˜n¤¸¦µ¥ŠµœŸ¼ožiª¥¦o°¥¨³ 5-10 Á„·—¤¸°µ„µ¦žª—š¸É¦»œÂ¦ŠÂ¨³˜o°Š„µ¦„µ¦¦´„¬µ
°»´˜·„µ¦–rœ¸Ê¡Å—oÁnœÁ—¸¥ª„´„¨»n¤°µ„µ¦žª—Á¦ºÊ°¦´Šš¸ÉÇœ¦¥µŠ‡r­nªœš¸ÉÁ®¨º°‹µ„„µ¦˜´—¦¥µŠ‡r
°°„ިoª (stump pain)
„¨Å„„µ¦Á„·—°µ„µ¦žª—Á¦ºÊ°¦´ŠÄœ¦¥µŠ‡rš¸ÉÅ—o™¼„˜´—°°„ިoªœ¸Ê¥´ŠÅ¤nÁž}œš¸É¦¼oÂœn´—˜nÁºÉ°
ªnµÁž}œ„µ¦˜°­œ°Šš¸ÉŸ·—ž„˜·…°Š¦³ž¦³­µšš´ÊŠÄœ­nªœž¨µ¥Â¨³­nªœ„¨µŠ ¡ªnµ¡¥µ›·­£µ¡
Äœ¦¥µŠ‡rš¸ÉšÎµÄ®oÁ„·—‡ªµ¤žª—„n°œÅ—o¦´„µ¦Ÿnµ˜´—°°„¤¸­nªœšÎµÄ®o°»´˜·„µ¦–r¨³‡ªµ¤¦»œÂ¦Š…°Š
‡ªµ¤žª—Á¡·É¤…¹Êœ ˜n°µ„µ¦žª—œ¸ÊŤn­µ¤µ¦™žj°Š„´œÅ—oš´ÊŠ®¤—‹µ„„µ¦¥´¥´ÊŠ„µ¦šÎµŠµœ…°Š
Á­oœž¦³­µšš¸ÉÁ¨¸Ê¥Š¦¥µŠ‡r­nªœœ´Êœ—oª¥¥µ (nerve block) ®¦º°„µ¦Ä®o¥µµš¸ÉÅ…­´œ®¨´Š
24

35. „µ¦¦´„¬µ„¨»n¤°µ„µ¦žª—Á¦ºÊ°¦´ŠÄœ¦¥µŠ‡rš¸ÉÅ—o™¼„˜´—°°„¨oª°µ‹¥µ„¤µ„ÄœŸ¼ožiª¥µŠ¦µ¥
ª·›¸Â¨³¥µš¸Éčo¦´„¬µ¥´ŠÅ¤n¤¸…o°¤¼¨„µ¦«¹„¬µŸ¨„µ¦¦´„¬µÃ—¥„µ¦Áž¦¸¥Áš¸¥š¸É¤¸„µ¦‡ª‡»¤˜´ªÂž¦
(randomized control trial) š¸É¤µ„¡° ÂœªšµŠ„µ¦¦´„¬µœ·¥¤ÄoÂœªšµŠ„µ¦¦´„¬µ…°Š°µ„µ¦žª—
ž¦³­µšÁ¦ºÊ°¦´Š (neuropathic pain) š´ÉªÅžš¸É¤¸°¥¼n„µ¦¦´„¬µ„¨»n¤°µ„µ¦žª—Äœ¦¥µŠ‡rš¸ÉÅ—o™¼„˜´—°°„
¨oª‡ª¦Äoª·›¸„µ¦°œ»¦´„¬rœ·¥¤Ã—¥Å¤nŸnµ˜´—®¦º°šÎµÄ®oŸ¼ožiª¥¤¸°µ„µ¦µ—Á‹ÈÁ¡·É¤…¹Êœ (non invasive
treatment) ¥„ÁªoœÁž}œ„µ¦Ÿnµ˜´—š¸ÉšÎµÄ®oŸ¼ožiª¥­µ¤µ¦™Äo¦¥µŠ‡rœ´ÊœÇšÎµŠµœÅ—o—¸…¹Êœ Ánœ „µ¦Ÿnµ˜´—
œÎµœ·ÊªÁšoµÅžž¨¼„š¸É¤º°®¦º°­nªœ…°Š¤º°š¸ÉÁ®¨º°°¥¼nÁ¡ºÉ°Ä®oŸ¼ožiª¥‹´®¦º°Á„¸É¥ªª´˜™»š¸É˜o°Š„µ¦Å—oµŠ­nªœ
„µ¦Ä®o¥µ‡ª¦Äo¥µÄœ„¨»n¤¥µ˜oµœ£µª³®¦º°Ã¦‡Ž¹¤Á«¦oµ (antidepressants) Äœ„¨»n¤ tricyclic ¥µ
¥´¥´ÊŠ sodium channels ¥µ¥´¥´ÊŠ calcium channels ¨³„µ¦Äo¥µ opioids ÄœŸ¼ožiª¥µŠ„¨»n¤
Ÿ¼ožiª¥‡ª¦Å—o¦´„µ¦¦´„¬µšµŠÁª«µ­˜¦r¢gœ¢¼Â¨³°µ¸ª³Îµ´— ¦ª¤š´ÊŠ„µ¦Äo„¦³Â­Å¢¢jµ„¦³˜»oœ
Á­oœž¦³­µš®¦º°ž¦³­µš­nªœ„¨µŠ¦nª¤„´„µ¦¦´„¬µª·›¸°ºÉœÇ „µ¦¦´„¬µ‡ª¦Áœoœ‡ªµ¤ž¨°—£´¥Äœ
„µ¦¦´„¬µÂ¨³®¨¸„Á¨¸É¥Š£µª³Âš¦„Žo°œ…°Š„µ¦¦´„¬µš´ÊŠšµŠ˜¦ŠÂ¨³šµŠ°o°¤Ä®o¤µ„š¸É­»— ™¹ŠÂ¤o
ž{‹‹»´œœ·¥¤Á¨º°„„µ¦¦´„¬µš¸É¤¸…o°¤¼¨Äœ¨´„¬–³ randomized controlled trials ¨³ meta analysis
¤µÄo„´œ¤µ„…¹Êœ ˜n„µ¦¦´„¬µ°µ„µ¦žª—˜o°Šž¦´˜µ¤Ÿ¼ožiª¥Â¨³­£µª³Âª—¨o°¤ ¦ª¤š´ÊŠÁ«¦¬“µœ³
…°ŠŸ¼ožiª¥Â¨³ž¦³­„µ¦–r…°ŠÂ¡š¥rŸ¼oÄ®o„µ¦¦´„¬µ —´Šœ´Êœ‡ªµ¤Á®Èœ…°ŠÂ¡š¥rŸ¼o­œÄ‹—oµœ„µ¦
‡ª‡»¤‡ªµ¤žª—„Ȥ¸­nªœ­Îµ‡´Äœ„µ¦Á¨º°„Ä®o„µ¦¦´„¬µ
4.5 Central neuropathic pain
°µ„µ¦žª—‹µ„¡¥µ›·­£µ¡…°Š¦³ž¦³­µš­nªœ„¨µŠ¡Å—ož¦³¤µ–¦o°¥¨³ 8 …°ŠŸ¼ožiª¥
懮¨°—Á¨º°—­¤°Š ¨³¡Å—o™¹Šž¦³¤µ–¦o°¥¨³ 40 ÄœŸ¼ožiª¥š¸É¤¸¡¥µ›·­£µ¡…°ŠÅ…­´œ®¨´Š
„¨Å„„µ¦Á„·—°µ„µ¦žª—‹µ„¡¥µ›·­£µ¡…°Š¦³ž¦³­µš­nªœ„¨µŠ¥´ŠÅ¤nš¦µÂœn´— ˜n
­´œœ·¬“µœªnµœnµ‹³Á„·—‹µ„„µ¦šÎµŠµœš¸ÉŸ·—ž„˜·…°Š spinothalamic pathway Ž¹ÉŠ„n°Ä®oÁ„·—„µ¦
Áž¨¸É¥œÂž¨Š…°Š neuronal excitability ¨³‡ªµ¤Ÿ·—ž¦„˜·…°Š„¨Å„„µ¦¥´¥´ÊŠ„µ¦œÎµ„¦³Â­
ž¦³­µš‡ªµ¤¦¼o­¹„…°Š¦³ž¦³­µš­nªœ„¨µŠ šÎµÄ®o¤¸„µ¦¦´¦¼o‡ªµ¤¦¼o­¹„š¸ÉÁž¨¸É¥œÅž‹µ„ž¦„˜·
ž{‹‹»´œ…o°¤¼¨Á„¸É¥ª„´„µ¦¦´„¬µ central neuropathic pain ¥´Š¤¸Å¤n¤µ„œ´„¨³­nªœÄ®n
‹³Áž}œ„µ¦ª·‹´¥š¸É¤¸‹Îµœªœ‡œÅ…oœo°¥ ®¦º°¤¸ª·›¸„µ¦ª·‹´¥š¸ÉŤnÁ®¤µ³­¤ —´Šœ´ÊœÁÁœªšµŠ„µ¦¦´„¬µ„µ¦
žª—‹µ„¡¥µ›·­£µ¡…°Š¦³ž¦³­µš­nªœ„¨µŠÄœž{‹‹»´œ‹¹ŠÄo…o°¤¼¨‹µ„ randomized controlled
trial Ž¹ÉŠ¤¸‹ÎµœªœÅ¤n¤µ„œ´„—´Š˜n°Åžœ¸Ê
1. Central neuropathic pain, post stroke : TCA
2. Spinal cord injury pain: calcium channel D2G1 ligands Ánœ pregabalin
3. Pain associated with multiple sclerosis: cannabinoids (level B)
4. Central neuropathic pain °ºÉœÇ: pregabalin, TCAs, lamotrigine, gabapentin (level B)
25
25

36. 26
°¥nµŠÅ¦„Șµ¤¤¸Ÿ¼ožiª¥®¨µ¥¦µ¥š¸É¤¸°µ„µ¦‹µ„¡¥µ›·­£µ¡…°Š¦³ž¦³­µš­nªœ„¨µŠÃ—¥
ŤnÁ…oµ„´š¸É„¨nµª…oµŠ˜oœ ®¦º°¦´„¬µ—oª¥¥µ—´Š„¨nµª…oµŠ˜oœÅ¤nÅ—oŸ¨—¸„È­µ¤µ¦™¡·‹µ¦–µÄo¥µš¸ÉÁž}œ
first ÁÁ¨³ second line š¸Éčo¦´„¬µ„µ¦žª—‹µ„ peripheral neuropathic pain Å—o
4.6 °ºÉœÇ
„¨»n¤°µ„µ¦˜n°Åžœ¸Ê¤´„¤¸°µ„µ¦žª—Ÿ­¤ (mixed pain) Ž¹ÉŠ neuropathic pain Áž}œ­nªœ
®œ¹ÉŠÄœ°µ„µ¦žª—š´ÊŠ®¤— —´Šœ´ÊœÄœ„µ¦¦´„¬µ‹¹Š‡ª¦¦´„¬µ‡ªµ¤žª—œ·—°ºÉœÇ‡ª‡¼nÅž—oª¥ ­Îµ®¦´
„µ¦¦´„¬µ neuropathic pain ÄœŸ¼ožiª¥Á®¨nµœ¸ÊÄ®o¦´„¬µ˜µ¤¨´„¬–³°µ„µ¦…°Š neuropathic pain ¨³
¡¥µ›·­¦¸¦ª·š¥µš¸ÉÁž}œ­µÁ®˜»Ž¹ÉŠ¤´„Ťn˜„˜nµŠ‹µ„Ÿ¼ožiª¥š¸É¤¸ neuropathic pain Á¡¸¥Š°¥nµŠÁ—¸¥ª
˜´ª°¥nµŠÁnœ
x Cancer pain: neuropathic pain ÄœŸ¼ožiª¥¤³Á¦ÈŠ°µ‹Á„·—‹µ„˜´ªÃ¦‡Á°Š Ánœ ¤³Á¦ÈŠ
„¦³‹µ¥Åžš¸ÉÁ­oœž¦³­µš ®¦º° „µ¦„—š´…°ŠÁ­oœž¦³­µš‹µ„„o°œ¤³Á¦ÈŠ ®¦º°Ÿ¨‹µ„
„µ¦¦´„¬µÁnœ „µ¦Ä®oÁ‡¤¸Îµ´— ®¦º° ¦´Š­¸¦´„¬µ Ÿ¼ožiª¥­nªœÄ®n¤´„Å—o¦´¥µÄœ„¨»n¤
opioids °¥¼n„n°œÂ¨oª‹¹Š¤´„Ä®o¥µÄœ„¨»n¤°ºÉœÇÁ­¦·¤ Ánœ gabapentin, pregabalin, TCAs,
SNRIs ¨³ antiepileptics ¨³‡ª¦¦³¤´—¦³ª´ŠŸ¨…oµŠÁ‡¸¥Š…°Š¥µÂ¨³°´œ˜¦„·¦·¥µ
¦³®ªnµŠ¥µÄœ„¦–¸š¸ÉŸ¼ožiª¥Äo¥µ®¨µ¥œ·—
x Painful polyneuropathy °ºÉœ ‡ª¦Á¨º°„čo¥µ˜µ¤°µ„µ¦…°ŠŸ¼ožiª¥¡¦o°¤„´Ä®o„µ¦¦´„¬µ
š¸É‹ÎµÁ¡µ³„´Ã¦‡œ´ÊœÇ Ánœ
o HIV neuropathy ¥µ antiretrovirals ®¨µ¥œ·—¤¸Ÿ¨ Á®œ¸É¥ªœÎµ ¥´¥´ÊŠ ®¦º°™¼„
šÎµ¨µ¥Ÿnµœ CYP450 ‡ª¦Á¨º°„¥µÂ„ožª—š¸É¤¸Ÿ¨˜n° CYP450 œo°¥š¸É­»— Ánœ
gabapentin Áž}œ˜oœ
o Drug-induced neuropathy ‡ª¦®¥»—¥µš¸ÉÁž}œ­µÁ®˜»Â¨³¦´„¬µ˜µ¤°µ„µ¦
o Guillain–Barre syndrome ¤¸„µ¦«¹„¬µ¦³¥³­´ÊœÃ—¥Äo gabapentin ®¦º° carbama-zepine
®¦º°Äo¦nª¤„´ opioids ®µ„čo¥µÁ—¸É¥ªÅ¤nÅ—oŸ¨
x Nerve injury pain Ánœ radicular pain (include back pain), post-traumatic/post-surgical
neuropathic pain ¨³ complex regional pain syndromes (CRPS) Äœ
¦³¥³Â¦„š¸ÉŸ¼ožiª¥¤¸°µ„µ¦žª—ÁŒ¸¥¡¨´œ ­nªœ®œ¹ÉŠ°µ‹Á„·—‹µ„„µ¦°´„Á­ —´Šœ´Êœ„µ¦Äo
paracetamol ¨³ NSAIDs °µ‹¤¸ž¦³Ã¥œrÄœnªŠ­´ÊœÇ ®µ„Ÿ¼ožiª¥¤¸°µ„µ¦žª—Á¦ºÊ°¦´Š
¨³¤¸¨´„¬–³š¸ÉÁ…oµÅ—o„´ neuropathic pain Ä®oÁ¨º°„čo¥µ˜µ¤¨´„¬–³°µ„µ¦…°Š
neuropathic pain ¦nª¤„´„µ¦¦´„¬µ°ºÉœ °¥nµŠÅ¦„Șµ¤‹µ„…o°¤¼¨š¸É¤¸„µ¦«¹„¬µ¡ªnµ
ž¦³­·š›·£µ¡…°Š¥µÄœ„µ¦¦´„¬µŸ¼ožiª¥„¨»n¤œ¸Ê¥´ŠÅ¤nÁž}œš¸É´—Á‹œÁ¤ºÉ°Áž¦¸¥Áš¸¥„´
neuropathic pain ‹µ„­µÁ®˜»°ºÉœÇ
26

37. 27
Á„–”r„µ¦­nŠ˜n° 5
„µ¦¦´„¬µ neuropathic pain ¤¸Ážjµ®¤µ¥Äœ„µ¦¦³Š´°µ„µ¦žª—Ä®o¨—¨Š°¥nµŠ¦ª—Á¦Èªš¸É­»—
Á¡ºÉ°žj°Š„´œž{®µš¸É°µ‹Á„·—…¹ÊœÁ¤ºÉ°¤¸°µ„µ¦žª—Á¦ºÊ°¦´Š (chronic pain) ®µ„ŤnÅ—oŸ¨˜µ¤Ážjµ®¤µ¥
¡š¥r‡ª¦ž¦¹„¬µŸ¼oÁ¸É¥ªµÁŒ¡µ³šµŠ­µ…µ„µ¦Îµ´—‡ªµ¤žª— ¨³/®¦º°Äœ­µ…µš¸ÉÁ„¸É¥ª…o°Š
®¦º°­nŠŸ¼ožiª¥˜n°Á¡ºÉ°„µ¦¦´„¬µ°ºÉœš¸ÉÁ®¤µ³­¤˜n°Åž ÂœªšµŠ„µ¦¡·‹µ¦–µ„µ¦­nŠ˜n° Å—o„n
1. ¡š¥rŤn­µ¤µ¦™°„­µÁ®˜»…°Š°µ„µ¦žª— ®¦º° Ä®o„µ¦ª·œ·‹Œ´¥ neuropathic pain Å—o
2. Á¤ºÉ°Â¡š¥rž’·´˜·˜µ¤ÂœªšµŠš¸ÉÂœ³œÎµ ®¦º°Á¤ºÉ°Ÿ¼ožiª¥Å—očo¥µÄœ…œµ—š¸ÉÅ—oŸ¨Äœ„µ¦¦´„¬µ
°¥nµŠ˜n°ÁœºÉ°Š ¤µ„„ªnµ 3 ­´ž—µ®r¨oª°µ„µ¦žª—¨—¨Šœo°¥„ªnµ¦o°¥¨³ 50 ‹µ„Á—·¤ ®¦º°
Ÿ¼ožiª¥¥´Šžª—¦»œÂ¦Š ‡º°¤¸‡³Âœœ‡ªµ¤žª—ÁŒ¨¸É¥¤µ„„ªnµ 7/10
3. Á¤ºÉ°Ÿ¼ožiª¥Å—o¦´„µ¦¦´„¬µ—oª¥¥µ„¨»n¤ first-line drugs °¥nµŠœo°¥ 2 œ·—¨oªÅ¤n˜°­œ°Š
®¦º°Á¤ºÉ°Á®Èœªnµ¤¸‡ªµ¤‹ÎµÁž}œ˜o°ŠÅ—o¦´¥µÂ„ožª—Äœ„¨»n¤ strong opioids
4. ¡š¥rÁ®Èœªnµ¤¸…o°nŠ¸ÊÄœ„µ¦¦´„¬µ—oª¥ invasive techniques ¨³/®¦º°„µ¦Ÿnµ˜´—
5. Á¤ºÉ°Ÿ¼ožiª¥¤¸°µ„µ¦žª—Á¦ºÊ°¦´Š¤µ„„ªnµ 1 že…¹ÊœÅž ¨³/®¦º° ª·œ·‹Œ´¥ªnµÁž}œÃ¦‡žª—Á¦ºÊ°¦´Š
(chronic pain syndrome) ®¦º°¤¸¨´„¬–³°¥nµŠ®œ¹ÉŠ°¥nµŠÄ——´Š˜n°Åžœ¸Ê
5.1 ¤¸°µ„µ¦žª—°¥nµŠ¦»œÂ¦Š‹œ¤¸Ÿ¨„¦³š˜n°‡»–£µ¡¸ª·˜ ¨³„µ¦—εÁœ·œ„·‹ª´˜¦
ž¦³‹Îµª´œ
5.2 Ťn­µ¤µ¦™ž¦´˜´ªÄ®oÁ…oµ„´£µª³žª—Á¦ºÊ°¦´ŠÅ—o
5.3 ¤¸ž{®µšµŠ‹·˜Áª ¤¸°µ„µ¦Ž¹¤Á«¦oµ ª·˜„„´Šª¨ ¤¸»‡¨·„£µ¡Áž¨¸É¥œÅž ÁŒºÉ°¥µ ˜„Ä‹
Šnµ¥
5.4 ¤¸ž¦³ª´˜·„µ¦¦´„¬µ°µ„µ¦žª—š¸ÉŸœ„Œ»„ÁŒ·œ ®¦º°ÂŸœ„Ÿ¼ožiª¥Äœn°¥‡¦´ÊŠ
5.5 ¤¸¡§˜·„¦¦¤„µ¦Äo¥µÂ„ožª—¤µ„„ªnµž„˜·®¦º° ¤¸ž¦³ª´˜·˜·—­µ¦Á­¡˜·— —ºÉ¤­»¦µÁ¦ºÊ°¦´Š
­¼»®¦¸É‹´—
5.6 Ÿ¼ožiª¥Áž¨¸É¥œ­™µœ¡¥µµ¨®¦º°Â¡š¥rŸ¼oÄ®o„µ¦¦´„¬µn°¥
5.7 Ťn¦nª¤¤º° ®¦º°Å¤n¤¸Â¦Š‹¼ŠÄ‹Äœ„µ¦¦´„¬µ
27

38. 28
£µ‡Ÿœª„ 1
‡»–£µ¡®¨´„“µœ (Quality of Evidence)
¦³—´ 1 ®¤µ¥™¹Š ®¨´„“µœš¸ÉÅ—o‹µ„
1.1 „µ¦ššªœÂ¤¸¦³ (systematic review) ‹µ„„µ¦«¹„¬µÂ„¨»n¤­»n¤˜´ª°¥nµŠ-‡ª‡»¤
(randomize-controlled clinical trials) ®¦º°
1.2 „µ¦«¹„¬µÂ„¨»n¤­»n¤˜´ª°¥nµŠ-‡ª‡»¤š¸É¤¸‡»–£µ¡—¸Á¥¸É¥¤ °¥nµŠœo°¥ 1 Œ´ (a well-designed,
randomize-controlled, clinical trial)
¦³—´ 2 ®¤µ¥™¹Š ®¨´„“µœš¸ÉÅ—o‹µ„
2.1 „µ¦ššªœÂ¤¸¦³…°Š„µ¦«¹„¬µ‡ª‡»¤Â˜nŤnÅ—o­»n¤˜´ª°¥nµŠ (non-randomized, controlled,
clinical trials) ®¦º°
2.2 „µ¦«¹„¬µ‡ª‡»¤Â˜nŤn­»n¤˜´ª°¥nµŠš¸É¤¸‡»–£µ¡—¸Á¥¸É¥¤ (well-designed, non-randomized, controlled
clinical trial) ®¦º°
2.3 ®¨´„“µœ‹µ„¦µ¥Šµœ„µ¦«¹„¬µ˜µ¤ÂŸœ˜·—˜µ¤Á®˜»Åž®µŸ¨ (cohort) ®¦º°„µ¦«¹„¬µª·Á‡¦µ³®r‡ª‡»¤
„¦–¸¥o°œ®¨´Š (case control analytic studies) š¸ÉÅ—o¦´„µ¦°°„ª·‹´¥Áž}œ°¥nµŠ—¸Ž¹ÉŠ¤µ‹µ„­™µ´œ
®¦º°„¨»n¤ª·‹´¥¤µ„„ªnµ®œ¹ÉŠÂ®nŠ/„¨»n¤ ®¦º°
2.4 ®¨´„“µœ‹µ„¡®»„µ¨µœ»„¦¤ (multiple time series) Ž¹ÉŠ¤¸®¦º°Å¤n¤¸¤µ˜¦„µ¦—εÁœ·œ„µ¦ ®¦º°®¨´„“µœš¸É
Å—o‹µ„„µ¦ª·‹´¥šµŠ‡¨·œ·„¦¼žÂ°ºÉœ®¦º°š—¨°ŠÂÅ¤n¤¸„µ¦‡ª‡»¤ Ž¹ÉŠ¤¸Ÿ¨ž¦³‹´„¬r™¹Šž¦³Ã¥œr
®¦º°Ãš¬‹µ„„µ¦ž’·´˜·¤µ˜¦„µ¦š¸ÉÁ—nœ´—¤µ„ Ánœ Ÿ¨…°Š„µ¦œÎµ¥µÁ¡Èœœ·Ž·¨·œ¤µÄoÄœ¦µª ¡.«.
2480 ‹³Å—o¦´„µ¦‹´—°¥¼nÄœ®¨´„“µœž¦³Á£šœ¸Ê
¦³—´ 3 ®¤µ¥™¹Š ®¨´„“µœš¸ÉÅ—o‹µ„
3.1 „µ¦«¹„¬µ¡¦¦–œµ (descriptive studies) ®¦º°
3.2 „µ¦«¹„¬µ‡ª‡»¤š¸É¤¸‡»–£µ¡¡°Äo (fair-designed, controlled clinical trial)
¦³—´ 4 ®¤µ¥™¹Š ®¨´„“µœš¸ÉÅ—o‹µ„
4.1 ¦µ¥Šµœ…°Š‡–³„¦¦¤„µ¦Ÿ¼oÁ¸É¥ªµ ž¦³„°„´‡ªµ¤Á®Èœ¡o°Š®¦º°Œ´œšµ¤˜· (consensus) …°Š
‡–³Ÿ¼oÁ¸É¥ªµ œ¡ºÊœ“µœž¦³­„µ¦–ršµŠ‡¨·œ·„ ®¦º°
4.2 ¦µ¥Šµœ°œ»„¦¤Ÿ¼ožiª¥‹µ„„µ¦«¹„¬µÄœž¦³µ„¦˜nµŠ„¨»n¤ ¨³‡–³Ÿ¼o«¹„¬µ˜nµŠ‡–³°¥nµŠœo°¥ 2
Œ´
¦µ¥Šµœ®¦º°‡ªµ¤Á®Èœš¸ÉŤnÅ—oŸnµœ„µ¦ª·Á‡¦µ³®r¤¸¦³ Ánœ Á„¦È—¦µ¥ŠµœŸ¼ožiª¥ÁŒ¡µ³¦µ¥
(anecdotal report) ‡ªµ¤Á®Èœ…°ŠŸ¼oÁ¸É¥ªµÁŒ¡µ³¦µ¥ ‹³Å¤nÅ—o¦´„µ¦¡·‹µ¦–µªnµÁž}œ®¨´„“µœš¸É¤¸‡»–£µ¡Äœ
„µ¦‹´—šÎµÂœªšµŠÁªž’·´˜·œ¸Ê
28