Sunday, 17 February 2019

The Links Between Neuropathy And Back Pain

Today's short post from spine-health.com (see link below) looks at the links between chronic back pain and neuropathy (nerve damage). So many people suffer from both back pain and neuropathic pain that the links seem obvious. A trapped nerve in the spine can lead to nerve damage on a wider scale - that seems pretty logical but very often patients are treated for either back pain or neuropathy but seldom both together. Where back pain is involved, finding the damage in the spine is essential to preventing neuropathic problems developing - very often, curing the back problem prevents the nerve pain. The problem arises when it's left too long and the nerve pain/damage becomes permanent. It's very confusing for patients caught between a rock and a hard place. They go to the rheumatologist for their back problems but unless the pinched nerves are glaringly obvious, they join a long list of back pain patients who basically take pain killers and a course of physiotherapy and are left to get on with it. Ignoring the potential for developing nerve damage can leave them untreated for years and condemn them to years of pain, which although spine-related, is affecting their nervous system through out their body. You need to stay on top of your case and...without being aggressive...ask the right questions of your doctor. Similarly, if you feel you have had both back pain and neuropathy for years but they have both been treated separately, you need to push for a more holistic approach. This article gives you much of the background information you need and the links are very useful.



All About Neuropathy And Chronic Back Pain
By Ralph F. Rashbaum, MD Peer Reviewed 2017


Neuropathic pain is distinct from other types of pain. If a person breaks a bone, pain signals are carried via nerves from the site of the trauma to the brain. With neuropathic pain, however, pain signals originate in the nerves themselves.




Neuropathic pain often occurs as a result of nerve damage or dysfunction. Read more details on how it affects Spinal Cord and Spinal Nerve Roots

 
How Neuropathic Pain Develops

In many cases, the nerves become damaged or dysfunctional after responding to an injury or trauma, causing hypersensitivity to pain. The nerves then send faulty signals of pain even when the injury has healed. The initial injury can occur in either the peripheral or central nervous system.

See Pain Signals to the Brain from the Spine



Neuropathic pain, or neuropathy, is a chronic condition, meaning it does not go away. Instead, the pain becomes the disease process. The terms sensory peripheral neuropathy and peripheral neuritis are sometimes used to describe neuropathy affecting the peripheral nerves.

See Chronic Pain As a Disease: Why Does It Still Hurt?

An estimated 7 to 10% of people have neuropathic pain.1 This article examines neuropathy and chronic back pain, and how the two conditions are related.


In This Article:


All About Neuropathy And Chronic Back Pain

Understanding Neuropathy Symptoms
Anatomy Of Nerve Pain
Types of Back Pain
Causes of Neuropathic Pain Video
Video: Understanding Different Types of Back Pain

 
When Back Pain Causes Neuropathy

Neuropathy can result from any type of pain that compresses or impinges on a nerve. A herniated disc, for example, could press against a nearby nerve, causing pain. Neuropathic pain originating from the back or spine may include:
Chronic pain radiating down the leg (lumbar radiculopathy, or sciatica)
Chronic pain radiating down the arm (cervical radiculopathy)
Pain following back surgery that starts gradually and persists, commonly called failed back surgery syndrome

See Radiculopathy, Radiculitis and Radicular Pain

Diabetes and regional pain syndrome (RPS), are common causes of neuropathy. Additional causes of include injury, disease, infection, exposure to toxins, and substance abuse. It is not always possible to pinpoint the cause.


Why Early Treatment is Crucial

Early treatment is important, since more aggressive treatment may be needed if symptoms are not addressed soon.

See Treatment Options for Neuropathic Pain

Over time, exposure to significant pain can cause changes to the central nervous system that make the body become more sensitive to even slight touch—a phenomenon known as central sensitization.

See Medications for Neuropathic Pain

As with other types of chronic pain, delays in treatment may also make other health problems more likely. Depression, anxiety, difficulty sleeping, and an inability to work and take part in other activities are some health issues associated with untreated neuropathy.

See Additional Treatments for Neuropathic Pain

References:
Van hecke O, Austin SK, Khan RA, Smith BH, Torrance N. Neuropathic pain in the general population: a systematic review of epidemiological studies. Pain. 2014;155(4):654-62.


https://www.spine-health.com/conditions/chronic-pain/all-about-neuropathy-and-chronic-back-pain

Saturday, 16 February 2019

Pot Politics: Can Marijuana Be The Answer To Your Pain Problems?

Today's post from paincommunity.org (see link below) is the third in a series of three articles by the same author on medical marijuana and its implications for pain. Links to the other two can be found at the end of this article. This post concentrates on the politics behind the current attitudes towards medical marijuana and although USA centered, is relevant for all pain patients considering using marijuana, wherever you live in the world. Your ease of access to the treatment is dependent on your local laws and as we all know, the law sometimes takes forever to catch up with reality. Nevertheless, where there's a will, there's way and people tend to use the internet, or local suppliers to buy their marijuana...despite the risks. As with everything, you need to do your own research on the subject of medical marijuana and the two previous articles by this author are a good place to start. More and more people are finding that medical marijuana can really benefit their pain issues but you need to be sure of your facts and whether it's suitable for your own particular case. Having done that, you need to decide how you're going to take it and which sorts are best for your pain and that's a minefield in itself. Do your homework first and don't jump in without some pre-knowledge. The better you're informed, the more likely it is that marijuana can be a useful tool in your pain treatment toolbox.

The Politics of Pot
by Micke Brown, BSN, RN | Jan 25, 2019 
 

This is the third and final series discussion about medical marijuana. I would be remiss if I did not cover the political climate which affects anyone who uses or is considering the use of medical marijuana for the management of pain. Issues should also be kept in mind for those who decide to prescribe this herb for their patient/client, the one who is living with ongoing pain. Just as opioids, which have become a political pawn, used for pain treatment options, marijuana has its supporters and detractors. While your healthcare provider and family may be supportive of this pain treatment option, insurance companies, employers, friends, law enforcement officers, and other health care specialists involved in your care may not. It is important to be aware of the potential roadblocks as you attempt to build an effective pain relief toolbox.

As of early 2019, federal law states that marijuana, whether recreational or medical, is illegal. The Drug Enforcement Agency (DEA) continues to list marijuana as a Schedule I drug, among other drugs, such as LSD and heroin, with “a high potential for abuse and no evidence of acceptable medical use.”

In spite of Congress and the Federal government failing to change, many state laws have relaxed the illegalities around the growing, distribution, sale and use of marijuana over the past decade. The 2018 midterm election saw changes in Michigan, Missouri, and Utah, which now have legalized marijuana in some way. DISA has provided a current, interactive map as well as a state by state grid on marijuana legislation.

States, like Colorado and Washington State, are leaders in tapping the economic advantages of marijuana as a cash crop, which in turn provides a much-needed tax revenue. A 20% tax has been attached to recreational marijuana in these states, with a projected national tax on an income of over 7 BILLION dollars at this time. As previously covered in my December 2017 blog: “Pot for Pain Relief? What the Research Gurus Say,” research continues to uncover the medical benefits from the use of this plant. And, some who are concerned about the drug overdose problem in the U.S., feel that medical marijuana may help reduce the reliance on opioid use. The clash of issues is apparent.

Should you decide to add marijuana into your pain treatment toolkit, keeping current on your state laws will be helpful, but may not dismantle the obstacles you can face if you choose this method for pain relief. States will continue to legalize as public opinion continues to change.

Insurance companies, employers, law enforcement, and healthcare providers may erect or maintain both real and potential barriers. Concerns about safety while driving, operation of machinery, critical decision making while working, interactions with other medications and/or medical conditions, along with mandatory drug testing policies have been cited as road blocks. Users must balance the risks with benefits as they decide.

As I stated in the September 2018 blog, “Medical Marijuana: How to Choose, How to Use”:

Just like any pain relief option, cannabis may work as a key component of one person’s pain tool kit and not for another. It is not a one size fits all treatment option. This is an option that should be discussed with your healthcare provider before seeking out a licensed marijuana prescriber and dispenser. If you are currently taking opioids for pain relief, find out if you will be required to taper off before cannabis is started.

Before having a discussing with your healthcare provider, be sure you have done your homework. Check laws and regulations on medical marijuana in your state and community as they vary. Some other areas to address are:
Will medical marijuana affect your ability to work and perform expected duties?
Will your job be secure or is there a risk of job loss if medical marijuana is legally prescribed?
Is there a risk of losing work-related security clearances due to medical marijuana use?
What do you need to know if you travel across state lines or outside the U.S. while using medical marijuana?
What are the purchasing rules and restrictions if you travel for business or recreation out of state or outside the U.S?

I hope this blog, as well as the others from the Medical Marijuana series, have been helpful. I invite you to post your questions, concerns, tips or experiences. Sharing information benefits everyone.

Read more:
Pot for Pain Relief? What the Research Gurus Say
Medical Marijuana: How to Choose, How to Use


https://paincommunity.org/the-politics-of-pot/

Friday, 15 February 2019

Low Vitamin D Levels Can Bring On Or Worsen Neuropathy

Today's post from medpagetoday.com (see link below) revisits the topic of low vitamin D levels having a negative effect on the nervous system. Other posts on this subject can be found here on the blog by using the Search button). It's important to note that, although this article specifically targets diabetic neuropathy patients, the principle applies to all nerve damage patients and low vitamin D can be a neuropathy pointer for all forms of the disease. Certainly, it seems that the majority of people who supplement their vitamin D levels, show some improvement in their neuropathy symptoms but first, you need to check that your vitamin D is actually low before embarking on supplementation. This requires a visit to the doctor and a vitamin level test. Unfortunately, neuropathy patients will often supplement on the basis of something read somewhere and this can be a dangerous move. Always supplement with the advice and go-ahead from your doctor.
 


Low Vitamin D Levels Linked to Painful Diabetic Neuropathy
by Scott Harris Contributing Writer, MedPage Today


New study accounts for confounding factors, including sun exposure
 

This Reading Room is a collaboration between MedPage Today® and: Expert Critique FROM THE ENDOCRINE SOCIETY Reading Room Justin B. Echouffo Tcheugui MD, PhD Johns Hopkins University Baltimore, MD

Emerging evidence suggest that serum vitamin D levels may contribute to the detection and treatment of painful diabetic neuropathy.

A recent British-based study reported significant lower levels of vitamin D levels among individuals with painful diabetic peripheral neuropathy, after accounting for a multitude of confounding factors. In this study, there was an inverse monotonic association between blood vitamin D levels and the extent of neuropathic pain, as well as the degree of blood glucose control. Lower vitamin D levels correlated with lower cold detection thresholds (a measure of small nerve fiber function) and subepidermal nerve fiber densities. These results suggest that vitamin D contributes to the underlying nerve damage among diabetic patients with painful neuropathy.

Contrary to prior studies, the newly published study was well conducted with a robust design. It corrected for confounding factors not accounted for in previous research; these factors that affect vitamin D levels include age, adiposity, sun exposure, and activity patterns of the subject. Moreover, the authors compared three groups of carefully phenotyped (through clinical and neurophysiological assessments) patients - a group of diabetic patients with neuropathy (further divided into those with pain and those without pain), a group of diabetic patients without neuropathy, and a group of healthy volunteers without diabetes. They relied on skin biopsy to differentiate between painful and painless peripheral neuropathy.

The aforementioned newly reported findings are consistent with those of a prior case report documenting an improvement in severe diabetic neuropathy symptoms in a patient after correction of vitamin D deficiency. Furthermore, the newly published results reinforce the case for considering vitamin D as a therapy for painful diabetic neuropathy. The findings suggest that correcting of vitamin D deficiency has the potential of arresting and reversing neuronal destruction, thus alleviating neuropathic symptoms and reducing the need for medications such as narcotics, which may exhibit severe side effects. Indeed, a prior study showed that a single intramuscular dose of 600,000 international units of vitamin D significantly reduced the symptoms of painful diabetic neuropathy.

Improvement of painful neuropathic symptoms points to the potential necessity for screening for vitamin D deficiency among individuals with painful diabetic peripheral neuropathy, as a replacement would lead to symptom improvement. However, prior to using vitamin D replacement for treating painful diabetic neuropathy in clinical practice, additional experimental evidence is needed. Such evidence would ideally originate from a randomized controlled trial that includes patients with painful diabetic peripheral neuropathy with low vitamin D levels, and shows that vitamin D supplementation significantly improves neuropathic pains. 


Full Critique


Vitamin D levels have a considerable effect on painful diabetic neuropathy, even when adjusting for sun exposure and other factors, according to new research.

A study in Diabetic Medicine found a significant difference in vitamin D levels in people with well-characterized painful diabetic peripheral neuropathy, which can be difficult to treat with existing options.

"We found that vitamin D levels were significantly reduced in those with painful neuropathy," said the lead author of the study, Solomon Tesfaye, MD, of Royal Hallamshire Hospital in England. "Moreover, the lower the blood vitamin D levels, the worse the pain and the poorer the glucose control."

The investigation builds on several prior reports with similar findings, Tesfaye and colleagues said. For example, a 2012 case report in Case Reports in Endocrinology initially documented improvement in severe diabetic neuropathy symptoms in a single patient after correcting a vitamin D deficiency.

"The correction of vitamin D deficiency cannot be harmful and has the potential to alleviate neuropathic symptoms and lower the need for medications, especially narcotics, with their often severe side effects," said the author of the case report, David Bell, MB, an endocrinologist based in Alabama. "In addition, with correction of vitamin D deficiency, there is the potential of arresting and perhaps reversing the progression of neuronal destruction."

In addition, a 2016 study of 143 participants found that a single intramuscular dose of 600,000 international units of vitamin D significantly reduced painful diabetic neuropathy symptoms.

The new study, however, corrected for several confounding factors from previous research, such as those that tend to affect vitamin D levels, including sun exposure, Tesfaye explained. "These studies were not conducted properly as they did not evaluate sunlight exposure or activity patterns of the subjects that were studied. They also did not carefully phenotype the peripheral neuropathy to differentiate between whether the patient had painful or painless peripheral neuropathy."

"We recruited very carefully phenotyped patients and divided our neuropathy group into those with and without pain, and we also had a control group of diabetic patients without any neuropathy, as well as another group of healthy volunteers without diabetes," he said.

Tesfaye and co-authors followed 45 white European patients with type 2 diabetes and 14 healthy volunteers who underwent clinical and neurophysiological assessments. Patients with type 2 diabetes were divided into three groups: those with painful diabetic peripheral neuropathy (17 patients), those with painless diabetic peripheral neuropathy (14), and those with no diabetic peripheral neuropathy (also 14).

All patients had seasonal sunlight exposure and daily activity measured, underwent a lower limb skin biopsy, and had 25‐hydroxyvitamin D measured during July to September.

After adjusting for age, body mass index, activity score, and sunlight exposure, the team found that vitamin D levels [nanomoles/liter (se)] were lower in people with painful diabetic peripheral neuropathy [34.9 (5.8)] compared with healthy volunteers [62.05 (6.7)], no diabetic peripheral neuropathy [49.6 (6.1)], and painless diabetic peripheral neuropathy [53.1 (6.2)] (P=0.03).

Tesfaye and colleagues then assessed the impact of vitamin D and six other independent variables on painful diabetic peripheral neuropathy. Vitamin D was the only variable that significantly contributed to the symptoms. Lower vitamin D levels also correlated with lower cold detection thresholds (r=0.39, P=0.02) and subepidermal nerve fiber densities (r=0.42, P=0.01).

"We found abnormal cooling detection thresholds, a measure of small nerve fiber function, with lower vitamin D levels," Tesfaye said. "Therefore, vitamin D appears to be low in those with painful neuropathy, and this may be contributing to the underlying nerve damage in those with painful neuropathy."

The study results could further bolster the case for considering vitamin D as part of an overall treatment strategy for type 2 diabetes patients with painful diabetic neuropathy, Tesfaye said.

"The crucial point will be if vitamin D supplementation does improve painful neuropathic symptoms. If it does, then our current practice will change in that we will have to screen patients with painful diabetic peripheral neuropathy to see if they have vitamin D deficiency, as a replacement would be helpful."

Although the study provides more evidence for that case, more research may be needed to solidify the role of vitamin D levels in understanding and addressing these symptoms and their underlying causes, Tesfaye cautioned.

"I think there is a great need now to do a randomized controlled trial of patients with painful diabetic peripheral neuropathy who have low vitamin D levels to see if vitamin D supplementation would improve their neuropathic pains significantly," he said. "Previous studies showed very positive effects, but none of them were large randomized and controlled trials and we do need an adequately powered, carefully conducted, randomized controlled trial to confirm the findings of these previous studies."


None of the authors reported any relationships with industry.


Primary Source

Diabetic Medicine Source Reference: Tesfaye S, et al "Reduced vitamin D levels in painful diabetic peripheral neuropathy" Diabet Med 2019; 36(1): 44-51.

Secondary Source

Case Reports in Endocrinology Source Reference: Bell D "Reversal of the symptoms of diabetic neuropathy through correction of vitamin D deficiency in a type 1 diabetic patient" Case Rep Endocrinol 2012; 165056: 1-3.

Additional Source
BMJ Open Diabetes Research and Care Source Reference: Basit A, et al "Vitamin D for the treatment of painful diabetic neuropathy" BMJ Open Diabetes Res Care 2016; 4(1): e000148.


https://www.medpagetoday.com/reading-room/endocrine-society/diabetes/77709

Thursday, 14 February 2019

Allodynia: When Your Skin Reacts To The Slightest Touch

Today's post from dailyhealthcures.com (see link below) will be familiar to many patients living with nerve damage. It concerns your skin becoming hyper sensitive to touch - to the point where the lightest contact can be extremely painful. it's called Allodynia; a word you may have heard of or maybe seen in your research on the internet but have never really understood (in that respect, it joins a long list of words associated with neuropathy - so don't worry, you're not alone). Anyway, there are various possible reasons for allodynia developing and these are discussed in the article below. of course, most neuropathy patients will be very well aware of allodynia sympoms in their feet or hands but it can occur all over the body and for that reason, it's probably best to get it checked out by your doctor. It's important here to emphasise that we're talking about extreme skin sensitivity without the presence of a rash because a rash signifies other more specific causes. In any case, this is an interesting article for people experiencing discomfort due to high sensitivity on their skin.


Skin Sensitive to Touch: Causes and Natural Treatments
by Daily Health Cures Editorial Team · Published May 14, 2017 · Updated January 24, 2018


When people discuss skin sensitive to touch, they tend to imagine a skin that is allergic to beauty products or prone to redness. However, that doesn’t sum up or explain a sensitive skin thoroughly. Skin sensitive to touch no rash can be a frustrating and painful condition.

When the skin hurts to touch even with the slightest brushing or touching of a light material, it is said to be extra sensitive. Allodynia is the medical term used for the skin which is sensitive to touch but doesn’t develop rashes (1). Such heightened skin sensitivity can be a sign of other underlying health issues.


What Causes Your Skin Sensitive to Touch?

There can be several reasons for developing a skin sensitive to touch, and the reasons could range from being as simple as a sunburn to a severe disease. Look for the causes behind before looking for a cure to treat Allodynia.


1. Fibromyalgia

Fibromyalgia is a musculoskeletal pain disorder and has no known cause. The body’s pain receptors get extra sensitive and develop a skin sensitive to touch. A genetic element is suspected as Fibromyalgia is known to run in families and cause skin pain without rash (2).

2. Sunburn

People love to sunbathe and be out in sunny weather. However, those leisurely activities are fine only up to a certain point as overexposure can lead to first-to-second-degree burns. It can make the skin sensitive, which can swell, get red and develop blisters.


3. Neuropathy

Neuropathy means something is wrong with the nerves. When skin sensitive to touch no rash develops, the underlying cause could be due to the chronic peripheral neuropathy. However, nerve damage can occur because of hereditary, kidney or liver disease, insecticide exposure, vitamin B12 deficiency and more (3).

4. Shingles

People who had chicken pox earlier may find the virus reappearing years later as shingles that can cause burning, pain, and numbness in skin. The condition begins with a red rash and is followed by the onset of the pain and blisters.

5. Migraines

Migraines can lead to the condition of skin sensitive to touch, but it can vary from person to person. The skin pain can heighten during hot and cold temperature or under extra pressure placed on the skin such as shaving or combing.


6. Midbrain Issues

The midbrain helps to evaluate different stimuli that control responses by a body. Any defect in the midbrain can cause exaggerated pain in skin and thus develop skin sensitive to touch no rash. Under this condition, there is nothing wrong with the skin or nerves, but the brain does not interpret the information correctly.


7. Anxiety

During increased stress and anxiety, one finds their skin sensitive to touch. The body releases chemicals during the stressful times and those chemicals overstimulate the nervous system. As a result, the senses get sharpened and develop hypersensitivity in the skin, and thus cause skin sensitive to touch.


8. Diabetes

Another reason behind the skin that hurts to touch could be diabetes that can cause nerve damage. The diabetic patients find an increased sensitivity in their legs, and there is no rash, but even a slight touch causes severe pain.


Natural Remedies for Skin Sensitive to Touch

There are several natural remedies to control the skin sensitive to touch and help improve the symptoms.


1. Neuropathy

Depending on the cause, you can follow neuropathy treat the skin sensitive to touch. The sensitive skin carries a burning sensation, and the symptoms may be localized or widespread.


2. Lifestyle Changes


Research shows that active lifestyle and physical activity is the good way to control fibromyalgia. Regular sleep and healthy nutrition can help ease the symptoms.


3. Lower Stress

Preventative measures can lower the migraine attacks. The butterbur plant is found to be an effective natural remedy to reduce stress and control migraines.


4. Vitamin B

In the case of sunburn, stop going outside under a harsh sun. You can use pain relievers and ice packs to reduce the pain and control the swelling. Vitamin B intake can help eliminate the tingling sensation in the skin.

As for the Herpes zoster, one can take an anti-viral drug to control the burning pain for skin that is sensitive to touch. Diabetes management plus B12 can help improve the condition.
You can use soothing creams and cold packs depending on the area affected. Using calamine lotion or oatmeal baths after having a shower can help alleviate this condition.


How to Treat Allodynia?

Allodynia is when you experience an unexpected painful response on the skin. About 50 percent of neuropathic pain patients suffer from Allodynia that leads to an extra painful skin to touch and changes in temperatures.

For intense pain, you can apply warm and cold compress on the affected area to soothe the pain. However, there could be several possible culprits behind that extra sensitive skin.
Studies show pharmacological treatment helps to control and relieve symptoms. Certain medications can lower the neuropathic pain and can be prescribed by the doctor, depending on the diagnosis.
In some allodynic patients, psychological treatments are helpful.
Electrical or magnetic stimulation can carry a beneficial effect in treating neuropathic pain associated with allodynia.

A combination of different treatments can help increase the quality of life and lower symptoms. The treatments for Allodynia may include supplements, hypnotherapy, pharmacological treatment and dietary changes under the guidance of a medical provider.

When to See a Doctor?

Sensitive or tender skin is a serious health condition that requires proper medical attention. See your doctor right away if your skin is sensitive to touch and even after trying those home remedies, you are not able to get any relief.

Schedule an appointment as that extra skin sensitivity is likely to interfere with your day-to- day activities. The doctor may recommend medications and ask you to take anti-inflammatory drugs. Some doctors may also prescribe topical pain medications and narcotic drugs. Get to the underlying cause and find relief from the skin sensitivity.

https://www.dailyhealthcures.com/pain/skin-sensitive-to-touch/

Wednesday, 13 February 2019

The Difficulty With Pain Measurement And Prognosis And Some Possible Solutions

Today's extensive post from wsj.com (see link below) looks at pain, how we measure it and how we treat it and concludes there has to be a better way of managing pain without throwing blanket opioids or other pain killers at it and leaving patients to manage on their own. Now if you ask any neuropathy patient to identify the strength of their pain on one of those smiley-face scales, you'll probably get 10 different answers withing a single day. There's always a measure of pain but it varies because of the nature of neuropathy. It's nerve pain and nerve pain is anything but consistent, so most of the testing methods are pretty much only snapshots at any given moment in time. This article looks into the possibility of measuring brain responses to pain and creating algorithms that will give a more accurate picture of someone's pain and therefore enable more targeted treatment and management. I know...I'm allergic to algorithms too...they seem so far removed from the actual person that they can't possibly accurately reflect someone's pain experience. However, this article is pretty persuasive that they do have a role to play. The piece also looks at other forms of pain diagnosis and treatment and like everything else at the moment, concludes that holistic approaches to pain are the only logical answer to reducing dependence on pain killers. it's a fascinating article and for long-term nerve pain sufferers...well worth a read.

 

A New Prognosis for Pain Care  By Laura Landro Feb. 6, 2019


Innovative ways to measure, understand and treat pain are allowing doctors to ease patients’ suffering—without relying on dangerous drugs

A new world of pain treatment is on the horizon.

 


Photo: Eiko Ojala  

Advances in measuring pain could show doctors how much pain a patient feels more vividly and help them dial the treatment up—or down—more precisely. Better ability to assess each patient’s risk for chronic pain, including identifying the genes that make it more likely, could lead to more personalized and effective treatments. And a deeper understanding of pain’s causes and new methods to treat it are starting to improve doctors’ ability to ease pain without relying on potentially dangerous and addictive drugs.


The need has never been more urgent. More than 50 million adults in the U.S. are living with chronic pain at an estimated annual cost of $560 billion in medical care, lost productivity and disability programs, according to federal data. Unlike acute pain—the sharp, instantaneous sensation that alerts the body to injury or trauma—chronic pain can persist long after normal healing, lasting for months or years.



To decrease lower back pain, University of North Carolina researchers are testing electrical currents that stimulate certain brain rhythms. Photo: Alex Boerner for The Wall Street Journal

Lower-back pain and migraines are among the most common complaints, but chronic pain can affect any part of the body, drastically limit activity and lead to hopelessness and depression.

With few tools to understand what each patient is feeling, and why, doctors have often turned to a blunt, one-size-fits-all treatment: prescription opioids, which can be effective in treating acute pain after surgery or in the advanced stages of cancer.

But there is scant evidence that opioids are effective for chronic, long-term pain outside of end-of-life care, and the sharp rise in opioid prescriptions after 1999 contributed to an epidemic of overdoses and deaths. In 2016, the Centers for Disease Control and Prevention recommended against opioids as first-line treatment of chronic pain. And doctors have become more cautious, leading to a decline in prescribing rates.

HEALTH CARE

Here are some of the advances that are improving the understanding of pain and medicine’s ability to treat it. 


How much does it hurt?

For decades, doctors have used a simple 1-to-10 numerical scale, and a range of smiley to frowning faces, to assess how much pain a patient is feeling. Now researchers are developing objective measures for pain by monitoring how the brain reacts to it.

This can allow doctors to determine how much pain a patient is feeling when the patient can’t communicate, such as infants or Alzheimer’s sufferers. It can also help doctors predict how patients will react to certain medications or procedures, which can make treatments more effective and aid in the development of new drugs.

In a test at Stanford University, volunteers were touched with prods that caused pain or ones that didn’t, and their brain activity was tracked with a noninvasive imaging system. Using an algorithm that detects patterns in brain activity, researchers could distinguish between painful and nonpainful stimuli more than 80% of the time. Sean Mackey, chief of the division of pain medicine and director of the neuroscience and pain lab at Stanford, says the real benefit to using brain scans may be in helping to test the effectiveness of new drugs or procedures. Artificial intelligence can take data from brain imaging and use it to make predictions about how patients will respond to treatment.

 
Follow-up studies have been used to detect whether someone is experiencing chronic pain based on brain activity or the structure of the brain.

His group has developed technology to image the entire central nervous system from the spinal cord to the brain, to better predict treatment response and whether someone with chronic pain will improve or worsen over time.

“If we had a way to use brain activity to predict the response to treatment, that is at the heart of precision medicine,” Dr. Mackey says. He warns, however, there are ethical issues to be resolved, such as whether brain scans could be used to deny treatment to patients if they don’t confirm the patient’s own description of pain.

Another area of research involves measuring theta waves, a type of brain activity. A study by researchers at Brown University in November found that measuring the power of theta waves in animals using electroencephalograms—a process involving electrodes attached noninvasively to the scalp—is an effective and direct test of pain, as well as the performance of pain medication.

Study co-author Carl Saab, director of the center for pain and neural circuits at Brown University and Rhode Island Hospital, says that in humans pain is more complicated.

But by combining theta-wave data and other information, artificial intelligence can develop algorithms for measuring pain and identifying pain types. The algorithms can accurately predict pain scores on the numerical and smiley-face pain scales used in clinics and emergency departments, Dr. Saab says.

The algorithms under development will be able to predict pain by type, according to Dr. Saab. For example, brain waves are different for acute back pain than they are for chronic back pain, and distinguishing between the two conditions is crucial for determining the best treatment such as opioids or surgery.

Using the algorithms could eventually “help patients convey their pain level with more accuracy and assist the doctor in reaching an objective pain diagnosis,” he says. This could lead doctors to prescribe fewer opioids, lowering the risk of addictions, and lead to better health outcomes.


He adds, “This is not going to trump or deny what the patient says, it is simply going to bring in this third perspective that is objective, which would be particularly useful if a verbal report cannot be obtained from the patient.” 


Where does the pain come from?

Researchers are developing assessments to provide a fuller picture of how pain affects a patient’s life. That has significant consequences for treatment. So, doctors are starting to examine how a patient’s other psychological and physical conditions can change the subjective experience of pain—such as how pain can be amplified by depression and anxiety.

At the University of Washington Center for Pain Relief in Seattle, researchers developed an online assessment called PainTracker where patients answer a series of questions to determine what impact pain has on their lives and help them better understand their condition and manage their recovery. Questions involve not just pain intensity but issues involving difficulty with sleep, mood, appetite and performing daily activities.

An evaluation of data from over 4,000 patients found that a substantial number were struggling with depression, anxiety and post-traumatic stress disorder and were severely disabled or worse. Many were at moderate to severe risk of opioid misuse.



Photo: Eiko Ojala

Learning about such issues through the PainTracker assessments can help busy doctors evaluate the patient’s pain experience and help steer them to the most effective treatments, the researchers say. “Many patients with chronic pain get hunkered down into this chronic crisis mode where they are just thinking about surviving into the next day,” says Mark Sullivan, a co-author of the study and professor of psychiatry and behavioral sciences. He says the assessments help doctors steer patients to interventions that have been shown to help manage pain, such as developing better sleep habits and behavioral therapy to develop resilience and coping skills.

Follow-up questionnaires are used to create a visual graph showing areas of improvement and engage patients as active participants in their care.


The researchers also incorporated the assessments into a web-based support tool, PainTracker Self-Manager, using concepts from so-called acceptance and commitment therapy, which has been shown to help patients learn to live with pain to limit the control it exerts over their life. In a pilot test, patients could receive coaching from nurses and social workers along with education, and found it helped patients improve their own management of chronic pain and satisfaction with their treatment. “You have to empower patients to do what they can to help themselves,” Dr. Sullivan says. 


Using Genetics to Understand and Treat Pain

Studies have shown that family history and shared genetic risk factors can play a role in the development of chronic pain. Understanding those risk factors—and identifying people who have them—could let doctors optimize treatments for those patients, and give them a better shot at recovery.

At the University of North Carolina, researchers have found that people with certain genetic variants are more likely to have chronic pain after exposure to trauma, such as sexual assault and motor-vehicle crashes. In a study of 1,500 blood samples of people who had experienced motor-vehicle trauma, published last year in the Journal of Neuroscience, the researchers found that those with the risk variant had impaired ability to regulate the stress hormone cortisol, and thus are more likely to experience chronic pain than people without the variant.

“The finding helps us understand why some people develop chronic pain after trauma and others do not, and also helped us identify a possible novel target for drug discovery,” says lead study author Sarah Linnstaedt, an assistant professor of anesthesiology and investigator at UNC’s Institute for Trauma Recovery. The goal is to develop a therapy that could help the body control cortisol levels after trauma exposure.

Dr. Linnstaedt’s lab is also investigating the role of sex hormones in driving increased chronic pain after trauma exposure in women.

Other researchers are investigating how to manipulate the body’s pain pathways—the interactions between molecular-level parts of the body that lead to different types of pain.

At St. Louis University, Daniela Salvemini, director of its center for neuroscience and professor of pharmacology and physiology, discovered pain pathways that are dependent on two particular molecules. In animal studies, scientists have been able to block or reverse pain with drugs that targeted those molecules.

Dr. Salvemini is now investigating whether those molecules can serve as biomarkers—measures of biological processes or interventions—for pain associated with a number of different health conditions. If so, doctors can optimize treatments for specific groups of patients that have those biomarkers. “Not everyone develops pain in the same manner or responds to drugs in the same manner, so the goal is to select patients who might be the best candidates for a drug,” Dr. Salvemini says.

Her team is working with doctors at university-affiliated medical practices who treat patients with conditions such as endometriosis, bladder pain and nerve pain caused by chemotherapy, to test for high levels of the molecules in their blood. That in turn would help confirm that a pain pathway is activated and determine whether patients would benefit from a drug that specifically targets the molecules. 


Going directly to the brain

To replace the need for drugs that can lead to addiction, researchers and device companies are also making advances in neuromodulation—the use of technology such as surgically implanted spinal-cord stimulators to interrupt pain signals with electrical pulses to the brain.

A new spinal-cord stimulator from Boston Scientific , the Spectra WaveWriter SCS System, allows patients to control how much of a sensation they feel in areas with pain. Maulik Nanavaty, president of the neuromodulation division, says that this choice allows doctors and patients to deliver therapy most comfortable to them, and help with chronic pain from failed back surgery and other intractable pain conditions.

First introduced in the 1960s, neuromodulators now include advances such as the ability to provide more personalized therapies to patients.

These devices, which are implanted into the patient, carry the risks of other invasive surgeries, such as infection, and cost $25,000 or more. But they are becoming more common and are generally covered by insurance for patients with difficult-to-treat pain syndromes or failed back surgeries.

Jim Davis, a retired Marine in North Carolina, had one of the devices implanted last August. Mr. Davis, 48, suffering chronic back pain after a truck accident, tried a number of other options including back surgeries and alternative therapies, but the pain returned. Prescription opioids “weren’t even taking the edge off, and I was more stoned than relieved of pain.” Neuropathy in his feet made it impossible to walk, and he even considered having both amputated.

The Boston Scientific device, he says, has allowed him to stop using a wheelchair and start swimming and scuba diving. He tweaks his setting on the device so he doesn’t have sensations at night because it’s easier to sleep without it. He sometimes turns it off for 20 minutes at a time.

“I’m not worried anymore about not being near my morphine pump or leaving the house without my pain pills,” Mr. Davis says.

Researchers are also testing neurostimulation approaches that don’t require surgery or implanted devices. Flavio Frohlich, director of the Carolina Center for Neurostimulation and associate professor of psychiatry at University of North Carolina, says that chronic pain disrupts normal patterns of brain activity in regions associated with pain, “so you get a persistent pain signal to the brain.”

With a treatment known as transcranial alternating-current stimulation, Dr. Frohlich and other researchers delivered weak alternating currents of electricity, imperceptible to study subjects, through electrodes on the scalp. In a study published in November in the Journal of Pain, they showed that by targeting one brain region, they could enhance naturally occurring brain rhythms known as alpha oscillations and significantly decrease symptoms of lower-back pain in just one session. 


A holistic approach to pain

Some pain-medicine experts are returning to an idea originally conceived in the 1970s—combining modern technology with holistic approaches. According to the National Institutes of Health, a growing body of evidence suggests approaches such as acupuncture, hypnosis, mindfulness meditation, spinal manipulation and yoga may help to manage chronic pain. Research also supports cognitive behavioral therapy, which teaches patients skills to overcome negative thoughts and behaviors, as a cost-effective way to manage some chronic pain.

The NIH last year doubled its budget for pain and addiction research to $1.1 billion. In addition to research on nonaddictive pain medicines and new biomarkers that might predict who is more likely to transition from acute to chronic pain, it is funding studies to identify the most effective nondrug and integrated therapies for specific pain conditions.

“There are appropriate uses for opioids for pain management, but the risks when they are used over the longer term have to be balanced with the benefits,” says Linda L. Porter, director of the Office for Pain Policy at the National Institute for Neurological Disorders and Stroke, part of the NIH. “We need to offer people with chronic pain something else, because they are desperate to get better and get back to their lives.”

Ms. Landro, a former Wall Street Journal assistant managing editor, is the author of “Survivor: Taking Control of Your Fight Against Cancer.” Email reports@wsj.com.

https://www.wsj.com/articles/a-new-prognosis-for-pain-care-11549508700

Tuesday, 12 February 2019

They're Only Just Scratching The Surface Of The Neuropathic Itch

Today's post from dermatologytimes.com (see link below) looks into one of the more obscure, difficult to diagnose and frustrating forms of neuropathy and that is the extreme itching that can appear out of nowhere and drive even the most hardened nerve damage patient to distraction. Many neuropathy patients develop this itching problem but because the cause is so difficult to pin down, it's often put down to allergic reaction, or insect infestation, or any number of other reasons and it can take months before the true cause is established, if at all. You would imagine that doctors would put two and two together with a patient who already has long-term neuropathy and form a link between the itching and the nerve damage but it rarely happens. This leads to frustration on all sides. This article looks into the complexities of establishing a neuropathic cause for extreme itching but its conclusions may leave you depressed if you're suffering from this condition...as if neuropathic symptoms weren't already bad enough!!


Presentation and management of the neuropathic itch
Ingrid Torjesen Dec 13, 2018 Volume: 39 Issue: 12

 
While neuropathic pain is a focus of research and drug development, the same cannot be said for neuropathic itch. (kelly marken - stock.adobe.com)


While neuropathic pain is a focus of research and drug development, the same cannot be said for neuropathic itch. As a result, the underlying mechanisms of neuropathic itch are poorly understood, diagnosis is challenging, and treatment options are limited.

Since inflammatory cutaneous signs like edema and erythema are characteristic of dermatological itch, and neurogenic inflammation can cause these signs in neuropathic itch as well, dermatologists should understand the underlying pathophysiology.

Neuropathic itch is the result of excess peripheral firing or dampened central inhibition of itch pathway neurons and a symptom of the same central and peripheral nervous system disorders that cause neuropathic pain, such as sensory polyneuropathy, radiculopathy, herpes zoster, stroke, or multiple sclerosis, according to Martin Steinhoff, M.D., M.Sc., department of dermatology and venereology, Hamad Medical Corporation, Doha, Qatar, who authored an article review that was published in The Lancet Neurology1.

The two conditions can occur simultaneously; however, unlike pain, itch is only felt in the skin or mucosa lining the body’s entrances.

Concomitant sensory loss and gain of function is observed in both neuropathic pain and itch, so a better understanding of the neuroanatomical and pathophysiological similarities and differences between the two conditions might identify existing but underused and novel treatment targets, he notes. To date, standardized case definitions to diagnose and differentiate the subforms of neuropathic itch and validated questionnaires to track symptoms are limited.

Diagnosis is complicated by the fact that different forms of neuropathic itch exist, such as focal vs. widespread and peripheral eral vs. central, as well as the fact that scratch-induced skin lesions can be mistaken as a primary (e.g., evidence of insect infestation) rather than a secondary symptom.

COMMON PRESENTATIONS

Small fibre peripheral neuropathy is one of the most common presentations of neuropathic itch and should be considered when patients present with unexplained chronic itch or scratch injuries in the length-dependent pattern on the limbs. It usually starts in the feet and progresses proximally in a lengthdependent pattern that sometimes also involves the hands.

Small fibre peripheral neuropathy occurs in approximately 40% of cases of fibromyalgia, and generalized axonopathies trigger more than half of all neuropathic itch presentations.

Focal mononeuropathies or oligoneuropathies that damage the small fibres within spinal nerves, plexi, or nerve roots are the major cause of focal neuropathic itch, Dr. Steinhoff writes. Itchy patches, which correspond to the cutaneous distribution of the damaged nerves or root, are most common on the head, upper torso, or arms, and are less common below the waist.

Compressive radiculopathy due to lateral spinal stenosis is the most common cause of brachioradial pruritus (the more distal patches), particularly after midlife. The second most common cause of truncal radicular neuropathic itch is herpes zoster, particularly at cervical and upper thoracic levels. Diabetic microvasculopathy should also be considered in patients with focal truncal neuropathic itch, as this requires prompt initiation of disease-specific treatment.

Ganglionopathies (neuronopathies) cause non-lengthdependent itch or itchy patches, and other sensory and radicular symptoms, neuropathic pain and proprioceptive ataxia. They can relate to cancer (particularly small-cell lung cancers), infection, or autoimmune disease, and imaging with contrast or cerebrospinal fluid analysis can help confirm these diagnoses.

Post-ganglionectomy ulcers were often misdiagnosed as being caused by deprivation of axonally transported nutritive trophic factors (trigeminal trophic syndrome), but then excessive and often painless scratching was recognized as the correct cause, Dr. Steinhoff writes. The para-midline nasal or the cheek is the characteristic location of the lesion after trigeminal ganglion or lower root injury, and the tip of the nose is usually spared. Non-trigeminal facial neuropathic itch can indicate lesions of the nervus intermedius of the cranial nerves VII or IX, or of the cervical spinal nerves C1 or C2, he adds. Herpes zoster is the most common cause of cranial neuropathic itch, and the forehead and anterior scalp are most commonly affected.

In diseases of the central nervous system, any type of lesion of the itch pathways in the spinal cord or brain can cause somatotopic neuropathic itch, including stroke, intramedullary neuromyelitis optica, intramedullary tumors, transverse myelitis, and spinal cord injury. Opioids and brain infections, such as Creutzfeldt-Jakob disease, can induce neuropathic itch, and neuropathic itch can present alone or with other symptoms such as colocalising sensory loss or weakness suggesting a neurologic origin.

The time between the onset of neuropathic itch or neuropathic pain can range between a few months to a few years after an event like a stroke, Prof. Steinhoff writes.

DIAGNOSTIC TOOLS

“Diagnosis is based primarily on recognizing clinical characteristics of specific neuropathic itch syndromes and appropriate confirmatory testing (e.g., for herpes zoster, diabetes),” Dr. Steinhoff says.

There are few diagnostic tools for neuropathic itch, and those emerging for chronic itch still require fine tuning for applicability to syndromes, he points out. Formal sensory testing (e.g., the Von Frey monofilament test) can highlight alloknesis and areas to treat topically, and measurement of epidermal nerve fibre density in PGP9·5-immunolabeled punch biopsies from the itchy skin, electrodiagnostic testing, and imaging can help to identify and localize causal neural injuries, Dr. Steinhoff writes. Autonomic testing, particularly the quantitative sudomotor axon reflex test, is useful for diagnosing small fibre peripheral neuropathy.

“Chronic itch questionnaires might improve diagnosis and enable the course of pruritus to be monitored,” he says. For example, the validated Massachusetts General Hospital Small-Fiber Symptom Survey captures “skin that itches for no reason.”

“If no dermatological or neurological causes for chronic itch can be identified, psychiatric conditions (e.g., trichotillomania, somatoform disorder) should be considered, particularly in patients with severe scratch injury,” he adds. “Rarely, a patient with no known physical cause for itch can become fixated on concerns over insect infestation (e.g., Ekbom syndrome or Morgellons disease, also termed delusional parasitosis).”

CURRENT MANAGEMENT APPROACHES


No specific therapies for neuropathic itch have been approved, and current treatment, such as opioids or antidepressants, is often based on clinical experience and trials. Antihistamines are prescribed for all forms of itch but are largely ineffective for neuropathic itch, Dr. Steinhoff writes; however, sedating antihistamines might be beneficial for improving sleep, reducing nocturnal scratching, and soothing scratch-induced skin inflammation.

“Treating scratch-induced lesions is important to reduce further itching, infection, scarring, and disfiguration,” he emphasized. Trimming fingernails or wearing gloves to bed can reduce scratching damage during sleep, and thermoplastic mesh coverage can improve wound healing by impeding further scratching.

“Cognitive behavioural therapy, physiotherapy, or meditation can also help people resist the urge to scratch,” Dr. Steinhoff writes. “Many patients benefit from occlusive therapy, where itchy patches are covered to reduce visual cues to scratch… Occlusive therapy physically protects the skin from further scratching and sun damage, and enhances penetration of topical therapies.”

Tightly bandaging itchy areas can provide relief by augmenting the inhibitory tone in the dorsal horn of the spinal cord, he notes, and if neuropathic itch is caused by compression of spinal nerves or roots, weight loss, physiotherapy, or other treatments to reduce nerve deformation may be of benefit.

In terms of pharmacological therapy, topical therapies should be considered first for peripheral neuropathic itch because they have few or no sideeffects. Topical local anesthetics are only effective for a few hours, and topical glucocorticosteroids are ineffective against primary causes of neuropathic itch but can soothe the associated inflammation that increases itch.

Daily subcutaneous injection of anesthetics near an injured superficial sensory nerve can provide effective short-term relief, and some patients can be taught to self-administer these.

Low-dose (0.025 – 0.1%) topical capsaicin has been used widely to treat neuropathic itch, Prof. Steinhoff highlights, but it requires reapplication four to five times a day. The first applications induce neurogenic inflammation and can cause pain, as well as worsen the itch. A few case reports suggest a higher concentration (8%) capsaicin patch benefits patients with brachioradial pruritus, notalgia paraesthetica, HIV-associated peripheral neuropathic pain, or diabetes-associated peripheral neuropathic pain, and subcutaneous injections of botulinum toxin A have shown efficacy in neuropathic itch, he notes.

Oral medications should be considered for patients with widespread neuropathic itch or refractory to topical treatments.

Systemic sodium channel blockers, such as carbamazepine and oxcarbazepine are the first-line choice, as they calm the ectopic neuronal firing. Gabapentin and pregabalin are commonly prescribed for patients with brachioradial pruritus and appear effective at similar concentrations as used for neuropathic pain.

Reference


Steinhoff M, Schmelz M, Szabó IL, Oaklander AL. Clinical presentation, management, and pathophysiology of neuropathic itch. Lancet Neurol. 2018;17(8):709-720. https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(18)30217-5/fulltext.

http://www.dermatologytimes.com/neurology/presentation-management-neuropathic-itch

Monday, 11 February 2019

A Good General Explanation Of Neuropathic Pain

Today's useful post from chronicpain.newlifeoutlook.com (see link below) is a general article about neuropathic pain and its different forms and causes. The problem is that neuropathy patients often gain their information from a variety of sources, which ends up with people having a somewhat patchy view of what's wrong with them. The doctors don't have the time to explain everything about nerve damage (after all, it's a disease with over 100 causes and over 100 forms!), so patients need to research for themselves to fill in the gaps. For that reason, this sort of sensible, easy to read article is useful for people to get a good general knowledge of the workings of their disease. (Other such articles are available here on the blog - use the Search function).There are gaps here too and you may need to do more research, depending on the complexity of your particular neuropathy but it's a good general guide to why neuropathy produces the weird symptoms it does. Worth a read - even for experienced patients.
 

What You Need to Know About Neuropathic Pain
Lana Barhum May 1, 2017


Chronic Neuropathic Pain

The number of people in the United States living with chronic neuropathic pain is 8.8 percent according to researchers at the Mayo Clinic in Rochester, Minnesota. However, it is possible this number is inaccurate due to people being misdiagnosed or incorrectly describing pain levels (e.g., mild vs. severe or sharp vs. dull).

If you are one of the 8.8 percent, you have many questions about what neuropathic pain is, its causes, and how it is diagnosed and treated. Here is some information that may help you to better understand what you are dealing with. 


What Is Neuropathic Pain?

Neuropathic pain is different than nociceptive pain. The later occurs as a result of an acute (abrupt onset) injury and, in most cases, is short-lived, but neuropathic pain is chronic, meaning it will persist, reoccur, and/or get worse over time.

Neuropathic pain is generally associated with your peripheral nervous system, which includes the somatic and autonomic nervous systems. Your somatic nervous system is responsible for transmitting signals from your brain to your organs, including muscles and skin, while your autonomic nervous system transmits signals from your senses, including taste and touch.

The type of pain associated with the peripheral nervous system may come from various health conditions, including diabetes and spinal stenosis. But neuropathic pain can also result from a brain or spinal cord injury. 


Risk Factors and Causes

Anything that leads to a loss of function in your sensory nervous system can cause you to develop neuropathic pain.

Nerve problems, from conditions such as carpal tunnel syndrome, can cause neuropathic pain as well as trauma from a nerve injury.

Certain heath conditions can put you at risk for developing neuropathic pain, including diabetes, cancer, HIV/AIDs, stroke, multiple sclerosis, and shingles. Vitamin deficiencies, chemotherapy treatments, alcoholism, infections, trauma, some medications, and toxins are also to blame.

When the cause of neuropathic pain cannot be determined, it is called idiopathic neuropathy. Idiopathic simply means having no known origin. 


Prevention

The best way to decrease your risk for developing chronic neuropathic pain is avoid developing it.

>Maintaining a healthy weight will decrease your risk for diabetes. The National Institute of Diabetes and Digestive and Kidney Diseases reports up to 70 percent of diabetics have some form of neuropathy. Diabetic neuropathy can be prevented by keeping blood glucose at normal levels. This will protect all the nerves throughout your body.

You also shouldn’t smoke or drink alcohol in excess. One study out of the Mayo Clinic found that of 205 smokers, 62 percent developed neuropathic pain.

It is also believed 25 to 66 percent of chronic alcoholics have alcohol neuropathy, as estimated by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and reported in the British Journal of Clinical Pharmacology.
Symptoms and Diagnosis

Symptoms of neuropathy might include a gradual onset of numbness, tingling, or a pins and needles feeling in the hands and feet. Symptoms may spread up into the arms and legs.

You may also experience pain that is sharp, stabbing, freezing, or burning. Lack of coordination, balance issues, muscle weakness, and paralysis are common if your motor nerves have been compromised.

If your autonomic nerves are affected, you may experience heat intolerance, sweating, blood pressure changes, and bowel, bladder, or digestive issues.

Neuropathy may affect one nerve or multiple nerves. Most people with neuropathy have multiple affected nerves in different places.

It is important to seek out medical attention as soon as your start noticing tingling, pain, and weakness in your hands or feet. Early diagnosis and treatment may help you control symptoms and prevent further nerve damage.

Diagnosis of neuropathy is generally based on symptoms and a physical exam. If you have diabetes or a recent case of shingles, a diagnosis can be easy to make, but with other conditions or no known cause, making a diagnosis could take some time.

Electrodiagnostic medicine, or EDX, is the most common way to find out whether a nerve has been damaged. EDX utilizes nerve studies to access touch, pain types, temperature, and vibration according American Board of Electrodiagnostic Medicine.

Your doctor may also request blood work to determine what other conditions might be causing your symptoms, imaging to look for injuries, and nerve and skin biopsies to look for any abnormalities or reduction in nerve endings. 


Treatment and Coping

There are different types of medications to treat neuropathic pain. Your doctor may want to start with an antidepressant or an anti-seizure medication, as both of these have been successful in treating neuropathic pain.

Sometimes by treating the condition causing symptoms, you may find relief from your neuropathic pain. For example, if you have diabetes, you can manage your pain by managing your blood sugar.

Exercise, diet and relaxation can also help. Other options your doctor may want you to try include nerve stimulation and physiotherapy (a combination of physical medicine and rehabilitation).

Some alternative therapies are also viable options for managing neuropathic pain. Various studies have shown acupuncture helps. One 2007 study, with results published in the European Journal of Neurology, found 76 percent of people treated with acupuncture had improved symptoms.

Other alternative therapy options include chiropractic care, fish oil supplements, and various herbs.

You can help yourself by seeking out support from loved ones, support groups, or a mental health provider. There are plenty of people who understand, who can share their experiences, and with whom you can discuss your feelings.

If stress is exacerbating your pain, learn to relax. Try listening to calming music, taking warm baths, or going for walks.

Make sure you pay attention to possible complications of neuropathic pain, including burns and skin trauma due to loss of feeling and numbness, infections to injured areas of your body, and falls associated with balance issues. 



Resources

National Institutes of Health (The Prevalence of Neuropathic Pain: Clinical evaluation compared with screening tools in a community population) WebMD (Neuropathic Pain Management) Cleveland Clinic (Peripheral Neuropathy) The National Institute of Diabetes and Digestive and Kidney Diseases (Nerve Damage (Diabetic Neuropathies) American Academy of Pain Medicine (Smoking and Neuropathic Pain) British Journal of Clinical Pharmacology (Alcoholic Neuropathy: Possible Mechanisms and Future Treatment Possibilities) National Institutes of Health (Practice Parameter: Utility of Electrodiagnostic Techniques in Evaluating Patients with Suspected Peroneal Neuropathy: An Evidence Based Review) European Journal of Neurology (Acupuncture Treatment Improves Nerve Conduction in Peripheral Neuropathy)

https://chronicpain.newlifeoutlook.com/common-sensations-with-neuropathy/

Sunday, 10 February 2019

The Super Hot Plant Chemical That May Be Able To Target The Worst Nerve Pain

Today's fascinating post from wired.com (see link below) should not be seen as a major breakthrough, leading to a super effective pain killer in the near future - the science and the plant itself are still in their infancy and the dangers of abusing this plant-based chemical should be obvious to anyone reading the article. However, the theory is fascinating in that it discusses the possibility that a chemical derived from a Moroccan succulent, can be successfully targeted at specific pain areas. If you've read about capsaicin, derived from chili peppers, being used to target nerve pain receptors than this is similar, except that the 'heat' produced by this plant is thousands of times hotter than the hottest chilies. Rather than going into further detail, why don't you read the article - it's interesting and informative and may provide an alternative to opioids that is more manageable and more effective, without the side effects.


This Chemical Is So Hot It Destroys Nerve Endings—in a Good Way 

Author: Matt Simon Matt Simon science 11.14.18


Getty Images

In Morocco there grows a cactus-like plant that’s so hot, I have to insist that the next few sentences aren’t hyperbole. On the Scoville Scale of hotness, its active ingredient, resiniferatoxin, clocks in at 16 billion units. That’s 10,000 times hotter than the Carolina reaper, the world’s hottest pepper, and 45,000 times hotter than the hottest of habaneros, and 4.5 million times hotter than a piddling little jalapeno. Euphorbia resinifera, aka the resin spurge, is not to be eaten. Just to be safe, you probably shouldn’t even look at it.

But while that toxicity will lay up any mammal dumb enough to chew on the resin spurge, resiniferatoxin has also emerged as a promising painkiller. Inject RTX, as it’s known, into an aching joint, and it’ll actually destroy the nerve endings that signal pain. Which means medicine could soon get a new tool to help free us from the grasp of opioids.

The human body is loaded with different kinds of sensory neurons. Some flavors respond to light touch, others signal joint position, yet others respond only to stimuli like tissue injury and burns. RTX isn’t going to destroy the endings of all these neurons willy-nilly. Instead, it binds to a major molecule in specifically pain-sensing nerve endings, called TRPV1 (pronounced TRIP-vee one).

This TRPV1 receptor normally responds to temperature. But it also responds to a family of molecules called pungents, which includes capsaicin, the active ingredient in hot pepper. “So when you put hot pepper on your tongue and it feels like it's burning, it's not because your tongue is on fire,” says Tony Yaksh, a professor in the anesthesiology and pharmacology department at UC San Diego who’s studied RTX. “It's simply activating the same sensory axons that would have been activated if your tongue had been on fire.”

RTX is a capsaicin analog, only it’s between 500 and 1,000 times more potent. When RTX binds to TRPV1, it props open the nerve cell’s ion channel, letting a whole lot of calcium in. That’s toxic, leading to the inactivation of the pain-sensing nerve endings.

This leaves other varieties of sensory neurons unaffected, because RTX is highly specific to TRPV1. “So you gain selectivity because it only acts on TRPV1, which is only on a certain class of fibers, which only transmit pain,” says Yaksh. “Therefore you can selectively knock out pain without knocking out, say, light touch or your ability to walk.”

So if you wanted to treat knee pain, you could directly inject RTX into the knee tissue. You’d anesthetize the patient first, of course, since the resulting pain would be intense. But after a few hours, that pain wears off, and you end up with a knee that’s desensitized to pain.

Researchers have already done this with dogs. “It is profoundly effective there, and lasts much, much longer than I might have expected, maybe a median of 5 months before the owners of the dogs asked for reinjection,” says Michael Iadarola, who’s studying RTX at the National Institutes of Health. “The animals went from basically limping to running around.” One dog even went 18 months before its owners noticed the pain had returned.

That’s a very targeted application, but what about more widespread pain? Cancer patients, for instance, can live in agony through their end-of-life care. Here, too, RTX might work as a powerful painkiller. In fact, the NIH is in the midst of trials with bone cancer patients.

“We use the same technique for administering this as we would a spinal anesthetic,” says NIH anesthesiologist Andrew Mannes. “The whole idea is you're not injecting into the spinal column itself, you're injecting it into the fluid that surrounds the spinal column.” Injecting straight into the cord would damage it. Patients are anesthetized for all of this, and treated with short-term painkillers when they wake. “That seems to get them over the worst of it, and then over the next few hours it subsides until the point where they don't feel the pain any longer.”

Here RTX is working on the same principle as if you injected it straight into a specific area of concern like a knee. But because it’s injected more centrally, it delivers widespread pain relief. "For many of the cancer patients, we need to have the drug remove pain from a lot of different regions," says Iadarola. "So we give it into a compartment where the nerves to the lower half of the body are gathered together."

Now, the thing with pain is, it evolved for a reason. It’s an indispensable tool for you to feel if you’re doing something to your body that you shouldn’t be, like holding a scalding cup of coffee. Of course we want to alleviate pain, but might that be problematic if it’s too effective?

For people with knee pain, not really—the injection is targeting a specific area, so the rest of your body can still feel pain. And for end-of-life care, a central injection can bring long-awaited relief. “We're doing that on cancer pain patients who have tried all other treatments and they've not been successful,” says NIH neurosurgeon John Heiss. “The FDA has only allowed us to have the indication for cancer patients with limited life expectancy, because the concern is that if you lose pain and temperature sensation you could have deleterious effects.”

RTX’s promise lies in its specificity. Think of it like a sniper rifle for pain, whereas opioids are more like hand grenades. Opioids target receptors all over the body, not a specific kind of sensory neuron. “That's why when you give it to somebody, you get problems with constipation, sedation, they can have respiratory depression,” says Mannes.

That and you have to take opioids constantly, but not so with RTX. “You give it once and it should last for an extended period of time because it is destroying the fibers,” says Mannes. “But the other thing with this to remember is there's no reinforcement. There's no high associated with it, there's no addiction potential whatsoever.”

If RTX does become widely available, by the way, it’s not going to be for you to treat a sore post-marathon knee—this is a serious drug for serious conditions. But by more directly addressing the root of pain, a plant with a hell of a kick could help us cut back on opioids and other grenade-like painkillers.

https://www.wired.com/story/resiniferatoxin/

Saturday, 9 February 2019

When The Drugs You Take For Other Conditions Can Cause Neuropathy As A Side Effect

Today's extensive post from medindia.net (see link below) looks in detail at one of the great ironies associated with nerve damage and that is that some of the drugs we're given to treat other complaints, can very often be the cause of our neuropathy itself. It's so unfair but it's a fact of life and it's up to us, along with our doctors, to carefully examine our whole medication intake so as to avoid interactions which may cause nerve damage. This isn't always as easy as it seems. With cancer treatment for instance, doctors sometimes have to make a choice based on what's going to do us more harm in the long run...chemotherapy drugs which kill cancer cells, or the neuropathy which often results from those very cancer drugs that can save our lives. In most cases however, it's simply a question of being alert to what we put in our bodies. For that we need to do our own research and if necessary, question our doctors carefully to make sure that the drugs they're prescribing won't do us more harm than good. It may be worth reading this article and scanning the list to see if any of the drugs you're taking can cause nerve damage (or make it worse) as a side effect. After that, be brave and ask your doctor some serious questions. There are very often alternatives available which won't damage your nerves any further. If you already have neuropathy, you'll know that putting in the hard work is worth the effort!

Drug-Induced Neuropathy
 
Written by Jayashree Thakwani | Medically Reviewed by The Medindia Medical Review Team on May 31, 2018


Overview

Causes

Symptoms and Signs

Diagnosis

Treatment

Risk Factors and Complications

Prevention

Frequently Asked Questions

Glossary

Latest Publications and Research

References
 
What is Drug-Induced Neuropathy? 
 Neuropathy is a disorder in which the peripheral nervous system gets damaged.

The peripheral nervous system is responsible for sending messages from the brain and spinal cord (central nervous system) to the rest of the body. A blood-nerve barrier protects the peripheral nerves. In some patients, genetic and metabolic factors could cause peripheral nerve toxicity which affects the peripheral nervous system.

Neuropathy leads to a loss of sensation or movement in parts of the body.

Peripheral nerve disorder is also known as peripheral neuritis or peripheral neuropathy.

Some commonly used therapeutic medications can cause adverse effects that could include neuropathy. This is known as drug-induced neuropathy. These medications cause nerve damage which may be reversible when the drug is discontinued; or in extreme cases, the nerve damage can be permanent.

Peripheral neuropathy is known as mononeuropathy when only one nerve is affected. In most cases, many nerves are involved; in that case, it is called polyneuropathy.

Some common symptoms can be numbness or tingling, muscle weakness or paresthesia (pricking sensation).

Peripheral neuropathy can be a slowly progressing condition and at times can be severe and debilitating. If diagnosed at an early stage, the progress of peripheral neuropathy can be controlled.

What are the Causes of Drug-Induced Neuropathy? 
Some medications can be toxic to the nerves and drug-induced neuropathy is caused by such medications. For example, many chemotherapy drugs used in cancer treatment are highly toxic and can kill neurons. Chemotherapy induced peripheral neuropathy (CIPN) is a common adverse effect of many commonly used cancer treatments.



What are the Drugs that are Known to Cause Neuropathy?
 Some categories of drugs are known to cause neuropathy:

Antimicrobials
Isoniazid
Ethambutol
Nitrofurantoin
Metronidazole
ChloroquineAntineoplastic agents
Vinca alkaloids (vincristine)
Paclitaxel
Cisplatin
DocetaxelBlood pressure or Cardiovascular drugs
Perhexiline
Hydralazine
Amiodarone – a blood pressure medication
Hypnotics and psychotropics
Methaqualone
ThalidomideDrugs for Autoimmune disease
Infliximab
LeflunomideAnticonvulsants
Phenytoin
Carbamazepine
PhenobarbitalDrugs to treat HIV/AIDS
Didanosine
Emtricitabine
Tenofovir

Antirheumatics
Indomethacin
GoldOthers
Disulfiram - used to treat alcoholism
Dapsone - to treat leprosy and severe dermatological conditions
Allopurinol - to treat gout
Thalidomide - to treat multiple myeloma and leprosy
Statins - to lower cholesterol
Colchicine - used to treat gout
What are the Symptoms and Signs of Drug-Induced Neuropathy? There are three known types of peripheral neuropathy, and the symptoms associated with each vary depending on the type:
Sensory neuropathy - In this type, the sensation is affected due to damage to sensory fibers. Common symptoms include pricking and tingling sensation, numbness particularly in the feet, and loss of balance.
Autonomic neuropathy - Affects the functioning of internal organs. This type results in damage to autonomic nerves which are typically responsible for involuntary movements in the body. These include breathing, heartbeat, bladder function, digestion, swallowing, bowel control, and sexual functions.
Motor neuropathy - In this type, motor nerves in the muscles get affected, and the patient is unable to move muscles as they become weak or experience muscular atrophy. Common symptoms include muscle weakness or paralysis, muscle cramps and foot drop.
The common symptoms of peripheral neuropathy include:numbness in the feet and hands, accompanied by tingling or shooting pain
difficulty in walking or losing balance while walking
weakness of limbs
poor gripping power of hands
burning sensation
muscle cramps
a feeling of wearing gloves or stockings, even when not wearing them
inability to feel normal pain
incontinence
breathing difficulties
excessive sweating
excessive sensitivity to touch
non-cardiac tachycardia
problems in sexual performance

How do you Diagnose Drug-Induced Neuropathy?
 
Peripheral neuropathy cannot be diagnosed with a single test.

A thorough investigation of the patient’s medical history is required to understand the symptoms and the likely cause of symptoms.

The physician may advise general blood tests to check diabetes, vitamin deficiencies, liver or kidney dysfunction, metabolic disorders and signs of an abnormal immune system.

More specialized neurological examinations could be conducted to check muscle strength and efficiency of nerve conduction; some of these include Electromyography (EMG) and Nerve conduction velocity test (NCV).

Magnetic Resonance Imaging (MRI) can help understand muscle quality and identify the cause of neuropathy in tumors or herniated discs.

Genetic tests may be suggested to understand the presence of inherited neuropathies.

A skin biopsy may be suggested to diagnose any fiber damage.

Spinal tap (lumbar puncture) test can be conducted to detect infections, tumors or autoimmune disorders like multiple sclerosis.
 
What are the Treatment Options for Drug-Induced Neuropathy?
 Drug-induced neuropathy though uncomfortable and debilitating, is not life-threatening. Symptoms usually go away when the toxic drugs are changed or discontinued or if the dosage is reduced according to the doctor’s advice.

Treatment however is based on the severity of symptoms and may include the following:

Reducing the dose of the causative drug that induces neuropathy
Substituting a less toxic medication
Pain caused due to neuropathy can be treated with two types of medications - anti-depressants and anti-seizure medications; they can be used individually or in combination. At times, the side effects of these medications can be worse than the neuropathy symptoms. Hence, it is important for the physician to evaluate the course of medication for each patient
Morphine, an opiate pain reliever may need to be prescribed to control severe pain
The healthcare provider may advise use of special shoes or footwear




 

What are the Risk Factors and Complications of Drug-Induced Neuropathy?

 The high-risk factors for drug-induced neuropathy include the use of medications to treat the following conditions:

Diabetes mellitus
Alcohol abuse
Vitamin deficiency
Infections such as shingles, hepatitis C, Epstein-Barr virus
Kidney, liver or thyroid disorders
Autoimmune diseases, such as rheumatoid arthritis and lupusComplications could include:
Inability to work because of permanent loss of sensation
Burns and skin trauma - as the person may not feel temperature changes or pain on parts of the body which have become numb
Infections - Loss of sensation in a particular area of the body can lead to infections, as the area can get injured without the person knowledge
Loss of movement or being susceptible to falls - due to lack of balance
How do you Prevent Drug-Induced Neuropathy?Patients who consume drugs known to be neurotoxic must regularly undergo neurological examination and functioning of the motor and sensory nerve conduction.

In general, patients who are under therapeutic treatment and who experience symptoms like pain, muscle cramps, and paresthesia during treatment must undergo neurological testing and motor-sensory nerve conduction.

Drugs must be cautiously used in patients with a risk of developing neuropathy, for example, in patients suffering from renal or hepatic failure, diabetes mellitus or malnutrition.

One must exercise regularly to overcome the occurrence of neuropathy.

The diet should be nutritious and should include fruits and vegetables, ginger and a right quantity of water. Foods containing gluten, refined grains, sugar and saturated fats must be avoided.


Latest Publications and Research on Drug-Induced Neuropathy


 Oral Anti-Vascular Endothelial Growth Factor Drugs and Ocular Side Effects. - Published by PubMed
Retinal ganglion cell loss in neuromyelitis optica: a longitudinal study. - Published by PubMed
Pathophysiology of drug-induce peripheral neuropathy in patients with multiple myeloma. - Published by PubMed
Ontology-based literature mining and class effect analysis of adverse drug reactions associated with neuropathy-inducing drugs. - Published by PubMed
Determinants of anti-retroviral regimen changes among HIV/AIDS patients of east and west Wollega zone health institutions, Oromia region, west Ethiopia: a cross-sectional study.


Published by PubMed

Latest Publications and Research on Drug-Induced Neuropathy

J Ocul Pharmacol Ther 2018 Jul 13

Oral Anti-Vascular Endothelial Growth Factor Drugs and Ocular Side Effects.

Fraunfelder FT, Fraunfelder FW

To evaluate possible associations between oral anti-vascular endothelial growth factor (VEGF) drugs and ocular side effects.... Read More

Source: PubMed

J. Neurol. Neurosurg. Psychiatry 2018 Jun 19

Retinal ganglion cell loss in neuromyelitis optica: a longitudinal study.

Oertel FC, Havla J, Roca-Fernández A, Lizak N, Zimmermann H, Motamedi S, Borisow N, White OB, Bellmann-Strobl J, Albrecht P, Ruprecht K, Jarius S, Palace J, Leite MI, Kuempfel T, Paul F, Brandt AU

Neuromyelitis optica spectrum disorders (NMOSD) are inflammatory conditions of the central nervous system and an important differential diagnosis of m... Read More

Source: PubMed
J. Physiol. Pharmacol.

Pathophysiology of drug-induce peripheral neuropathy in patients with multiple myeloma.

Luczkowska K, Litwinska Z, Paczkowska E, Machalinski B

Multiple myeloma (MM) is a disease of unknown, complex etiology that affects primarily older adults. The course of the disease and the patients' survi... Read More

Source: PubMed
J Biomed Semantics

Ontology-based literature mining and class effect analysis of adverse drug reactions associated with neuropathy-inducing drugs.

Hur J, Özgür A, He Y

Adverse drug reactions (ADRs), also called as drug adverse events (AEs), are reported in the FDA drug labels; however, it is a big challenge to proper... Read More

Source: PubMed
BMC Pharmacol Toxicol

Determinants of anti-retroviral regimen changes among HIV/AIDS patients of east and west Wollega zone health institutions, Oromia region, west Ethiopia: a cross-sectional study.

Bokore A, Korme B, Bayisa G

Human Immunodeficiency Virus (HIV) is one of the main causes of morbidity and mortality; because of this it continues to be a major global public heal... Read More

Source: PubMed

Published on May 30, 2018
Last Updated on May 31, 2018

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