What is the treatment for nerve pain caused by wearing a weighted vest?

Treatment of Nerve Pain from Weighted Vest Use

Immediately discontinue weighted vest use and begin physical therapy with nerve mobilization techniques, combined with first-line pharmacologic treatment using pregabalin 75 mg at bedtime, titrating to 150 mg twice daily over one week. 1, 2

Immediate Management: Remove the Offending Cause

• Stop wearing the weighted vest immediately to eliminate ongoing nerve compression or traction injury, as continued use will perpetuate symptoms and delay recovery 3, 4
• The nerve injury pattern from weighted vests most commonly affects the brachial plexus through shoulder strap compression/traction (rucksack palsy), presenting as paresthesias, pain, cramping, and muscle weakness in the upper extremities 3
• Direct trauma, compression from equipment, or excessive stretching of peripheral nerves requires cessation of the causative activity as the foundation of treatment 4

First-Line Nonpharmacologic Treatment

• Initiate physical therapy immediately focusing on nerve mobilization techniques, specifically cervical spine and brachial plexus mobilization to relieve nerve tension and reduce symptoms 1, 3
• Apply local heat therapy to the affected shoulder/neck region for moderate pain relief, which can be combined with other modalities for additive benefit 1, 5
• Consider transcutaneous electrical nerve stimulation (TENS) as part of a multimodal approach, though evidence is limited and it should never be used as monotherapy 1, 6

First-Line Pharmacologic Treatment

Pregabalin is the preferred first-line medication for neuropathic pain with the following dosing:

• Start at 75 mg at bedtime on day 1 2, 7
• Increase to 75 mg twice daily (150 mg/day total) after 3-7 days 2, 7
• If inadequate response after 1 week, increase to 150 mg twice daily (300 mg/day total) 2, 7
• Maximum dose is 300 mg twice daily (600 mg/day) for patients with ongoing pain who tolerate lower doses, though this carries higher discontinuation rates due to adverse effects 7

Alternative first-line option if pregabalin is unavailable or not tolerated:

• Gabapentin starting with 600 mg on day 1, increasing every 3 days to 1800 mg divided in 3 doses (typical effective range 1800-3600 mg/day) 2

Second-Line Pharmacologic Treatment

If gabapentinoids fail or are contraindicated after 3-4 weeks at therapeutic doses:

• Tricyclic antidepressants: Nortriptyline or desipramine 10-25 mg at bedtime, titrating slowly to maximum <100 mg/day to minimize anticholinergic effects 1, 2
• SNRIs: Duloxetine 30 mg daily, titrating to 60 mg daily if needed 1, 5
• Topical therapies: Lidocaine patches or cream applied directly to painful areas, which has stronger evidence than topical amitriptyline or ketamine 1

Combination Therapy for Refractory Pain

• If monotherapy provides inadequate relief (pain ≥4/10 after 3-4 months at therapeutic doses), combine pregabalin with a tricyclic antidepressant (nortriptyline) for additive benefit 2
• NSAIDs (naproxen, ibuprofen) can be added for any concurrent myofascial pain component 1, 5

Interventional Procedures for Refractory Cases

If pain persists despite optimal pharmacologic management:

• Refer to pain management specialist for consideration of nerve blocks (intercostal or periorbital depending on affected nerve distribution) using corticosteroid with long-acting sodium channel blocker 1
• Dorsal column stimulation may be considered for severe refractory neuropathic pain, though data are limited 1

Critical Pitfalls to Avoid

• Never continue weighted vest use even with modifications, as ongoing compression/traction will prevent nerve recovery 3, 4
• Avoid opioids as first or second-line therapy due to lack of long-term efficacy data for neuropathic pain and significant harm potential including addiction 1, 2
• Do not use SSRIs (paroxetine, fluoxetine, citalopram) as they have inconsistent evidence for neuropathic pain 2
• Set realistic expectations: Neuromodulators require 3-4 months at therapeutic doses to achieve maximum pain reduction; patients must continue treatment even without immediate relief 1
• Screen for psychological comorbidities: Chronic neuropathic pain commonly presents with anxiety and depression requiring concurrent mental health support through cognitive behavioral therapy or referral to mental health specialists 1

Prevention of Recurrence

If weighted vest use is resumed after complete symptom resolution:

• Use wider, better-padded shoulder straps with proper adjustment to distribute load 3
• Incorporate hip belt to reduce shoulder strap pressure 3
• Reduce total vest weight and duration of wear 3
• Strengthen shoulder girdle muscles through resistance training before resuming vest use 3