Is An MRI An Appropriate Test For Neuropathy

Today's post from painmedicinenews.com (see link below) talks about the ongoing doubt amongst medical experts as to what the best form of testing for neuropathy actually is. The high incidence of MRI testing, especially in North America, is intended to rule out other potential problems, rather than to establish neuropathy (which it can't really do). This stems from the fact that doctors are frequently doubtful that they're dealing with a neuropathy problem and want to make sure they're not missing anything else. Considering the high cost of MRIs, this does seem a little wasteful when other tests and the patient's own accounts can be far more accurate indicators of neuropathic problems.

High Rate of MRI Found in Study of Peripheral Neuropathy Diagnosis

But analysis did not examine whether imaging was appropriate or not.

ISSUE: APRIL 2012 by Rosemary Frei, MSc

With more than one dozen diagnostic tools, identifying peripheral neuropathy (PN) can be complex and costly. That is why investigators at the University of Michigan attempted to define diagnostic practice patterns in order to identify opportunities to improve efficiency of PN care.

The researchers identified 1,031 individuals diagnosed with PN between 1996 and 2007 through the Health and Retirement Study and the linked Medicare Standard Analytical Files (Ann Intern Med 2011;172:127-132). They included patients who were at least 65 years old in 1996, and created a matched comparison group. Among the subjects, 41.5% had diabetes and 44.4% of these had diabetic neuropathy; 80% of the nondiabetic individuals had idiopathic neuropathy.

The researchers focused on 15 relevant tests for PN to determine the number and patterns of tests used six months before and after the incident neuropathy diagnosis. After assessing 15 PN diagnosis tests, the investigators found that four were performed most often, on average, but testing patterns were highly variable, with more than 400 different patterns identified. The most common testing pattern was used only in 4.8% of patients.

About one-fourth—23.2%—had at least one magnetic resonance imaging (MRI) of the brain or spine, whereas a glucose tolerance test was rarely obtained (1%). Almost one-fifth (19.8%) of patients with neuropathy received electromyography. A complete blood cell count was ordered in 73.1% of patients, thyrotropin level in 55.2%, comprehensive metabolic panel in 53.2%, erythrocyte sedimentation rate in 28.7% and an antinuclear antibody test in 11.2%.

Additionally, a fasting glucose level test was ordered in 23.4% of patients with neuropathy. A hemoglobin A_1c level was ordered in 43.2% of those with neuropathy and 17.1% of nondiabetic patients. Vitamin B₁₂ levels were ordered in 32.6% of patients with neuropathy and in 40.6% of nondiabetic patients.
The large number of tests translated into high levels of Medicare expenses during the diagnostic period, at $14,362 per patient per year.

“High MRI use is probably for many reasons including physicians not being confident that someone has PN, the fact that no cause is identified for many cases with neuropathy, which pushes physicians to order more tests and because patients often prefer more testing, especially MRIs,” said Brian Callaghan, MD, assistant professor of neurology at University of Michigan Medical School, Ann Arbor.

The team concluded that more research is needed on the optimal approach for diagnosing PN. “First, I think we need to firmly establish what the best tests are for the evaluation of this condition. Next, we need to increase awareness among physicians including internists and neurologists that see this common condition,” said Dr. Callaghan.

Despite the high use of MRI, the evidence indicates two-hour oral glucose tolerance, fasting glucose, vitamin B₁₂ levels and serum protein electrophoresis provide the highest true-positive rate and the greatest potential for guiding subsequent interventions (Neurology 2009;72:185-192).

Vera Bril, MD, suggested that the high use of MRI likely is linked to testing for comorbid conditions, rather than for PN itself. “You need to know why the physicians ordered the MRIs; it’s a leap to assume it’s inappropriate,” said Dr. Bril, professor of neurology at the University of Toronto and head of neurology at the University Health Network and Mount Sinai Hospital, Toronto, Canada.
“The patients in my clinic of this age often have spinal degenerative disease in addition to PN. I don’t do MRIs in my straightforward PN patients, but if they have spinal involvement. I’ll look further at it, including possibly with MRI.”

http://www.painmedicinenews.com/ViewArticle.aspx?d=Clinical%2bPain%2bMedicine&d_id=82&i=April+2012&i_id=826&a_id=20593

Is Zonisamide A Good Idea For Neuropathic Pain

Today's post from onlinelibrary.wiley.com (see link below) looks at Zonisamide as a possibly effective drug for reducing neuropathic pain. Zonisamide is one of the anti-epileptic/ anti-convulsant drugs that are designed to treat epilepsy. Like some other anti-convulsants, it's now being prescribed to treat neuropathic pain and discomfort. However, this study shows that there is very little evidence to support its effectiveness in suppressing nerve pain and that other anti-epileptics are far more effective - for instance, Gabapentin and pregabalin (Lyrica). However, there are also questions surrounding the effectiveness of pregabalin especially for neuropathy caused by diabetes and HIV (see other articles on this blog), not least from the manufacturers themselves! Gabapentin has a far better reputation but as this article shows, Zonisamide hasn't proved to be effective at all. Worth discussing with your doctor or neurologist, if anti-convulsants are being prescribed for you.
 

Zonisamide for neuropathic pain in adults
R Andrew Moore1,*, Philip J Wiffen1, Sheena Derry1, Michael PT Lunn2 
Editorial Group: Cochrane Pain, Palliative and Supportive Care Group
Published Online: 22 JAN 2015

Abstract

Background

Antiepileptic drugs have been used in pain management since the 1960s; some have shown efficacy in treating different neuropathic pain conditions. The efficacy of zonisamide for the relief of neuropathic pain has not previously been reviewed.

Objectives

To assess the analgesic efficacy and associated adverse events of zonisamide for chronic neuropathic pain in adults.

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (via CRSO), MEDLINE, EMBASE, and two clinical trials databases (ClinicalTrials.gov. and the World Health Organisation Clinical Trials Registry Platform) to 1 August 2014, together with reference lists of retrieved papers and reviews.

Selection criteria

We included randomised, double-blind studies of at least two weeks' duration comparing zonisamide with placebo or another active treatment in chronic neuropathic pain. Participants were adults aged 18 and over. We included only full journal publication articles and clinical trial summaries.

Data collection and analysis

Two review authors independently extracted efficacy and adverse event data, and examined issues of study quality. We considered the evidence using three tiers. First tier evidence derived from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention-to-treat analysis without imputation for dropouts; at least 200 participants in the comparison, 8 to 12 weeks duration, parallel design); second tier evidence derived from data that failed to meet one or more of these criteria and were considered at some risk of bias but with adequate numbers in the comparison; and third tier evidence derived from data involving small numbers of participants that were considered very likely to be biased or used outcomes of limited clinical utility, or both.

We planned to calculate risk ratio (RR) and numbers needed to treat (NNT) and harm (NNH) for one additional event using standard methods expected by The Cochrane Collaboration.

Main results

We included a single study treating 25 participants (13 zonisamide, 12 placebo) with painful diabetic neuropathy over 12 weeks. No first or second tier evidence was available for any outcome. The small size of the study and potential major bias due to a high proportion of early study withdrawals with zonisamide precluded any conclusions being drawn. There were two serious adverse events (one death) in zonisamide-treated participants, which were apparently not related to treatment.

Authors' conclusions

The review found a lack of evidence suggesting that zonisamide provides pain relief in any neuropathic pain condition. Effective medicines with much greater supportive evidence are available.

Plain language summary

Zonisamide for neuropathic pain in adults

Neuropathic pain can arise from damage to nerves and injury to the central nervous system. It is different from pain messages carried along healthy nerves from damaged tissue (a fall, or cut, or arthritic knee). Neuropathic pain is treated by different medicines than those used for pain from damaged tissue. Medicines like paracetamol or ibuprofen are not usually effective in neuropathic pain, while medicines that are sometimes used to treat depression or epilepsy can be very effective in some people with neuropathic pain.

Zonisamide is one of a type of medicine normally used to treat epilepsy. Some of these medicines are also useful for treating neuropathic pain. We looked for clinical trials that used zonisamide to treat neuropathic pain. We found a single study with 25 participants treated either with zonisamide or placebo. Study reporting may have led to major over-estimation of any treatment effects because most (8/13) participants treated with zonisamide withdrew before the end of 12 weeks of treatment for a variety of reasons, mostly adverse events (side effects).

There was too little information, which was of inadequate quality, to give any guidance as to whether zonisamide works as a pain medicine in any neuropathic pain condition. Other medicines have been shown to be effective in some types of neuropathic pain.

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011241.pub2/abstract

Is Marijuana Effective Against Neuropathic Pain

Today's post is from scientistlive.com (see link below) and is yet another article about the benefits of marijuana for neuropathy patients. It's based on another small study by researchers at San Diego School of Medicine but the 'cannabis as analgesic' evidence is mounting with time. Others are also working on cannabis derivatives which don't give the high and don't require you to smoke, which could be beneficial to ex-smokers and people who aren't keen on getting stoned. An extract of cannabis has been developed into a drug for multiple sclerosis called Sativex. This is taken as a spray under the tongue. An artificial form of cannabis’ active ingredient delta 9-tetrahydrocannabinol (THC) is also licensed, as dronabinol (Marinol). These preparations do not cause the ‘high’ of the illegal drug.
*The biggest problem for neuropathy patients who wish to go down this road, is the legal one. It's then a lottery as to where you live and what the laws are but wherever that may be, let's hope that it doesn't lead to what happens in tomorrow's video post, which may put you off forever!

Marijuana effective against HIV pain 
  

In a double-blind, placebo-controlled clinical trial to assess the impact of smoked medical cannabis, or marijuana, on the neuropathic pain associated with HIV, researchers at the University of California, San Diego School of Medicine found that reported pain relief was greater with cannabis than with a placebo. The study, sponsored by the University of California Center for Medical Cannabis Research (CMCR) based at UC San Diego, will be published on line, August 6 in the journal Neuropsychopharmacology.

Led by Ronald J. Ellis, M.D., Ph.D., associate professor of neurosciences at UCSD School of Medicine, the study looked at 28 HIV patients with neuropathic pain not adequately controlled by other pain-relievers, including opiates. They took part in the controlled study as outpatients at the UCSD Medical Center. The proportion of subjects achieving pain reduction of 30 percent or more was greater for those smoking cannabis than those smoking the placebo.

"Neuropathy is a chronic and significant problem in HIV patients as there are few existing treatments that offer adequate pain management to sufferers," Ellis said. "We found that smoked cannabis was generally well-tolerated and effective when added to the patient's existing pain medication, resulting in increased pain relief."

Each trial participant participated in five study phases over seven weeks. During two five-day phases, randomly selected participants smoked either cannabis or placebo cigarettes made from whole plant material with cannabinoids (the psychoactive compound found in marijuana) removed, both provided by the National Institute on Drug Abuse. Outcome was tested by standardised tests measuring analgesia (lessened pain sensation), improvement in function and relief of pain-associated emotional distress.

Using verbal descriptors of pain magnitude, cannabis was associated with an average reduction of pain intensity from 'strong' 'to mild-to-moderate' in cannabis smokers, according to Ellis. Also, cannabis was associated with a sizeable (46% versus 18% for placebo) proportion of patients reporting clinically meaningful pain relief.

The study's findings are consistent with and extend other recent research supporting the short-term efficacy of cannabis for neuropathic pain, also sponsored by the CMCR.

"This study adds to a growing body of evidence that indicates that cannabis is effective, in the short-term at least, in the management of neuropathic pain," commented Igor Grant, M.D., professor of psychiatry and director of the CMCR.

http://www.scientistlive.com/European-Science-News/Pharmacology/Marijuana_effective_against_HIV_pain/20850/

Is HIV always the big bad wolf

This is part of an article by Bradford McIntyre on the site http://www.hivaidspositivestories.com and raises an important question for all people with HIV. Is the blame for every disease or complaint that you get, transferred onto HIV and if so, is that really the case? It's certainly easy for health professionals to blame HIV and/or the HIV medication for your neuropathy but the fact is that there are about 100 possible causes for neuropathy (see elsewhere here on the blog). It makes you think!

So much fear has been created around HIV infection and AIDS. The camouflage uniforms worn in the army, disguise and hide, so not to draw attention, able to blend in. The fear associated with HIV/AIDS has kept us in the dark, many fear losing their family. friends, home and job, causing people to hide the fact they have been infected with the HIV virus. So no one can see, hear, or know the truths of those living with HIV and AIDS. Most often when individuals die from HIV related illness or AIDS, the funeral announcements rarely say HIV/AIDS was the cause, but use cancer, heart disease or any other camouflage.


How can we tell the real number of HIV related deaths? How can the public know and understand HIV/AIDS, without the truth? Individuals dealing with HIV and all those around them who are affected but not infected, they know these truths!
Science, pharmaceutical companies, the medical profession and government, have all but ignored much of what many people living with HIV/AIDS have to say, which is a major contribution in the understanding of this virus. Science and the medical profession provide HIV/AIDS information to the media. The media takes this information and in so doing, does it without a real balance of understanding. Unfortunately the fear has undermined our understanding. We see people dying, and certainly in many parts of the world there is malnutrition, lack of medical attention and affordable pharmaceutical resources, causing countless deaths. We see the fear associated with sex and the need for safe sex practices! We hear about the deaths.


We hear about drug cocktails, medications being approved. We see people taking a handful of pills. We hear about the resistance to drugs, and we visually, through the media, see those sick with wasting syndrome, PCP pneumonia, kaposi's sarcoma , or crippled by neuropathy.


What is alarming about this situation is the medical profession holds the HIV virus responsible for any and all illness when a patient is diagnosed infected with HIV, using the excuse that a condition is HIV related. It is because of this rampant over diagnosis that little or no search is undertaken for what is causing the health problem. Many have died, many suffered greatly due to mis-diagnosis or no diagnosis. Other diseases occur, and with a condition in progress or out of control and very little attention given it, this allows for many suffering and dying. Not from HIV, but from an invasion of bacteria, fungi, viruses and cancers, unaware to those not looking.
We don't see individuals living a happy and full life, whether it be with or without drug treatments. And we don't see it because the fear has people afraid to talk about HIV/AIDS or disclose they have been infected. So we don't have people coming forward to tell their side of HIV/AIDS. How are we going to get people to come forward when the stigma attached to HIV/AIDS has created so much fear. People are hiding their HIV infection! This is likened to the early days of cancer, hiding the fact, only whispering the C word! Everyone who develops cancer does not die, it makes no sense to believe everyone who is infected with HIV will get sick or die either! We don't see those who get sick but benefit from the drugs and have their health restored, many returning to the work force. We don't see or hear about individuals who test positive for HIV or have AIDS, in relationships, falling in love. We don't see the many relationships where one partner is infected and one is not, and the partner who is negative, is not infected.


The public needs to understand HIV and let go of the fear, each person taking part in a global prevention strategy. These days pharmaceutical resistance is evident, with HIV, not only is a person infected with a strain or possible multiple strains, but along with it, comes the possibility of resistance to all the drugs the infected individual has taken.
We don't know how each person will react to HIV infection. We need to put money back into wellness!
We must not wane from our efforts in safe sex education, prevention, and research. Never was it more important to keep up our efforts, creating less toxic and affordable drugs, and providing proper health care including alternative therapies and supplements.


With proper awareness and education, we can go about living our lives responsibly, " showing up for life", without fear. Not afraid of talking about HIV/AIDS or conversations about safe sex.
Letting go of the fear, we can all talk to our family and friends and co-workers we discuss our personal lives with. Our employer can know health related information. And, if need be, we can ask for help and receive help! We can also eliminate false perceptions and judgments due to shear ignorance. There is more power in people knowing the truth, than there ever was in the fear and hiding! A shift in perception is nothing short of a Miracle!

by Bradford McIntyre

http://www.positivelypositive.ca

How Good Is The Scrambler Treatment For Neuropathy

Today's post from mayoclinic.org (see link below) is a strong claim for the benefits of the so-called 'scrambler' treatment for neuropathy. The scrambler treatment is basically one of the several electro-stimulation devices on the market today. It is somewhat surprising that the Mayo clinic places so much faith in this apparatus but they do admit that it may not work for all patients and as such, it joins the ranks of other electrical stimulant devices like TENS. You have to make up your own mind in the end and discuss it carefully with your doctor or specialist and not just the clinic that offers it as part of their services. It may also be wise to be prepared for failure or disappointment but there's no doubt that some people are helped by these treatments. The reader's comment at the end of this article may well be worth reading - it does offer an alternative opinion.

Breaking Away From Pain With the Help of 'The Scrambler'
Posted by Hoyt Finnamore (@hoytfinnamore)

Karen Safranek didn't take a worry-free step for 10 years. Severe peripheral neuropathy — a side effect of breast cancer treatment she received in 2002 — left her with constant burning, tingling, numbness and pain in both her feet.

Over time, Karen tried dozens of treatments to rid herself of the discomfort. Nothing worked. So in 2012 when she found out about a clinical research trial available at Mayo Clinic for people who had peripheral neuropathy after chemotherapy, she was interested, but not optimistic.

"I tried so many things. Anything a doctor recommended or heard about, or anything I heard about, I'd give it a try if I could," Karen says. "But years past, and the pain didn't get any better. By 2011, life was not good. I was analyzing my house to figure out where we could put a wheelchair ramp. At that time, I thought it wouldn't be much longer before I couldn't walk anymore."

This new treatment was different. With MC-5A Calmare Therapy, often called "the scrambler" for short, Karen noticed improvement following the first session. After completing a series of treatments, she was pain-free for the first time in more than a decade. Through her participation in the clinical trial and occasional follow-up treatments at Mayo Clinic, Karen has been able to leave peripheral neuropathy behind and reclaim her life.

Battling pervasive pain

Karen began to notice symptoms of peripheral neuropathy shortly after she started receiving chemotherapy. By the end of her treatments, her breast cancer was gone, but she had constant shooting pain and numbness in her feet and legs that left her weak and unable to maintain her balance.

Peripheral neuropathy is a common side effect of some chemotherapy drugs. For many people, the condition fades away after treatment is over. But for some, like Karen, it can last long after other chemo side effects are gone and can have a significant impact on day-to-day life. The effect on Karen's life was overwhelming.

"It hurt if I was sitting, walking or standing," she says. "Blankets hurt my legs. I wasn't getting a good night's sleep. Going back to work wasn't an option. In time, it got so bad that whenever I went somewhere, I would analyze where I had to park my car and how far it was to get to the building. If there wasn't a spot close enough for me to walk the distance to and from my car, I would just go home."

Retraining the brain
Traditionally, chronic peripheral neuropathy has been challenging to successfully treat. Like many others who have this debilitating disorder, Karen tried everything she and her doctors could think of to relieve her pain. But still she suffered. Then in December 2013, Karen learned of the clinical trial at Mayo Clinic that would change everything for her.

Peripheral neuropathy happens as a result of nerve damage. The damaged nerves send aberrant signals to the brain, causing pain and the other symptoms of peripheral neuropathy. During her treatment sessions as a participant in the research study, the damaged nerves in Karen's feet were connected by electrodes to the scrambler. The device sent painless electrical signals to the damaged nerves, and the nerves relayed those signals to the brain. The new signals broke the pain cycle by retraining Karen's brain to understand that it was not really experiencing pain.

Reclaiming her life

Although the scrambler does not ease symptoms of peripheral neuropathy in all cases, Karen's response was dramatic.

"I was tremendously better after just one treatment," she says. "My feet and legs felt light and pain-free. Previously, I had felt as though they were very heavy to lift and walking was comparable to wearing cement shoes. After the treatment, I could walk really fast. I could take the stairs. I could even run."

After a total of 10 treatment sessions in January 2013, Karen no longer had any symptoms. The effects of the treatment were not permanent, however. She returned to Mayo Clinic for additional scrambler treatment nine months after her first sessions and again eight months after that.

Even though she knows she'll likely need follow-up care over the long-term to keep peripheral neuropathy at bay, Karen is enthusiastic about the difference the treatment has made for her.

"Before this, I wasn't able to do some of the smallest things. I couldn't go grocery shopping alone. If I reached up to take an item off the shelf, I'd lose my balance and tip over. I couldn't walk on uneven ground because I couldn't feel my feet. I'd just fall down," she says. "Being able to participate in this clinical trial at Mayo Clinic with the scrambler, it brought my life back to me. It's a miracle. It really is."
..................................................................................................
COMMENT:
Oscar Lonzo (@oscarlonzo) · 9 hour(s) ago · I hope everyone appreciates how nonsensical the sentence, "The device sent painless electrical signals to the damaged nerves, and the nerves relayed those signals to the brain," is? I suggest anyone interested in this device contact a local neuroscientist and inquire as to the validity of that statement. I'm confident that they will agree with my own assessment that ALL that Ms. Safranek experienced was some benign TENS therapy and ALL she achieved was a placebo effect.

The device itself was "invented" by character named Giuseppe Marineo. In its original incarnation, it was designed to treat AIDS. Fortunately, Italian authorities arrested Mister Marineo for practicing medicine without a license before he injured too many people. Subsequently, it became a device to cure cirrhosis by "adjusting" hepatocellular "entropy." While that didn't get him in trouble with authorities, it also didn't attract much attention, and perhaps that led to its next "incarnation" as a device to treat pain. You can check out his "deltard" website and read all about the latest marvels it achieves in removing scars and reversing the effects of aging.

In promoting his "research," Mister Marineo has in various publications claimed to have a "MD,PhD," "MD,DSc," "PhD" degrees and has only this month claimed "DSc,ScD" degrees! Unfortunately, Mister Marineo has NONE of those. In fact, I seriously doubt he has ever attended college! Indeed, I'd be willing to bet hard currency that Dr. Loprinzi hasn't the faintest idea where Marineo got his degrees and wouldn't be willing to try and find out either!

The company that has been promoting this QUACK medical device for over EIGHT YEARS now is called "Calmare Technologies" -- a near bankrupt penny stock ("CTTC") trading in the "pink sheets." It's currently being sued by GEOMC -- the company that manufactured the device for them -- because CTTC hasn't paid them. According to GEOMC, ALL of the devices CTTC has distributed are outdated and in need of servicing. Does Dr. Loprinzi's patients know that? Indeed, does Dr. Loprinzi know how to determine whether the device is indeed putting out the appropriate "signals." If he does, then he must have his own personal oscilloscope because the device itself has NO mechanism for ascertaining whether it's producing the correct signals.

Congratulations to Mayo for the part its playing in promoting fraud and medical quackery in the US. I'm sure all the naive victims of chronic pain who read thie article and who, in consequence, find themselves looted of the 3-5 THOUSAND dollars charged for this "therapy" NOT covered by insurance will applaud you.

http://sharing.mayoclinic.org/discussion/breaking-away-from-the-pain-with-the-help-of-the-scrambler/