Leg Pain not always Neuropathy

This blog almost always relates HIV-related, foot and leg pain to Neuropathy but that's not always the case and it's always worth bearing in mind that there are other possible causes, before jumping to conclusions. When you're HIV positive, it's easy to pin a label on a problem at the first sign of trouble, after all, when it comes to secondary infections, virus, or drug related conditions, we're prone to almost everything (and they wonder why some people become hypochondriacs!) This article from Pain.com (see link below) outlines the commonest causes of leg pain. The true cause will eventually be discovered by your doctors but keeping an open mind before you get the diagnosis weeks or months later, is always advisable.

Leg Pain
May 21, 2011

In addition to injuries and muscle cramps, various medical conditions can cause leg pain. This article covers some of the medical conditions that can cause leg pain. Medical conditions involving the cardiovascular system will be discussed in a separate article in this series about leg pain.

Peripheral neuropathy is not a disease in itself, but a symptom of nerve damage in the limbs that is caused by other medical conditions. Peripheral neuropathy is common in patients with diabetes, HIV/AIDS, vitamin B12 deficiency, cancer, lupus, syphilis, lyme disease, rheumatoid arthritis, sarcoidosis, hypothyroidism, toxic exposure, certain genetic diseases and so on. Peripheral neuropathy is a common symptom and it can be inherited, caused by an infection, caused by exposure to certain chemicals, experienced as a side effect of some medications, caused by metabolic disorders or nutritional deficiencies, caused by inflammatory diseases, caused by oxygen starvation or caused by trauma to a peripheral nerve.

Peripheral neuropathy commonly affects the feet and legs. If a nerve that carries sensation from the body to the central nervous system is damaged, a person may experience pain, burning, numbness or tingling in the leg or foot. Proprioception, or the ability to sense where a body part is without looking, can also be affected and a person can become more uncoordinated. If a motor nerve that supplies a muscle is damaged, a muscle becomes weak because it can not contract as well. It is possible for some muscles to become paralyzed, depending on the extent of the nerve damage. In some cases, muscles may cramp up instead of becoming flaccid and weak. Treatment of peripheral neuropathy involves treating the underlying cause of the problem, along with symptomatic care for pain and physical or occupational therapy if necessary.

Another possible medical cause of leg pain is a bone infection, called osteomyelitis. Osteomyelitis is a bacterial infection that can be caused by several different types of bacteria. People can contract a bone infection via a wound, such as when an open fracture occurs or when a person has surgery, or an infection can spread to the bone from a different part of the body. A type of skin infection called cellulitis can spread to underlying tissues and bones in the leg, or an internal infection like a bladder infection can spread to other parts of the body through the bloodstream.

Any patient with a suppressed immune system due to aggressive immunosuppressive therapy or an immune deficiency like HIV/AIDS is more likely to develop infections, including osteomyelitis. Treatment for osteomyelitis includes antibiotic medications to get rid of the infection and medications to control pain. If the infection is not treated early, it is possible for the infection to spread to other tissues in the leg, making amputation of the leg necessary. It is also possible for a person with an untreated infection to go into septic shock when the bacteria infect the bloodstream.

If your leg pain is in your joints, you may have arthritis, or joint inflammation. There are many different types of arthritis, including osteoarthritis, gout and rheumatoid arthritis. More information about the various types of arthritis can be found at http://pain.com/library/2011/05/01-arthritis-awareness-month/. Infections in the joint capsule itself can also cause joint pain. Osteoarthritis, the most common type of arthritis, is caused by “wear and tear” on the cartilage of the joint. Rheumatoid arthritis is an autoimmune disease. Gout is caused by having too much of a substance called uric acid in your body, which builds up in the joints and causes pain and inflammation. Common symptoms of many different types of arthritis include joint pain, joint stiffness or decreased joint mobility and joint swelling. Treatment for arthritis varies depending on the type of arthritis. Talk to your doctor if you think you may have arthritis pain.

Fibromyalgia is a medical condition that can cause muscle pain in the legs and in other parts of the body. In addition to muscle pain, people with fibromyalgia may also have chronic fatigue, sleep disorders, tension headaches and mood disorders. The cause of fibromyalgia is unknown, but researchers think that people with fibromyalgia have a lowered tolerance to pain because of abnormalities in the way that their brains process pain signals. Treatment for fibromyalgia is symptomatic and aims to control pain, improve sleep and treat mood disorders. Not all aspects of fibromyalgia can be treated medically; for example, the frustration that a patient with fibromyalgia may feel in not knowing how to deal with chronic pain and fatigue may benefit from counseling.

Peripheral neuropathy, infections, arthritis and fibromyalgia are just a sampling of the medical conditions that may cause leg pain. These conditions are not as common as muscle cramps and injuries, but a good proportion of older people develop some degree of osteoarthritis and peripheral neuropathy can be caused by a variety of medical conditions. Always talk to your doctor if you have persistent leg pain and you do not know what is causing it.

http://pain.com/library/2011/05/21-leg-pain-3/

HIV Related Neuropathy

Today's video is an Australian view of how HIV can cause neuropathy, whether from the virus itself or the drugs. It comes from PainClinician.com (see link below) and is basically a teaching video for other medical professionals. The difference with most of the other neuropathy videos posted here on the blog, is that if this is what medical students are learning, then we can look at the disease from the point of view of the doctors who treat us. It seems to be full of up to date information and reflects modern medical thinking but apart from the odd scientific term here and there, which may not be so easily understood, the vast majority of the 11 minutes, is pretty interesting to the average neuropathy and HIV patient and explains a few areas which may have previously seemed vague.




http://painclinician.com/video/hiv_related_neuropathy

Hepatitis C And Neuropathy

Today's post from hepcsupport.org (see link below) talks about the link between hepatitis C and neuropathy. It is suspected that the blood condition EMC which is associated with hepatitis C, is responsible for causing nervous system abnormalities, thus explaining why so many people with hepatitis C also display symptoms familiar to many neuropathy patients. In this case, new treatments for hepatitis C are emerging and becoming more widely available. There's even a good chance that a combination therapy similar to the HIV anti-viral combos will be available for Hepatitis C patients. The research so far however, on the links between Hep C, EMC and Neuropathy, is thin on the ground to say the least.

A PAINFUL CONNECTION: HCV, CRYO, NEUROPATHY

By Mary Lou Reazor|March 24th, 2013|

There is a very strong association between HCV and a blood condition called Essential Mixed Cryoglobulinemia (EMC). People with hepatitis c, who suffer numbness or tingling of their extremities, know from experience there is also an association between HCV and Neuropathy. Increasingly, their claims are finding support according to researchers and clinical physicians.

Among other symptoms, EMC can cause nervous system abnormalities. Researchers have not explained the connection between HCV, Neuropathy and EMC, nor have they found significantly effective treatments, but knowledge is sure to increase as more people are diagnosed with HCV and its symptoms.

Neuropathy refers to any disease of the nervous system, resulting from localized inflammation of nerves. Patients complain of numbness, tingling and muscle weakness. Symptoms appear in the body’s extremities, the condition is called “Peripheral Neuropathy”. A physical exam may also reveal decreased deep tendon reflexes.

In both Encephalopathy and Neuropathy, the key change is inflammation of blood vessels (Vasculitis). The vessels are responding to immune system products floating in the blood vessels directly. The immune-globulins that are involved are called Cryoglobulins because they turn into a cool gel at cool temperatures. Since cold temps readily affect the small and middle-sized vessels in the extremities, the Cryoglobulins are more likely to form in them. Cryoglobulemia is the condition of having cyroglobulins in the blood.

There are several possible new treatments in “the pipeline”. There are several anti-viral agents that have shown promise in clinical trials, and researchers are developing several HCV specific protease inhibitors similar to those used for HIV retro-virus.

http://hepcsupport.org/a-painful-connection-hcv-cryo-neuropathy/

B Vitamins Alpha Lipoic Acid and other Nutrients for Neuropathy

There have been other posts on the blog (see alphabetical list on the right) about both Alpha Lipoic Acid and nutrients in general which may or may not help with neuropathy. Today's post comes from MDJunction (see link below) and is an excellent account, though without any indication of the writer's qualifications. That said, she says nothing that isn't found on most related sites on the Web (and provides more detail than most) and that may, in your opinion, be verification enough.
The general concensus from neurologists is that they support B-Vitamins and both Alpha Lipoic Acid and Acetyl-L Carnitine as supplements which may improve neuropathic problems but you should be aware that neither is cheap and in most countries, neither is covered by any sort of insurance policy. If the case is proved, it seems unfair to discriminate on the basis of who can and who can't afford a treatment but that's a whole other story!
Also, always take extra B-vitamins with advice from your doctor - it's easy to create an imbalance in your body and cause more harm than good.
If you decide to try supplements, (after consultation with your doctor) shopping around on the Net may help reduce costs.

Peripheral Neuropathy- Nutrients
Jackie
Mar 23 2011

Neuropathy: Nutrient Therapies

Although there has been virtually no research on the use of nutrient therapies for HIV-related neuropathies, there has been a fair amount of research (mostly in other countries) on their use for diabetic neuropathies. Since it appears likely that at least some of the mechanisms for the nerve damage may be similar in the two diseases (inflammation and oxidative damage to the nerves combined with B vitamin deficiencies), there is reason to believe that therapies which have proven useful for diabetics may also work for at least some people living with HIV who develop neuropathy. Many people living with HIV have reported to me that they have successfully eliminated neuropathy with some combination of the nutrient therapies discussed here. Thus, in addition to the other treatments mentioned, I would stress the importance of therapy with the B vitamins and other nutrients, especially acetyl-L-carnitine, gamma-linolenic acid, alpha-lipoic acid, magnesium, and chromium. I would definitely consider including the nutrients that have been shown to help rebuild the myelin sheath around nerves and/or improve nerve functioning such as choline, inositol, gamma linolenic acid, B6, B12, niacin, thiamine, biotin, folic acid, and magnesium.

Biotin, choline, inositol, and thiamine are B vitamins that have all been found useful in treating the peripheral and autonomic neuropathies found in diabetes and may also help with HIV-related neuropathies. In a study at the University of Athens, it was shown that regular, long-term use of biotin in diabetics was very effective both for improvement in nerve conduction and relief of pain. Improvement in nerve conduction occurred after only 4-8 weeks of therapy. In this study, biotin was given via daily intramuscular injection (10 mg/day) for 6 weeks; then 3 times per week (10 mg), intramuscularly, for 6 weeks; then 5 mg/day taken orally for up to two years. The researchers hypothesize that deficiency, inactivity, or unavailability of biotin in diabetics may result in disordered activity of the biotin-dependent enzyme, pyruvate carboxylase, leading to an accumulation of pyruvate and/or a depletion of aspartate, either of which could adversely affect nervous system metabolism. There are a number of reasons why HIV-positive persons may be deficient in biotin and, thus, potentially at risk for a similar problem. It has been suggested that those with neuropathy symptoms might try 10-15 mg/day orally, taken in conjunction with the other B vitamins found useful for improving nerve function.

B12 deficiency is a known cause of neuropathy so this vitamin, along with its coworker folic acid, should certainly be included in any program aimed at eliminating this symptom. Typical symptoms of peripheral neuropathy related to B12 deficiency include the type of leg and foot pains experienced by many. B6 deficiencies are also known to cause both carpal tunnel syndrome (with symptoms of numbness, tingling, and pain in the hands and wrists) and degeneration of peripheral nerves and may be responsible for some peripheral neuropathy problems.

Choline and inositol also seem to be very important parts of the combination of vitamins needed for neuropathy resolution. Diabetic neuropathy is known to be associated with a reduction in myo-inositol levels in nerves and tissues. The decreased level of myo-inositol is believed to cause a decrease in the activity of the sodium-potassium pump and, thus, to change the sodium permeability of nerves. Both diets high in inositol and inositol supplementation have been shown to improve diabetic neuropathy. Researchers at the University of Alabama found a statistically significant improvement in nerve function in diabetics placed on a diet high in inositol. Included in the diet were high-inositol foods such as cantaloupe, peanuts, grapefruit, and whole grains. Other researchers have reported that supplementation with inositol in doses of 2-6 grams per day has resulted in improvements in neuropathy. Robert Atkins, M.D., has reported his successful use of 2-6 grams per day for reversing diabetic neuropathy, and notes that physicians at St. James Hospital in Leeds, England, have reported good results with even smaller dosages.

In addition to the use of inositol itself, treatment with acetyl-L-carnitine can help raise nerve myo-inositol content. Florida researchers have found that peripheral nerve function in diabetes is linked to nerve myo-inositol content and that acetyl-l-carnitine can raise the levels of myo-inositol in the nerves of animals with experimentally induced diabetes. It also apparently protects the nerve membranes from free-radical damage, as evidenced by reduced malondialdehyde levels in the animals treated with acetyl-l- carnitine.

Thiamine has also been seen to be useful in treating diabetic neuropathy. Stanley Mirski, M.D., has reported that a large percentage of his diabetic patients who suffer from neuropathy have achieved improvements with daily thiamine supplementation in doses of 50-100 mg. Using a fat-soluble form of thiamine such as thiamine tetrahydro-furfuryl disulfide may be preferable because of the relatively poor absorption of water-soluble forms of this vitamin. This type is contained in Cardiovascular Research's Allithiamine. A large number of HIV-positive people have reported to me their successful elimination of neuropathy with the combined use of the B vitamins discussed here. The information on acetyl-l- carnitine is too recent for much in the way of anecdotal reports to have surfaced, but it might be an important addition to improve the chances for successful elimination of neuropathy.

Alpha-lipoic acid has long been used in Europe for the treatment of peripheral neuropathy in diabetics. A number of controlled clinical trials have shown its usefulness for reducing both the pain and numbness suffered by those with diabetic neuropathy, and its use for this condition is approved in Germany. Its antioxidant properties may help protect the nerves from the inflammation and oxidative damage that HIV induces, as has been shown to be true with diabetic neuropathy. Because of its liver protective and antioxidant benefits, it has been included as a component of the programs of many of my clients for several years now. It may have contributed to the success of the neuropathy elimination programs some of them have used.

Gamma linolenic acid is an essential fatty acid found in borage oil, grape seed oil, black currant oil, and evening primrose oil that has been shown to be successful in reversing nerve damage in diabetics suffering from peripheral neuropathy. In a double-blind, placebo-controlled study using 480 mg of GLA daily, all the diabetics given the fatty acid experienced gradual reversal of nerve damage and improvement in the symptoms related to the peripheral neuropathy, while those on placebo gradually worsened. It is thought that GLA may help to rebuild the myelin sheath around the nerves, thus restoring proper nerve conduction.

Magnesium is also known to be necessary for nerve conduction; deficiency is known to cause peripheral neuropathy symptoms. Thus, including optimal amounts of magnesium might contribute to elimination of neuropathy. There have also been reports of chromium deficiency causing peripheral neuropathy. I learned this too recently for chromium to have been included in most of the neuropathy therapy programs used by my clients in the past and, thus, I'm not sure what it might contribute. However, chronic infection is known to deplete body stores of chromium, so adding a dose of perhaps 200-400 mcg/day to a complete nutrient protocol might be reasonable.

In addition to all the nutrient supplements, an analysis of data coming out of the Immune Enhancement Program in Portland, Oregon, appears to show that their program, which includes Chinese herbs along with acupuncture and various other therapeutic approaches, results in improvement in neuropathy for some.

If you are considering supplementation with any of the B vitamins discussed above, never forget that although B vitamins are by and large non-toxic, any individual B vitamin should always be taken along with the full B complex to prevent imbalance in the body. Long-term use of very high doses of individual B vitamins taken alone, without the rest of the B complex, can induce imbalances or deficiencies in other B vitamins.

About Alpha Lipoic Acid

Alpha-lipoic acid (ALA), also known as lipoic acid (or thioctic acid), is a sulfur-containing fatty acid found inside every cell of the human body. The main function of alpha-lipoic acid is to generate the energy required to keep living organisms alive and functioning. Lipoic acid plays a key role in a variety vital energy-producing reactions in the body that turn glucose (blood sugar) into energy.

Alpha-lipoic acid is a potent biological antioxidant that has been shown to slow the oxidative damage in cells, and in many cases stabilize or even reverse cell damage. Alpha-lipoic acid is so effective as an anti-oxidant because it works on both water and fat-soluble free radicals that cause oxidation and cell damage in the body. Notwithstanding its popularity, the exact mechanism responsible for the medicinal affects of alpha-lipoic acid is still not fully understood.

Some research suggests that certain nerve diseases may occur as a result of free radical damage. Since alpha-lipoic acid can reach all parts of a nerve cell it can potentially protect nerve cells against such damage. This is the rationale behind studies on the potential benefits of alpha-lipoic acid for diabetic neuropathy.

Experimental studies show that alpha-lipoic acid may exhibit a renal protective effect in individuals with diabetes. Alpha-lipoic acid increases glucose uptake in the cells and appears to reduce symptoms of diabetic complications including cataract formation, vascular damage, and polyneuropathy (nerve damage). A study published in Diabetic Medicine in 1999 showed that patients treated with 600 mg of ALA 3 times daily for 3 weeks had improvement of diabetic symptoms from polyneuropathy. In another study using 600 to 1,800 mg of ALA daily, individuals treated showed improved insulin sensitivity. Most studies supporting the use of alpha-lipoic acid to reduce symptoms of diabetic peripheral neuropathy employed intravenous alpha-lipoic. Evidence for the use of oral lipoic acid, in connection with diabetes remains weak and contradictory.

Another group of nerve cells in diabetics, the autonomic nerves, which control the function of internal organs, may also become damaged. When this same phenomenon occurs in the heart, a condition known as cardiac autonomic neuropathy, it leads to irregularities of heart rhythm. There is some evidence that alpha-lipoic acid may be helpful for this condition.

Some in the scientific community believe that alpha-lipoic acid can actually reverse the damage in aging cells of the brain. Alpha lipoic acid has also been used both in oral and topical forms as a way for keeping skin healthy and young in appearance. There have been studies documented in medical literature indicating that supplemental ALA may even be beneficial in patients with glaucoma.

NutritionalTree.com is a great consumer resource that collects user reviews for alpha lipoic acid products.

Dosage

The common dosage of alpha-lipoic acid for complications of diabetes is 100 to 200 mg three times daily. In studies that found benefit of supplementing with alpha-lipoic acid, several weeks of treatment were often necessary for effects to develop. However, some studies have indicated as much as 600-1,800 mg per day of alpha-lipoic acid for optimal benefit in people with specific health concerns such as diabetes, liver cirrhosis and atherosclerosis.

If you are healthy and want to promote optimal health, a dose of 30 - 300 mg per day may be sufficient.

Lipoic acid appears to have no significant side effects at dosages up to 1,800 mg daily.

http://www.mdjunction.com/diary/jackies-journey-back-to-health/peripheral-neuropathy-nutrients

Will Neuropathy Diagnosis Go Over The Fiscal Cliff

 Today's post comes from the Neuropathy Association E-news letter for November 2012 (see link below) and highlights a potentially very difficult time for neuropathy patients in the United States. Hopefully solutions can be found, now that plunging off the fiscal cliff has been temporarily averted but these sort of spending cuts are just the sort that will remain on the statute books irrespective of macro decision making in Washington. Not that EMGs are the be all and end all of neuropathy testing (a patient's account of symptoms is more often than not enough to confirm diagnosis) but EMGs and the like are useful tools in establishing the extent of neuropathic damage and certainly in measuring its progress. If you are living in the USA it may well be worth reading and supporting this  campaign by the Neuropathy Association.

 

A MESSAGE FROM THE PRESIDENT AND CEO
Tina Tockarshewsky November 2012

Dear Friend,

A clear and present danger for our community is now upon us, and your support is essential.

It was recently announced in the 2013 Medicare Physician Fee Schedule from the Centers for Medicare & Medicaid Services (CMS) that reimbursement payments to physicians for needle electromyography (EMG) tests and nerve conduction studies (NCSs) will be severely reduced by 30%-70% beginning on January 1, 2013. EMG and NCSs are the primary diagnostic tools for peripheral neuropathy as well as other neuromuscular diseases like ALS, MS, and Parkinson’s. Implementing these cuts will deny millions access to proper diagnosis and care.

We are hearing from many physicians that they will no longer be able to afford to practice neuromuscular medicine...and many currently in practice will simply stop seeing Medicare patients!

This Neurological Fiscal Cliff Will Hurt Neuropathy Patients!

 

This is a crisis unlike any we have ever known before…and is a potential game changer for ALL patients and medical professionals working with the neuropathy community. Early diagnoses will be reduced and misdiagnoses will increase. Patient access and care will suffer, exacerbating the challenges already facing neuropathy patients.

A 2010 poll by The Neuropathy Association showed that many patients already face significant delays in diagnosis, during which irreparable nerve damage continues:

 

Two Ways You Can Help

First: In the coming days, we will announce a process for contacting members of Congress and posting comments on these proposed changes on the Centers for Medicare & Medicaid Services website. Please watch your emails for this announcement and respond immediately. Please also know that we are working with our medical professional society partners to respond to this crisis.
And keep in mind that other insurers follow Medicare’s actions. So, even if you are not on Medicare, this change has the potential to impact everyone in the neuropathy community.

Second: Support our year-end fundraising efforts, and KEEP US IN THE FIGHT. In these difficult times for the economy and the Association, your generous contributions are our lifeline – and help protect your interests as well as those of untold numbers of future patients.
Thank you for taking action.

Neurologists to See Cuts in 2013 Medicare Payments
The Center for Medicare and Medicaid Services (CMS) recently released new code values that could result in decreased payments to neurologists. Specifically, physicians who provide nerve conduction and needle EMG services will face dramatic cuts of more than 50 percent for some services starting January 1, 2013. This is a drastic cut that will be especially hard on neurology practices large and small, many of which rely on these services to meet their bottom line. Patients also will pay the price with less access to these services. Private health insurers often follow Medicare payment rules as well, which will exacerbate the situation.
- American Academy of Neurology

Editor’s Note: Please refer to the President and CEO's message above for more information about this breaking issue that negatively impacts access to critical evaluation and care for people with neuropathy, and how The Neuropathy Association is working with the American Academy of Neurology, the American Association of Neuromuscular & Electrodiagnostic Medicine, and the American Academy of Physical Medicine & Rehabilitation to address this issue.

http://www.neuropathy.org/site/PageServer?pagename=Resources_PubArchivesM_E

Foot Problems With Neuropathy

Today's post from wecare.ca/blog (see link below) talks almost exclusively to diabetes patients with neuropathic foot problems and doesn't mention HIV as also being a possible cause of neuropathy (Not surprising; there are more than a hundred causes!) but that doesn't take away from the fact that the symptoms and possible problems for your feet are exactly the same and once neuropathy is established, have the same cause. If you're trawling the Net for information about neuropathy you will more often than not be directed by your search engine to diabetes sites purely because diabetes is the best known and most common cause of neuropathy. It's important to realise that you're in the right place, even if your own cause is very different. Most of the symptoms of peripheral neuropathy are the same for all and many of the treatments are the same too. Today's post gives everyone with neuropathy some useful information as to why their feet are playing up and why ulcers etc may be appearing. Having absorbed this, it may be wise to look further to neuropathy sites associated with your own cause or causes but all information gathered will be useful to you in learning to live with the problem.

The Pins and Needles of Peripheral Neuropathy

November 12th, 2012 | Posted by SueKelly in Care Connections

Most people know what it is like to experience the numbing effect of ‘pins and needles’. But if you are diabetic or suffer from circulatory problems – this ailment can be a serious and ongoing concern.

Peripheral neuropathy is damage to the nerves in the limbs and particularly the feet where the body’s nerves are the longest. The risk of developing neuropathy increases the longer a person has been afflicted with diabetes or congestive heart failure or other circulatory problems. The nerve damage prevents people from knowing when their feet are too hot, too cold or sore or painful. Therefore a person loses the warning signs that their feet could be in jeopardy. This is called “loss of protective sensation”.

Loss of protective sensation (LOPS) contributes significantly to ulcer development. In healthy individuals, irritants like bunions, blisters or calluses may cause an unconscious change of gait. In people living with diabetes who experience LOPS as a result of peripheral neuropathy, no discomfort is felt, so pressure on specific sites is continued, directly affecting the development of ulcers. Early detection of LOPS and implementation of preventative strategies will reduce the rates of limb-threatening complications.

Many foot ulcers begin in innocent ways. As a visiting nurse I was always curious how a problem started and would ask my clients what was the first sign that brought them to the doctor? Often the response was one of embarrassment and foolishness as they described the simple way it began – a blister, a piece of torn skin or a small amount of bleeding. The harmless scratch burgeoned from a trivial occurrence to a condition that threatened the maintenance of limbs and in some cases, life.

The following signs may be an indication that you have peripheral neuropathy or decreased circulation. If you have any one of these symptoms, make an appointment to see your health care professional.


Signs of Peripheral Neuropathy

Signs of Poor Circulation

Pain, tingling, burning and numbness that starts in the feet and slowly progresses up the calves; tends to be worse at night

Inability to detect excessive heat such as in a bath or a heating pad

Any small sore, cut or ingrown toenails

Weakness in small muscles of the feet that cause the toes to claw, or in more serious cases foot drop will develop

A change in gait

Swelling or redness on any part of the foot

The existence of a bunion, callus, corn or wart

Absence of foot pulses

A pale colour of the feet when the feet are raised

Feet that feel cold

Pain at rest

Pain at night relieved by hanging the feet over the side of the bed

A blue colour to the toes

A reddish colour of the feet

Swelling of the feet


Given the alarming statistics of foot problems in patients living with diabetes, it is prudent to assess all diabetics for their level of risk related to foot problems. Special attention needs to be paid to the elderly and over-weight clients. In older clients limited mobility and poor eyesight may prevent them from properly examining their feet – a task that should be done daily. In obese patients, excessive weight will be an impediment to easy foot inspection.

People with diabetic foot ulcers face incredible challenges in their family, social and work lives, which sometimes affect their sense of self-worth. From the ease with which the ulcers seem to develop, to the future unpredictability imposed by the condition, people describe the dramatic impact that having a foot ulcer has on their activities of daily living. There is a great deal of stress and fear that comes with the uncertainty of not knowing when and if the ulcer will heal and in some cases whether or not amputation will become an eventuality.

To learn more about taking care of your feet, read the blog 7 Steps to Healthier Feet for Diabetics and do all you can to ensure a healthier and independent future.

http://www.wecare.ca/blog/?p=562

How Effective Is Carbamazepine For Neuropathy Pain

Today's post from onlinelibrary.wiley.com (see link below) is an objective assessment of the effects of carbamazepine on neuropathic pain and as such is always useful for neuropathy patients looking for confirmation that what they're being prescribed is what the doctor says it is. Carbamazepine has become increasingly popular recently, as an alternative to other anti-epilepsy drugs such as Lyrica, which has a possibly deserved bad press. However, does the research show that it works? This article suggests that it does...for some people but with caveats. Pretty much the same as all other drugs used to treat neuropathic pain then! Worth a read if you're on Carbamazepine, or likely to encounter it in the course of your treatment options.

Carbamazepine for chronic neuropathic pain and fibromyalgia in adults 
Philip J Wiffen1,*, Sheena Derry1, R Andrew Moore1,Eija A Kalso2,3
Editorial Group: Cochrane Pain, Palliative and Supportive Care Group
Published Online: 10 APR 2014
Assessed as up-to-date: 7 FEB 2014

DOI: 10.1002/14651858.CD005451.pub3

Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
The Cochrane Library
Read a clinical summary of this review on

Abstract

Background

This is an update of a Cochrane review entitled 'Carbamazepine for acute and chronic pain in adults' published in Issue 1, 2011. Some antiepileptic medicines have a place in the treatment of neuropathic pain (pain due to nerve damage). This updated review considers the treatment of chronic neuropathic pain and fibromyalgia only, and adds no new studies. The update uses higher standards of evidence than the earlier review, which results in the exclusion of five studies that were previously included.

Objectives

To assess the analgesic efficacy of carbamazepine in the treatment of chronic neuropathic pain and fibromyalgia, and to evaluate adverse events reported in the studies.

Search methods

We searched for relevant studies in MEDLINE, EMBASE and CENTRAL up to February 2014. Additional studies were sought from clinical trials databases, and the reference list of retrieved articles and reviews.

Selection criteria

Randomised, double blind, active or placebo controlled trials (RCTs) investigating the use of carbamazepine (any dose, by any route, and for at least two weeks' duration) for the treatment of chronic neuropathic pain or fibromyalgia, with at least 10 participants per treatment group. Participants were adults aged 18 and over.

Data collection and analysis

Two study authors independently extracted data on efficacy, adverse events, and withdrawals, and examined issues of study quality. Numbers needed to treat for an additional beneficial effect (NNT) or harmful effect (NNH) with 95% confidence intervals (CIs) were calculated from dichotomous data.

We performed analysis using three tiers of evidence. 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, at least 8 weeks' duration, parallel design), second tier 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 from data involving small numbers of participants that was considered very likely to be biased or used outcomes of limited clinical utility, or both.

Main results

Ten included studies (11 publications) enrolled 480 participants with trigeminal neuralgia, diabetic neuropathy, and post stroke pain. Nine studies used a cross-over design, and one a parallel group design. Most of the studies were of short duration, lasting four weeks or less.

No study provided first or second tier evidence for an efficacy outcome. Using third tier evidence, carbamazepine generally provided better pain relief than placebo in the three conditions studied, with some indication of pain improvement over mainly the short term, but with poorly defined outcomes, incomplete reporting, and in small numbers of participants. There were too few data in studies comparing carbamazepine with active comparators to draw any conclusions.

In four studies 65% (113/173) of participants experienced at least one adverse event with carbamazepine, and 27% (47/173) with placebo; for every five participants treated, two experienced an adverse event who would not have done so with placebo. In eight studies 3% (8/268) of participants withdrew due to adverse events with carbamazepine, and none (0/255) with placebo. Serious adverse events were not reported consistently; rashes were associated with carbamazepine. Four deaths occurred in patients on carbamazepine, with no obvious drug association.

Authors' conclusions

Carbamazepine is probably effective in some people with chronic neuropathic pain, but with caveats. No trial was longer than four weeks, had good reporting quality, nor used outcomes equivalent to substantial clinical benefit. In these circumstances, caution is needed in interpretation, and meaningful comparison with other interventions is not possible.

Plain language summary

Carbamazepine for chronic neuropathic pain and fibromyalgia in adults

Neuropathic pain is pain coming from damaged nerves. 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 pain from damaged tissue. Medicines like paracetamol or ibuprofen are not effective in neuropathic pain, while medicines that are sometimes used to treat depression or epilepsy can be very effective in some people. Our understanding of fibromyalgia (a condition of persistent, widespread pain and tenderness, sleep problems, and fatigue) is lacking, but fibromyalgia can respond to the same medicines as neuropathic pain.

Carbamazepine was developed to treat epilepsy, but it is now used to treat various forms of chronic pain. We performed searches (up to February 2014) to look for clinical trials where carbamazepine was used to treat neuropathic pain or fibromyalgia. We found 10 studies involving 418 people involved in testing carbamazepine. Studies were not generally of very good quality. Most were very small, as well as of short duration. Studies lasting only one or two weeks are unhelpful when pain can last for years.

There was not enough good quality evidence to say how well carbamazepine worked in any neuropathic pain condition. Pooling four small studies showed that it was better than placebo, but the result cannot be relied upon. There was not enough information from these studies to make any reliable comment on adverse events or harm.

Carbamazepine is probably helpful for some people with chronic neuropathic pain. It is not possible to know beforehand who will benefit and who will not. 


http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005451.pub3/abstract

Autonomic Neuropathy Can Affect Your Whole Body

Today's post from neuropathydr.com (see link below) looks at the dangers of peripheral neuropathy progressing to autonomic neuropathy, although you will need to use the search facility here on the right of the blog to find more detailed articles about autonomic neuropathy (there are plenty). Basically, autonomic neuropathy is when your nerve damage begins to affect functions that you take for granted and have no control over (breathing, digestion, sexual function, blood pressure, sweating, to name but a few). It can seriously affect your quality of life and it's important to be aware of the possibility. Some neuropathy causes are more likely to lead to autonomic problems than others (for instance, diabetes, cancer and HIV) but that's not a hard and fast rule. it's important to look out for the signs and alert your doctor or specialist as soon as possible.
 

Neuropathy Pain Is Serious Business! The Hidden Dangers of Autonomic Neuropathy
Posted by Editor on January 1, 2015
 
Neuropathy Pain Can Lead to Serious and Life-Threatening Nerve Damage. Here’s What You Need to Know for Your Long-Term Health.

You already know that neuropathy pain can significantly impair your quality of life on a daily basis, and in a long-term way. But did you realize that ignoring neuropathy pain can actually contribute to the development of life-threatening illness?

When there is nerve damage to your autonomic systems (the parts of your body that function automatically, like digestion and blood pressure), these systems are likely to stop behaving like they should. This is called autonomic neuropathy, and it can actually threaten your life. Any impairment of autonomic systems is an immediate danger to your health.

When are you at risk for autonomic neuropathy? You should consult a qualified neuropathy physician if you have any of these conditions that are frequently associated with neuropathic pain and damage from autonomic neuropathy:

Diabetes
Cancer that is being treated with chemotherapy
AIDS or HIV
Lupus

It is also extremely important for you to seek the support of a NeuropathyDR® clinician if you are experiencing any of these nerve damage symptoms:

Unusual sweating
Dizziness
Tingling or numbness in extremities
Change in the way you feel sense hot and cold temperatures
Sexual problems
Loss of ability to control your limbs or fingers and toes

You might also be in a high-risk category for developing autonomic neuropathy related to neuropathic pain if you have had a severe injury or amputation. In these cases, be sure to see a NeuropathyDR® clinician for a consultation now, instead of waiting for symptoms to develop.

There are times when a trained physician can detect nerve damage before any symptoms arise, and early intervention in treatment is key—not just to quality of life over time in terms of neuropathy pain, but also avoiding life-threatening scenarios related to autonomic neuropathy.

http://neuropathydr.com/autonomic-neuropathy-pain/?utm_source=rss&utm_medium=rss&utm_campaign=autonomic-neuropathy-pain

Can Acupuncture Work For Neuropathy

Another long but extremely useful article from pain-topics.org (see link below) today. It discusses a new study trying to determine once and for all, the usefulness of acupuncture in relieving chronic pain. It's a long-running argument, with many people swearing by the effectiveness of acupuncture and many others putting down any benefits to a placebo effect. The layman might reasonably think that acupuncture might have beneficial effects on nerve damage - it just seems logical, especially when you think that the needles are placed on acupuncture points along the main nerve pathways. However, whether that's more wishful thinking than fact is discussed here. One thing is sure; if you go ahead with acupuncture (which more often than not will not be covered by your insurance) then you should always go to someone who knows what they're doing; preferably someone who also has a doctor's qualification.

 

Acupuncture Aids Chronic Pain – Sort Of

Thursday, September 13, 2012

The largest and most rigorous study to date, employing a meticulous data meta-analysis, provides evidence that acupuncture is more than just an elaborate placebo for treating chronic pain. However, placebo effects do appear to play a considerable role and the contribution of the type and quality of acupuncture itself may be of relatively minor consequence. So, the debate over the value of acupuncture in chronic pain management seems unsettled.

Writing in an advance online edition of the Archives of Internal Medicine, Andrew J. Vickers, DPhil, of Memorial Sloan-Kettering Cancer Center, New York, and colleagues used data from previously published randomized controlled trials (RCTs) encompassing nearly 18,000 patients from the United States, United Kingdom, Germany, Spain, and Sweden [Vickers et al. 2012]. Going beyond the usual rigors of meta-analysis, the authors acquired individual patient data from 29 high quality randomized controlled trials (RCTs) comparing acupuncture with either sham (placebo) acupuncture or no acupunture (ie, usual care) in 3 chronic pain conditions: back and neck (musculoskeletal) pain, osteoarthritis, and chronic headache.

Patients in all RCTs had access to analgesics and other standard treatments for their pain, so either true acupuncture or sham acupuncture was an add-on therapy. Sham acupuncture, representing a placebo-control condition, included needles inserted superficially or at non-acupuncture points, devices with needles that retracted into the handle rather than penetrating the skin, or non-needle approaches such as deactivated electrical stimulation or detuned laser.

Results of this study, funded by the U.S. Natonal Center for Complementary and Alternative Medicine (NCCAM), suggest beneficial effects of accupuncture. After adjustments to eliminate biases unduly favoring acupuncture, the following standardized effect sizes were reported:

1. Patients receiving acupuncture had less pain, with effect sizes of 0.23 (95% CI, 0.13-0.33), 0.16 (95% CI, 0.07-0.25), and 0.15 (95% CI, 0.07-0.24) Standard Deviations (SD) in comparison with sham acupuncture controls for back and neck (musculoskeletal) pain, osteoarthritis, and chronic headache, respectively.
2. Standardized effect sizes for acupuncture in comparison to no acupuncture controls (ie, usual care) were 0.55 (95% CI, 0.51-0.58), 0.57 (95% CI, 0.50-0.64), and 0.42 (95% CI, 0.37-0.46) SD for back and neck (musculoskeletal) pain, osteoarthritis, and chronic headache, respectively.

These results were robust to a variety of sensitivity analyses, including those accounting for possible publication bias and weaknesses in some of the included trials. The statistically significant effects of true versus sham acupuncture in the first analysis above indicate that acupuncture is more than merely a placebo; however, the researchers concede that the effect sizes, representing differences between the two approaches, are relatively small.

The authors conclude that factors in addition to the specific effects of needling are important contributors to the therapeutic efficacy of acupuncture. Additionally, even though effect sizes for acupuncture compared with usual care in relieving pain are only moderate, the researchers advise that acupuncture is effective for the treatment of chronic pain and is therefore a “reasonable referral option.”

COMMENTARY:
According to background information in the Vickers et al. article, an estimated 3 million adults in the United States alone receive acupuncture treatment each year. Yet, they add that the lack of an accepted biological mechanism to explain the physiological effects of this therapy, and its provenance in theories and practices outside of traditional medicine, still make acupuncture highly controversial.

In a commentary accompanying the Vickers et al. article, Andrew L. Avins, MD, MPH — of Kaiser-Permanente, Northern California Division of Research, Oakland — notes that the debate over acupuncture as a bona fide therapy for pain is ongoing [Avins 2012]. To date, at least 60 meta-analyses addressing unresolved questions surrounding acupuncture have been conducted without reaching definitive answers.

Research and arguments on both sides of the debate have been presented in various Pain-Topics UPDATES [here]. In the most recent UPDATE on this topic [here], Edzard Ernst, MD, PhD and others discuss broad-scale reviews of the scientific literature on acupuncture, finding that evidence in its favor for a variety of pain conditions is equivocal, inconsistent, or inconclusive in many cases.

This meta-analysis by Vickers et al. was indisputably thorough and rigorous, involving dozens of scientists from multiple countries over a period of years. Their extensive search uncovered 955 studies for consideration, attesting to the extent and diversity of research on acupuncture, but also to the inferior quality of so much of the research. The research team identified only 31 high quality studies meeting their stringent inclusion criteria and were able to obtain individual data records for 29 of those to perform their very exacting meta-analyses. That is, they did their own calculations of outcome results, not relying on those of the original study authors.

The findings of the meta-analysis are scientifically and clinically important; however, the authors acknowledge the following regarding the effects of acupuncture found in their data:

“…an important part of these total effects is not due to issues considered to be crucial by most acupuncturists, such as the correct location of points and depth of needling. Several lines of argument suggest that acupuncture (whether real or sham) is associated with more potent placebo or context effects than other interventions. Yet, many clinicians would feel uncomfortable in providing or referring patients to acupuncture if it were merely a potent placebo. Similarly, it is questionable whether national or private health insurance should reimburse therapies that do not have specific effects.

Our finding that acupuncture has effects over and above those of sham acupuncture is therefore of major importance for clinical practice. Even though on average these effects are small, the clinical decision made by physicians and patients is not between true and sham acupuncture but between a referral to an acupuncturist or avoiding such a referral. The total effects of acupuncture, as experienced by the patient in routine practice, include both the specific effects associated with correct needle insertion according to acupuncture theory, nonspecific physiologic effects of needling, and nonspecific psychological (placebo) effects related to the patient's belief that treatment will be effective.”

Also, it should be emphasized, as noted earlier, that acupuncture did not exert effects in isolation from “usual medical care,” since in all cases acupuncture (or sham acupuncture) was add-on therapy. So, effects of acupuncture, though modest, were beyond and above those typically achievable by pharmacotherapy or other traditional treatments for chronic pain.

However, it is difficult to assess just what those added benefits of acupuncture might be and their clinical impact. Effect sizes were presented in the meta-analysis as standard deviation units (essentially Cohen’s d scores). For example, the favorable effect=0.57 SD of acupuncture for osteoarthritis would denote an improvement of roughly a 1/2 standard deviation on the end-point measurement scale used to assess pain, functionality, or something else.

Vickers and colleagues note that, in deriving effect sizes, their meta-analysis combined different end points, such as pain and function, measured at different times. Despite this variation, they claim that their results were stable; for example, effect sizes generally did not change when analyses were restricted to only pain end points and measured at specific follow-up times (eg, 2 to 3 months after randomization). However, as Avins notes in his commentary, these standardized effect sizes can be problematic when trying to assign absolute measures of improvement.

Vickers et al. believe that their overall observed estimate of roughly 0.50 SD favoring acupuncture over usual care is of clear clinical importance, but Avins observes that this is difficult to substantiate. The clinical relevance of this would vary with the outcome being assessed (eg, pain, functionality, mood, etc.), how it is being measured, and the standard deviation. For example, given a hypothetical average baseline osteoarthritis pain score of 60mm on a 0-to-100mm VAS and a standard deviation of 20mm, acupuncture might exert an 18% improvement of about 11mm (0.57 effect size X 20mm) and patients would still have moderate pain measuring 49mm on the VAS. A recent UPDATE [here] discussed research finding that 12mm denotes the Minimum Clinically Significant Difference (MCSD) in a VAS score that is perceived by patients as being of any consequence. So, from a patient’s perspective, would this sort of benefit be sufficient to justify the time, inconvenience, and expense of acupuncture?

Another disquieting aspect is the admitted placebo aspect of acupuncture. Although Avins argues in his commentary that placebo-based mechanisms have a place in pain management practice, he also recognizes that in traditional medicine new therapies must clearly show superiority over placebo to gain regulatory approval. In the Vickers et al. meta-analysis, acupuncture compared with sham/placebo demonstrated statistically significant improvements but only small effect sizes (0.15 to 0.23 SD) that might not be considered of clinical significance. If acupuncture were judged according to the same stringent criteria as a pharmacotherapy would it be approved by regulatory agencies?

Unfortunately, the Vickers et al. meta-analysis does not examine sham/placebo acupuncture compared with usual care, so the differential effects attributable to acupuncture alone, devoid of the placebo component, cannot be calculated. Still, Avins argues for an appreciation of placebo effects, writing…

“Perhaps the recognition that some patients find benefit in CAM therapies (many of which may, indeed, operate primarily through placebo mechanisms) should force us to examine our perceptions of placebo effects and question why so many of us feel threatened by their existence. …. At the end of the day, our patients seek our help to feel better and lead longer and more enjoyable lives. It's ideal to understand the mechanism of action, which carries the potential for developing more and better interventions. But the ultimate question is: does this intervention work (or, more completely, do its benefits outweigh its risks and justify its cost)?”

Through their meta-analysis, Vickers and colleagues reveal evidence that benefits of acupuncture, while modest, may provide advantages going beyond usual care for patients with diverse types of chronic pain. At the same time, considerable therapeutic effects may be due to factors such as a patient’s belief that treatment will be helpful, as well as placebo and other context effects, while a much smaller acupuncture-specific component may or may not involve such issues as specific needling points and the type or depth of needling. All of this may be unsatisfactory to what Avins calls “the quack-hunter community” who continue to argue against the validity of CAM therapies that rely more on placebo or other nonspecific effects than validated biological mechanisms of action.

REFERENCES:
> Avins AL. Needling the Status Quo: Comment on “Acupuncture for Chronic Pain.” Arch Intern Med. 2012(Sep); 172(11):1-2 [abstract here].
> Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for Chronic Pain: Individual Patient Data Meta-analysis. Arch Intern Med. 2012(Sep);172(11):1-10 [abstract here].

http://updates.pain-topics.org/2012/09/acupuncture-aids-chronic-pain-sort-of.html

New Book About Neuropathy Jan 2014

Today's post from novapublishers.com (see link below) is another advertisement for a new book about Neuropathy. We normally don't advertise for publishers, in the same way that we don't advertise for clinics or private companies but if the book seems to be a taking a slightly different approach, it may offer more information to its readers than the standard texts. There are many books about neuropathy available and this one does state that they aim to 'challenge' their readers, which may mean that it's difficult to read, however, ordering it via a library, or glancing through in a bookshop may help with your decision as to whether it's going to help you or not. It does discuss neuropathies associated with HIV infection, where many others avoid the subject completely.

Contemporary Issues in Peripheral Neuropathy

Editors: Daniel L. Menkes (UCHC Neurology Department, Farmington, Connecticut, USA)

Book Description: There are many books on polyneuropathy available that are comprehensive in nature. Many of these are encyclopedic in their scope. However, there are very few books that review the basics of clinical neurophysiological testing, genetics and the commonly encountered neuropathies. There are even fewer that are willing to address less commonly encountered neuropathies such as amyloidosis and neuropathies associated with HIV infection. Many such textbooks also avoid interdisciplinary topics such as the management of pelvic floor dysfunction and the surgical treatment of compression and traumatic neuropathies. This book addresses this void by dividing this book into three distinct sections. The first three chapter section addresses basic clinical neurophysiological techniques, genetic testing and the inherited neuropathies. The larger middle section addresses acquired demyelinating neuropathies, monoclonal gammopathies, HIV neuropathy and familial amyloidosis. The final section concludes with a summary of neuropathies affecting pelvic function and a plastic surgeon’s approach to the treatment of compression and traumatic neuropathies. The authors who wrote these chapters have extensive expertise in these topics such that the literature review was comprehensive. The final chapter on the surgical treatment of compression neuropathies may be viewed as controversial by some and even heretical by others but it provides a unique perspective on the management of patients who are symptomatic and yet have relatively unremarkable clinical and electrodiagnostic investigations. The reader will find up to date information on a variety of topics; common and uncommon. This book attempts to educate as well as challenge the reader. (Imprint: Nova Biomedical)

Table of Contents: Preface Chapter 1. The Role of Clinical Neurophysiology in the Diagnosis of Peripheral Neuropathies (Elisabeth Chroni, Department of Neurology, University of Patras, Greece) Chapter 2. Role of Genetic Testing in Peripheral Neuropathy (Charles H. Whitaker, University of Connecticut Health Center Farmington, Connecticut, USA and others) Chapter 3. Hereditary Peripheral Neuropathies (Meriem Tazir, Mounia Bellatache and Sonia Nouioua, Service de Neurologie, CHU Mustapha Bacha, Algiers, Algeria, and others) Chapter 4. Guillain–Barré Syndrome (Akiyuki Hiraga, Masahiro Mori and Satoshi Kuwabara, Department of Neurology, Graduate School of Medicine, Chiba University, Japan) Chapter 5. Evolving Concepts in the Pathogenesis of Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP) (Paolo Ripellino, Thomas Fleetwood, Roberto Cantello and Cristoforo Comi, Department of Translational Medicine, Section of Neurology and Interdisciplinary Research Centre of Autoimmune Diseases (IRCAD), Amedeo Avogadro University, Novara, Italy) Chapter 6. Chronic Inflammatory Demyelinating Polyneuropathy in Children: A Pediatric Neurologist's Perspective (Christian Ionita, Connecticut Children's Medical Center/University of Connecticut Health Center, Connecticut, USA) Chapter 7. Monoclonal Gammopathy of Undetermined Significance and Polyneuropathy (Kam Newman, Ihab El-Hemaidi, Jagar A. Jasem and Mojtaba Akhtari, Section of Transfusion Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA and others) Chapter 8. Peripheral Neuropathies in HIV Infection (Maurizio Osio, Caterina Nascimbene, Alessandra Vanotti and Cristoforo Comi, Neurology Department. University of Milan, "L. Sacco" Hospital, Milan, Italy and others) Chapter 9. Familial Amyloid Polyneuropathy (FAP): Clinical Features, Pathophysiology, and Treatment (Mª Teresa Tomás, Helena Santa-Clara, Élia Mateus and Estela Monteiro, Exercise and Health Laboratory, Interdisciplinary Center for the Study of Human Performance, Lisbon, Portugal and others) Chapter 10. Peripheral Neuropathy in Pelvic Floor Dysfunction (Consuelo Valles-Antuna and Jesus M. Fernandez-Gomez, Hospital Universitario Central de Asturias, Universidad de Oviedo, Spain) Chapter 11. The Surgical Treatment of Peripheral Neuropathies: A Plastic Surgeon’s Perspective (Sean Wolfort, Surgery Department, Florida State University, and University of Central Florida, Florida, USA) Index

		https://www.novapublishers.com/catalog/product_info.php?products_id=46986&osCsid=1e608f8a26aa73770b1f10f4ab284d91

Common Testing Tools For Neuropathy

Today's post from painhq.org (see link below) is another article highlighting the commonest diagnosis/testing tools with regard to neuropathy. This is especially useful for people who have been told they probably have neuropathy but must undergo certain tests to establish that. Hopefully, your doctor will listen carefully to your story and conclude that there's enough evidence to diagnose nerve damage but many doctors (and insurance companies) require more than that - scientific proof. Unfortunately, even these tests can't prove neuropathy 100% but they are an accepted part of the process you go through. By the way, you're entitled to ask your doctor why you're having certain tests and not others. That may be perfectly reasonable but you deserve an explanation as to why.

How is neuropathic pain diagnosed?
Last updated August 5, 2014
 
Diagnosing neuropathy is often difficult because the symptoms are highly variable. A thorough neurological examination is usually required and involves taking an extensive patient history (including the patient’s symptoms, work environment, social habits, exposure to any toxins, history of alcoholism, risk of HIV or other infectious disease, and family history of neurological disease), performing tests that may identify the cause of the neuropathic disorder, and conducting tests to determine the extent and type of nerve damage.

A general physical examination and related tests may reveal the presence of a systemic disease causing nerve damage. Blood tests can detect diabetes, vitamin deficiencies, liver or kidney dysfunction, other metabolic disorders, and signs of abnormal immune system activity. An examination of cerebrospinal fluid that surrounds the brain and spinal cord can reveal abnormal antibodies associated with neuropathy. More specialized tests may reveal other blood or cardiovascular diseases, connective tissue disorders, or malignancies. Tests of muscle strength, as well as evidence of cramps or fasciculations, indicate motor fiber involvement. Evaluation of a patient’s ability to register vibration, light touch, body position, temperature, and pain reveals sensory nerve damage and may indicate whether small or large sensory nerve fibers are affected.

Based on the results of the neurological exam, physical exam, patient history, and any previous screening or testing, additional testing may be ordered to help determine the nature and extent of the neuropathy.

Computed tomography, or CT scan, is a noninvasive, painless process used to produce rapid, clear two-dimensional images of organs, bones, and tissues. X-rays are passed through the body at various angles and are detected by a computerized scanner. The data is processed and displayed as cross-sectional images, or "slices," of the internal structure of the body or organ. Neurological CT scans can detect bone and vascular irregularities, certain brain tumors and cysts, herniated disks, encephalitis, spinal stenosis (narrowing of the spinal canal), and other disorders.

Magnetic resonance imaging (MRI) can examine muscle quality and size, detect any fatty replacement of muscle tissue, and determine whether a nerve fiber has sustained compression damage. The MRI equipment creates a strong magnetic field around the body. Radio waves are then passed through the body to trigger a resonance signal that can be detected at different angles within the body. A computer processes this resonance into either a three-dimensional picture or a two-dimensional "slice" of the scanned area.

Electromyography (EMG) involves inserting a fine needle into a muscle to compare the amount of electrical activity present when muscles are at rest and when they contract. EMG tests can help differentiate between muscle and nerve disorders.

Nerve conduction velocity (NCV) tests can precisely measure the degree of damage in larger nerve fibers, revealing whether symptoms are being caused by degeneration of the myelin sheath or the axon. During this test, a probe electrically stimulates a nerve fiber, which responds by generating its own electrical impulse. An electrode placed further along the nerve’s pathway measures the speed of impulse transmission along the axon. Slow transmission rates and impulse blockage tend to indicate damage to the myelin sheath, while a reduction in the strength of impulses is a sign of axonal degeneration.

Nerve biopsy involves removing and examining a sample of nerve tissue, most often from the lower leg. Although this test can provide valuable information about the degree of nerve damage, it is an invasive procedure that is difficult to perform and may itself cause neuropathic side effects. Many experts do not believe that a biopsy is always needed for diagnosis.

Skin biopsy is a test in which doctors remove a thin skin sample and examine nerve fiber endings. This test offers some unique advantages over NCV tests and nerve biopsy. Unlike NCV, it can reveal damage present in smaller fibers; in contrast to conventional nerve biopsy, skin biopsy is less invasive, has fewer side effects, and is easier to perform.

https://www.painhq.org/learning/knowledge-base/category/clinical-assessment/neuropathic-pain-overview/how-is-neuropathic-pain-diagnosed

An explanation of various treatments for neuropathy Warning! It aint gonna go viral on YouTube!

We're going to drop in on the 2006, Rare Neuroimmunologic Disorders Symposium to listen to and watch a talk given by Joanne Lynn MD. For the first two and a half minutes you may well wonder why, because the video takes some time to get to the point, or at least the points that are relevant to us. Apart from that, the good lady is not exactly the most inspiring speaker to listen to but stay with it because there is so much useful information and explanation which is specific to our problems. Apart from that, the slides that are shown, explain the difficult vocabulary that would normally go in one ear and out of the other.

You must remember that this is a medical professional talking to other medical professionals and therefore, there aren't very many fireworks to keep your attention but it's worth the effort. I've watched this three times and have learned something new and useful each time.

You can read the transcript of the video on: http://www.myelitis.org/newsletters/v7n2/newsletter7-2-02.htm
It helps!

Neuropathy Book Recommendation

Today's post from ireport.cnn.com (see link below) is a review of a new book about living with neuropathy. In this case, the author is speaking from personal experience and can therefore bring a fresh and more relevant approach to the subject. Many books about neuropathy can tend to err on the side of the scientific and become somewhat 'dry' reading matter but here Dean S Lewis tells a tale that most readers will be able to identify with. In his case, the cause was antibiotics but the end-result was the neuropathy most people know all too well. Possibly his best piece of advice is something this blog wholeheartedly endorses and that is to gather as much information as you possibly can about the disease and relate it to your own situation. It's a cliche but knowledge really is power!




Living With Peripheral Neuropathy: 9 Simple Steps Guide To Reduce The Pain
By noblex | Posted March 19, 2015

http://www.listfree.org/146932-dean-s-lewis.html

Dean S. Lewis took some antibiotics, not knowing his life would change forever. This was in 1998. His body reacted negatively to the antibiotics. Every organ in his body except the brain failed. Not even his heart was working. For two months, he lay in the intensive care unit dying. He spent one of the two months in a medically induced coma. Doctors said only a miracle would restore his fortunes. A miracle happened and he has lived to tell the story. However, Dean was left with chronic medical conditions, one being peripheral neuropathy.

Dean has written a book entitled “Peripheral Neuropathy: Nine Simple Steps to Reduce Your Pain” which teaches others with neuropathy how to manage it. He also gives daily tips to people living with neuropathy, in their journey to overcome it.

Dean is a fighter. While his parents worried about his life and whether or not he would leave the ICU alive, he believed he would somehow survive. He is now doing great. He has perfected ‘the art’ of controlling his neuropathy. Dean has a regimen he follows to keep his symptoms at bay. Some of the symptoms he deals with today include tingling in his legs. The tingling has, however, reduced significantly after strictly following his regimen.

He is now a fulltime clinical analyst. He interacts with physicians, nurses and others in the medical field. His work involves implementing the medical practitioners’ requests for information from their database. He is also a life coach. Anyone with a chronic condition can contact Dean for help. He inspires many with his personal story of struggle, endurance and overcoming. Dean pursues his goals. He was able to attend World Cup 2014 in Brazil. He prepared his mind and body for the grueling schedule months before the trip to be in the most optimal condition.

Dean practices gratitude every morning. He knows every day is a gift and is very grateful for one more day of life. He says he experiences numbness in his feet when he wakes up in the morning. So, he starts by getting his body to literally feel his feet. He exerts tension on his feet and muscles to allow his body to wake up in phases.

Once this is done, he steps on the floor and does his cardio, stretches and pushups. This way, his muscles stay strong. This is very helpful when dealing with peripheral neuropathy. Dean says exercise strengthens the muscles and give the nerves the stimulation they need to keep the body fit.

Over the years, Dean has been told over and over again he should share the story of his survival and overcoming peripheral neuropathy. He also used to attend neuropathy support groups and he would listen to people’s frustrations and see their pain. He loved speaking in these gatherings and would inspire those suffering to hope for a life beyond the frustrations of neuropathy. All these happenings pushed him to write the book “Peripheral Neuropathy Nine Simple Steps To Reduce The Pain” which is available on Amazon.
Dean has had moments he wanted to give up. He says it was especially challenging when he experienced so much pain. He says a lot of times when he would skip his regimen or not get enough sleep or push himself a little too far, he would experience so much pain that he would feel like giving up. Dean, however, says he would remember how far he has come and push himself back to his regimen as a way out of his pain.

Dean advices anyone suffering from a chronic illness to gather as much information about the condition as they possibly can. He says this is where it all begins. Once you know the condition you are suffering from, Dean says you can start to understand how you can overcome it. According to Dean, it is also okay to ask for help. “Don’t be afraid to speak to a friend… Don’t feel that there’s something wrong with you. Listen: everyone has something to deal with,” Dean says.

Dean’s mindset was a big contributor to getting his life back on track after the neuropathy experience. Long before he could walk and drive again, he would use his mind to strengthen and reform his neural pathways by imagining himself driving. Though he could not move, Dean believes this helped him recover faster.
Today, he takes no pain killers. He has been liberated. He wants to show others how they can overcome peripheral neuropathy or other chronic conditions.

http://ireport.cnn.com/docs/DOC-1226290

Can Avoiding Dairy Help With Neuropathy Vid

The third video clip from Dr John Hayes Jr this week, looks at why it may be sensible to cut down on or eliminate dairy products in your diet. You may not make a direct connection between nerve pain and diet but if you have neuropathy,  it is worth watching this clip and then thinking about your dietary choices (especially if you're in a diabetes risk group).


Episode 7 – Why Avoid Dairy? Part 1 of 2
Thursday, April 25th, 2013 Posted by John Hayes Jr

Dr. Hayes explains why consuming dairy is not ideal for anyone, especially those suffering from peripheral neuropathy and chronic pain.

http://beatingneuropathy.tv/2013/04/episode-7/

Can Massage Help With Neuropathy Symptoms

Today's post from  cancertherapyadvisor.com (see link below) is directed towards neuropathy patients who have nerve damage thanks to chemotherapy treatment but there is no reason at all to suggest that this form of treatment and the study thereof, can't also apply to all neuropathy patients suffering with the same symptoms. This is the key to researching neuropathy on the internet - you should never ignore articles ostensibly directed towards a particular disease when it comes to nerve damage. Once you have neuropathy, all treatment information is useful. That said, the conclusions of this study are pretty thin and although massage seems a very attractive treatment to most neuropathy sufferers, there's very little evidence to suggest that it really can reduce symptoms to any great extent. However, massage certainly may help you feel better and along with acupuncture, may well be worth a try if your medications aren't producing the goods (as most of them don't).

Massage Therapy May Reduce Chemo-induced Peripheral Neuropathy

Jason Hoffman, PharmD, RPh 

September 19, 2016

 

Massage therapy may reduce peripheral neuropathy symptoms among patients receiving neurotoxic chemotherapy, according to a study presented at the 2016 Palliative Care in Oncology Symposium.¹

Chemotherapy-induced peripheral neuropathy (CIPN) is known to negatively affect quality of life and can necessitate dose reductions of anticancer drugs. There is, however, no consensus of an effective strategy to improve CIPN. For the present study, researchers evaluated massage therapy as primary prevention and as a treatment option for CIPN.

For this prospective study, investigators enrolled 62 patients receiving cytotoxic chemotherapy. All participants underwent 2 massage therapy sessions; CIPN was measured using a validated survey instrument at baseline, after the first session, and after the second session.

Nearly all patients reported at least 2 CIPN-related symptoms. The most common symptoms were numbness and tingling of feet, numbness and tingling of feet, feeling weak all over, trouble walking, and joint pain or muscle cramps.

After the first massage therapy session, between 52% and 100% of patients reported improvement in CIPN-related symptom categories. Improvement in CIPN-related symptoms, with the exception of vestibulocochlear symptoms, continued from the first session to the second session of massage therapy.

Among the 25 patients initially prescribed analgesics, 56% had no progression of CIPN-related symptoms following the first session of massage therapy. After the second session, 38% of the 13 presenting patients reported no progression of symptoms, and 31% reported complete symptom resolution. Nearly one-third had symptom progression.

The findings suggest that clinicians should consider incorporating massage therapy as an approach to improving CIPN.
                          
Reference

1. Menendez AG, Cobb R, Carvajal AR, et al. Effectiveness of massage therapy (MT) as a treatment strategy and preventive modality for chemotherapy-induced peripheral neuropathy (CIPN) symptoms. Poster presented at: 2016 Palliative Care in Oncology Symposium; September 9-10, 2016; San Francisco, CA.
2.  
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Neuropathy In The Winter

Very topical at the moment in the Northern hemisphere (and in 6 months, applicable to the Southern hemisphere too) today's post from blog.dana-farber.org (see link below) gives some helpful and timely hints about taking care in the winter if you have neuropathy. It's all to do with lack of feeling in your feet and hands and not being able to judge your footing in slippery circumstances. It's vital that you are always aware of the possibility of falling. Many neuropathy patients suffer broken bones from falls in the winter purely because the wrong signals reach your brain. This article is simply put and worth a read, if only to remind you of what you are probably already well aware of.

Tips for Managing Neuropathy During Winter 
January 15, 2014 Dana-Farber 

Staying warm and healthy during the winter can be challenging for anyone in most parts of the country, but it can be especially difficult for cancer patients, particularly those who may be experiencing treatment-related neuropathy.

Peripheral neuropathy is a temporary or long-lasting nerve problem that may occur as a result of certain chemotherapy drugs. It can cause pain, numbness, tingling, or loss of feeling, usually in the hands or feet, making snowy weather and freezing temperatures all the more challenging.

Clare Sullivan, BNS, MPH

“Peripheral neuropathy occurs from certain treatments affecting the nerves in the body, especially the nerves that sense pain, heat, cold, touch, balance, and fine motor movement,” says Clare Sullivan, BSN, MPH, Clinical Program Manager, Patient Education at Dana-Farber Cancer Institute, who urges patients with neuropathy to take extra precautions in cold weather.

If you experience numbness in the hands and feet as a result of cancer treatment, consider these tips from Sullivan:

Keep hands and feet warm and dry

Invest in good, warm gloves and extra socks during the winter. Layers will help keep your hands and feet dry, which may help ease numbness in colder weather.

Wear boots with traction

This will create an extra layer between your feet and the snow or ice, giving you additional protection against the elements, while helping keep you steady on slippery ground and prevent falls.

Dress warm

Wear a warm coat with thick padding to protect your body, especially your lower arms. Staying warm will help maintain circulation to and from the hands, and may lessen pain and help maintain your range of motion.

Walk with hands out of pockets

Keep your hands free and stretched out to prevent falls and protect yourself when they do occur. Rather than confining your hands to your pockets, which can create cramping and increase the likelihood of falls, wear warm gloves and keep your hands free instead.

View this Dana-Farber Slideshare presentation to learn more about neuropathy diagnosis, treatment, and management from Cindy Tofthagen, PhD, ARNP, an assistant professor of nursing at the University of South Florida, and post-doctoral fellow at Dana-Farber and the University of Massachusetts.

http://blog.dana-farber.org/insight/2014/01/tips-for-managing-neuropathy-during-winter/