Saturday, 25 June 2016

Neuropathy Often Affects Cancer Patients Too

Today's post from (see link below) talks about neuropathies directly related to cancer treatment and yet as you read through the article, you quickly notice that much of what is written applies to many other neuropathy causes and is therefore relevant to the general reader. It's the nature of nerve damage - so many causes and so many types but very many symptoms, that everybody has in common. That applies to the treatments suggested here too. Irrespective of the cause of your neuropathy, you may find some of the suggestions here useful, although they're by no means extensive and there are many more options (also for cancer patients). Unfortunately as science advances and ageing is prolonged, more and more people are being diagnosed with cancer and because neuropathy is a common side effect of the cancer drugs, the information here may apply to many more people than the target group alone.

Peripheral Neuropathy
Approved by the Cancer.Net Editorial Board, 03/2016

The peripheral nervous system consists of the nerves outside of the brain and spinal cord. Your brain and spinal cord are called the central nervous system. Peripheral nerves carry information between your central nervous system and the rest of the body. Peripheral neuropathy is nerve damage to the peripheral nervous system. Depending on which nerves are affected by peripheral neuropathy, you may notice some of these symptoms:

Change in sensation, especially in your hands and feet, such as numbness, tingling, or pain

Muscle weakness, called myopathy

Changes in organ function, resulting in constipation or dizziness

Peripheral neuropathy can happen because of:

Disease, such as cancer, diabetes, or a thyroid disorder

Nutrition problems, such as too little vitamin B12

Inherited conditions, such as Charcot-Marie-Tooth disease

Cancer treatment may also cause this disorder or make it worse.
Cancer-related risk factors

Peripheral neuropathy is a relatively common side effect. Anyone diagnosed with cancer is at risk for this condition. These factors can increase the risk:

Tumor location. A tumor pressing on a peripheral nerve or one that grows into a nerve may damage the nerve.

Chemotherapy. Specific types of chemotherapy, particularly in high doses, can injure peripheral nerves. These drugs include:

Bortezomib (Velcade)

Platinums, including cisplatin (Platinol), oxaliplatin (Eloxatin), and carboplatin (Paraplatin)

Taxanes, including docetaxel (Docefrez, Taxotere) and paclitaxel (Taxol)

Thalidomide (Synovir, Thalomid)

Vinca alkaloids, including vincristine (Vincasar), vinorelbine (Navelbine), and vinblastine (Velban)

Radiation therapy. Radiation therapy may damage nerves. Symptoms may take years to appear.

Surgery. Operations on the lung or breast may lead to neuropathy. Having a leg or arm removed may cause it, too.

Cancer-related disorders. Paraneoplastic disorders are rare disorders. They arise when the immune system reacts to cancer cells. These disorders may cause peripheral neuropathy. These disorders are more common in people with lung cancer. Shingles is a viral infection that often causes pain and a rash in people with weakened immune systems. It may also cause neuropathy.

Before starting cancer treatment, tell your doctor if you already have symptoms of neuropathy. You should also discuss any of the other risk factors (listed below) that you may have. They are associated with peripheral neuropathy.
Other risk factors

The following preexisting conditions are known to cause neuropathy. Having any of these may put people with cancer at higher risk for developing neuropathy.


Alcohol abuse

Infections, such as HIV-AIDS

Autoimmune diseases, such as lupus and rheumatoid arthritis

Hypothyroidism (an underactive thyroid)

Kidney disease or kidney failure

Hereditary peripheral neuropathy conditions, such as Charcot-Marie-Tooth disease

Lead poisoning or exposure to pesticides

Extreme stress


Neuropathy is different for every person. The symptoms and their severity depend on which nerves are damaged and how many nerves are affected. Symptoms may develop during or shortly after cancer treatment. Neuropathy may also slowly develop or worsen after treatment has ended. This occurs most commonly in those who receive platinum drugs and drugs called taxanes. There are 3 types of peripheral nerves that can become damaged.

Sensory nerves. Peripheral neuropathy usually affects your sense of touch and feeling in the hands and feet. Here are the symptoms when the sensory nerves are affected.

Common symptoms are tingling, burning, a buzzing “electricity” sensation, or numbness. It usually starts in the toes and fingers. It can continue along the hands and feet toward the center of the body

You may feel like you're wearing tight gloves or stockings, even though you aren't

You may have an uncomfortable sensation in your hands or feet that may get worse when you touch something

Objects on your feet that usually aren't painful, such as a shoe or bedcovers, may cause pain.

You may notice an increased sense of pain, usually described as pinching, sharp stabs, burning, and electrical shocks

You may notice that it is difficult to feel hot and cold temperatures or to know if you've injured yourself

You may have a hard time knowing where your feet and hands are in space. This is called loss of position sense. It may make walking or picking up objects more difficult, especially if you are in a dark room or working with small objects

Motor nerves. Motor nerves send information between your brain and muscles. When these nerves are injured, you may have these symptoms:

Trouble walking and moving around

Your legs and arms may feel heavy or weak, causing balance and coordination problems

It may be difficult to use your hands and arms

You may have trouble with everyday tasks, such as texting or buttoning a shirt

You may have muscle cramps and notice muscle loss in the hands and feet

Autonomic nerves. These nerves control the body functions you don’t think about to make happen, such as blood pressure and bowel and bladder function.

Symptoms include:

Inability to sweat normally

Gastrointestinal problems, such as diarrhea and constipation

Dizziness or lightheadedness

Trouble swallowing

Sexual problems

If you have any of these symptoms, talk with your doctor or another member of your health care team so that you can get help managing them.
Preventing neuropathy related to chemotherapy

There is no proven way to prevent neuropathy from chemotherapy. There is no good evidence that any medications, vitamins, or supplements can help you avoid neuropathy. Several antidepressants and other medications are being studied, but there has not been a proven benefit in preventing neuropathy from chemotherapy. The American Society of Clinical Oncology (ASCO) does not recommend using the following vitamins or supplements to prevent neuropathy from chemotherapy:


Calcium and magnesium


Vitamin E 

Managing neuropathy

Relieving side effects, also called palliative care, is an important part of cancer care and treatment. Talk with your health care team about any symptoms you have, including new ones or a change in symptoms.

How peripheral neuropathy is treated depends on what caused it and its symptoms. Many people fully recover in a few months or a few years. Sometimes, the condition may be more difficult to treat and may require long-term management. Your doctor will work to diagnose and remove the cause of your neuropathy and manage its symptoms. There are a number of methods to provide relief from symptoms:

Medication. Although medication cannot cure neuropathy, it may relieve the pain. However, it does not relieve numbness. The most common medications to treat neuropathy pain are anticonvulsants and antidepressants. For neuropathy related to chemotherapy, ASCO recommends the antidepressant duloxetine (Cymbalta). Over-the-counter pain medications may be recommended for mild pain. Prescription nonsteroidal anti-inflammatory drugs or very strong painkillers called analgesics may be prescribed for severe pain. Topical treatments, such as lidocaine patches and creams, may also help control pain. Topical 1% menthol also seems to be helpful, based on early studies.

Better nutrition. Eating a diet rich in B vitamins (including B1 and B12), folic acid, and antioxidants may help manage neuropathy. You should also eat a balanced diet and avoid drinking too much alcohol.

Physical and/or occupational therapy and interventional treatments. Physical and/or occupational therapy can keep muscles strong and improve coordination and balance. Therapists can often recommend devices that may allow you to more easily complete your usual daily activities. Regular exercise may also help reduce pain. Devices that stimulate the skin with electricity may also be useful for treating neuropathy pain, but more research is needed.

Integrative medicine. Massage, acupuncture, and relaxation techniques may help decrease pain and reduce mental stress. Additional tips:

Place stress mats in your home and work environment to cushion your feet

Wear shoes with a rocker-bottom sole

Safety at home

Having peripheral neuropathy increases your chances of hurting yourself, especially in the home. If you have sensory or motor difficulties, these tips may help you avoid injury:

Keep all rooms, hallways, and stairways well lit.

Install handrails on both sides of stairways.

Remove tripping and slipping hazards, like small area rugs and clutter.

Install grab bars in the shower or handgrips in the tub. Lay down skid-free mats in the tub.

Make sure that your shower or bathwater is below 110 degrees Fahrenheit. Use a thermometer to check. Set your water heater at a lower temperature.

Clean up spilled water or liquids immediately.

Use nonbreakable dishes.

Use potholders while cooking and rubber gloves when washing dishes.

If you drive, make sure you can fully feel the gas and brake pedals and the steering wheel. Make sure you can quickly move your foot from the gas pedal to the brake pedal.

If your doctor prescribes a cane or walker, use it when moving from one room to the next. 

More Information

Nervous System Side Effects

American Society of Clinical Oncology Clinical Practice Guideline: Prevention and management of chemotherapy-induced peripheral neuropathy in survivors of adult cancers

Side Effects

Additional Resources

LIVESTRONG: Neuropathy

Foundation for Peripheral Neuropathy: What Is Peripheral Neuropathy

Friday, 24 June 2016

Is Massage Really Wise For Neuropathy?

Today's post from (see link below) warns about the possible disadvantages of massage therapy. Many people with neuropathy symptoms somehow assume that massage will help them feel better and in many cases they do but you need to go to a massage therapist who knows what he or she is doing. The idea that you may come away with symptoms that are worse than before should be enough to make you think about whether a good pummelling is really good for your nerves or not. Gentle massage may well be very effective in calming down painful nerve areas, or generally making you relax but the minute the masseur goes for deep tissue and joint massage may be the moment you ask how much experience he or she has with neuropathy. You probably know yourself, if you've tried massaging your neuropathic feet. Half the time you can't feel anything due to the numbness but the moment you push just that little bit too hard to relieve the burning or tingling, you can be suffering for days. Always best to go to a qualified masseur with relevant experience, or else the happy ending may not be as happy as you thought (goes for all kinds of massage!!)

What Could Possibly Go Wrong With Massage?
Rare but real adverse effects of massage therapy, especially “deep tissue” massage
updated July 16 2014 by Paul Ingraham, Vancouver, Canada bio

People think of massage therapy as a “safe” therapy, and of course it mostly is. But things can go wrong, or at least a bit sour. While serious side effects in massage therapy are extremely rare, minor side effects are downright common. A 2007 survey of 100 massage patients1 found that 10% of 100 patients receiving massage therapy reported “some minor discomfort” in the day following treatment. This would mainly be a familiar slight soreness that is common after a massage, known as “post-massage soreness and malaise” (PMSM) — and I’m surprised only 10% reported it. The massages they were getting must have been quite gentle.2

Interestingly, 23% reported unexpected benefits that had nothing to do with aches or pains. (Benefits for musculoskeletal problems were not documented.)

This study is underpowered. It cannot and does not rule out rare and/or serious side effects of massage therapy, which do exist. You could probably do several studies of 100 patients without encountering a single nasty situation. But what if you surveyed 1,000 patients? Or 10,0000? Massage is not completely safe — what is? — and other adverse effects would almost certainly turn up in a big enough survey. Nevertheless, according to one of alternative medicine’s most vigorous critics, Dr. Edzard Ernst, “Serious adverse events are probably true rarities.”3 And yet, reviewing the literature again in 2013, Ernst and Posadzki found at least 18 reported examples of “moderately severe” reactions to normal massage, especially of the neck.4
When massage goes bad

So what could possibly go wrong? Massage can…
directly cause new injuries (mostly quite minor, but not all)
aggravate existing injuries and chronic pain problems
distract patients from more appropriate care
mildly stress the body And don’t forget, of course, that that pointlessly draining your wallet is another kind of pain. If someone spends $5,000 on massage therapy that has only a minor therapeutic effect, or none at all, is that an “injury”? It’s an insult, at the least!

In my decade (2000–2010) as a massage therapist, I met many patients who had been harmed by massage therapy to some degree — fortunately, mostly just expensive disappointments and minor backfires, but quite a few more serious cases too.5 

Sensory injury

A painful, alarming sensory experience can actually dial up pain sensitivity — even long term.6 Furthermore, vulnerability to this awful phenomenon is much more common and significant in desperate patients who already have chronic pain — so they seek and tolerate intense therapy. People experiencing pain system dysfunction can have minor & major setbacks in response to excessively painful massage.

The experience of pain is affected by many factors, including emotional and psychological ones. People in chronic pain usually experience some degree of pain neurology dysfunction, and a breakdown of the relationship between how bad things feel and how much is really wrong. That breakdown can be seriously worsened by threatening sensations. Thus, people experiencing pain system dysfunction can have minor and major setbacks in response to excessively painful massage.

One of my readers suffered this kind of disaster. She was injured by “fascial release” therapy, a style which is often too intense and may focus on treating connective tissues to the exclusion of considering the patient’s comfort and nervous system.

I may have been too aggressive with a few patients over the years. I never did serious harm this way as far as I know, but I’m sure that I occasionally did more harm than good. This failure was due entirely to my ignorance of pain science: despite being an unusually well educated massage therapist, I simply did not know that an intense massage could change pain sensitivity itself. Does your therapist?
Pain is Weird Pain science reveals a volatile, misleading sensation that is often more than just a symptom, and sometimes worse than whatever started it ~ 9,000 words
The Pressure Question in Massage Therapy What’s the right amount of pressure to apply to muscles in massage therapy and self-massage? ~ 4,500 words
Poisoned by massage

Excessive pressure probably has another predictable outcome: a light poisoning. Seriously.

For example: an 88-year old man collapsed the day after an unusually strong 2-hour session of massage therapy.7 He had too much myoglobin in his blood, and it was poisoning his kidneys and generally making him feel rotten. It’s not a sure thing that his condition was cause by the massage — but it is quite likely. It is almost certainly a perfect example of one of those rare but serious complications of massage. Another case study comes up below.

Ironically, many people believe that massage is a detoxification treatment, but in fact it’s probably the opposite. Ironically, many people believe that massage is a detoxification treatment, but in fact it’s probably the opposite. Post-massage soreness and malaise is probably caused by mild rhabdomyolysis (“rhabdo”): poisoning by the waste products of injured muscle.

True rhabdo is a medical emergency in which the kidneys are poisoned by myoglobin from muscle crush injuries. But many physical and metabolic stresses cause milder rhabdo-like states — even just intense exercise, and probably massage as well. There are many well-documented cases of exertional or “white collar” rhabdo, and there is a strong similarity between PMSM and ordinary exercise soreness. A rhabdo cocktail of waste metabolites and by-products of tissue damage is probably why we feel a bit cruddy after all biological stresses and traumas — including massage, sometimes.

PMSM is just an unavoidable mild side effect of strong massage. And for a few more vulnerable patients, it could actually be a little dangerous.
Poisoned by Massage Rather than being “detoxifying,” massage may cause a modestly toxic situation in the body ~ 4,500 words 

Other examples of massage wounds

The neck is not generally a fragile structure, but it is in some people. Another serious example of an adverse effect of massage is what happened to my barber — either a brain stem injury or mini-stroke caused by careless massage of a vulnerable neck. One of my own patients was injured the same way by another therapist, vomiting and retching for hours afterwards (a nasty symptom of brain stem impingement, or ripping of an artery going to the brain). I came close to doing this to another patient — that’s three examples of such patients in my career — but I’m proud to say that I spotted the warning signs and avoided disaster.

A weird case of brain artery damage (extracranial internal cartoid artery dissection, specifically) was reported in 2004 by the Southern Medical Journal: a 38-year-old woman gave herself a stroke by using a vibrating massage tool for long and too hard on her neck.8 Obviously such an incident has little to do with professional massage. Nevertheless, it demonstrates that the arteries of the neck are a little bit fragile — and I have no doubt that there are poorly trained or incompetent therapists out there would might get carelessly exuberant in this region, while trying to treat the scalenes: see Massage Therapy for Neck Pain, Chest Pain, Arm Pain, and Upper Back Pain.

Another weird, extreme case study paper tells the horror story of one person’s awful experience with a severe reaction to (apparently) infrared heat and massage therapy.9 The trouble started after several treatments. His neck and arms were swollen, the pain became “unbearable,” and his “serum muscle enzymes were increased” — which means some degree of rhabdo, which implicates the massage itself as a significant mechanism of injury. Massage is not likely to “blame” for the incident, though — it was probably interacting with some unidentified vulnerability in the patient, such a muscle disease or a complication caused by a medication. Clearly massage and heat alone do not normally cause such severe side effects! Nevertheless, the potential for very unpleasant interactions exists.

“Alternative therapies may have serious complications, and patients usually do not report them unless asked specifically,” the authors point out.

I am one-degree of separation from a patient whose femur (the big leg bone!) was fractured by a massage — it was a weak and injured femur already … but wow!

Nerves aren’t nearly as vulnerable to pressure as people generally think — most of them can actually take quite a licking and keep on ticking without a single symptom — but they aren’t invulnerable. And I once caused a nerve injury myself: it was a minor injury, but it did — augh — result in weeks of aggravating discomfort for my client. The Archives of Physical Medicine & Rehabilitation reported a similar spinal accesory nerve injury: “a rare and illustrative case of spinal accesory neuropathy associated with deep tissue massage leading to scapular winging [the shoulder blade sticking out] and droopy shoulder as a result of weakness of the trapezius muscle.”10
What Happened To My Barber? Either atlantoaxial instability or vertebrobasilar insufficiency causes severe dizziness and vomiting after massage therapy, with lessons for health care consumers ~ 2,750 words 

Lessons for professionals and patients

These are rare but real incidents. Healthy people are unlikely to be injured by massage. Most of dangers are related to undetected vulnerabilities, and they emphasize the importance of alternative health professionals being trained to spot the scary stuff. The measure of a health professional’s competence is not what they do with relatively healthy patients, but whether they have the training and humility to realize when they are on thin ice.

Manual therapists need to know that the most important part of their job is the smart management high-risk situations that they may see only a handful of times in their entire career. It’s like being on guard duty: 99.9% of the time, nothing bad happens. But how do you handle a curve ball when it finally comes?

Consumers need to know that cocky, overconfident therapists who trash-talk “mainstream” health care are all-too-likely to be ignorant of critical warning signs, or dismissive of them. The skeptical salamander thinks these therapists shouldn’t be allowed to touch anyone. See Missing Serious Symptoms.

About Paul Ingraham

I am a science writer, former massage therapist, and assistant editor of I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook and Google, but mostly Twitter.

Cambron JA, Dexheimer J, Coe P, Swenson R. Side-effects of massage therapy: a cross-sectional study of 100 clients. J Altern Complement Med. 2007 Oct;13(8):793–6. PubMed #17983334. BACK TO TEXT

Indeed, that seems very likely given the context. I doubt they would test painfully strong massage on 100 people without mentioning the intensity. However, painfully strong massage is quite common “in the wild.” Certainly intense massage is unusually common here in Vancouver, where there’s a regrettable professional predeliction for it. BACK TO TEXT
Ernst E. The Safety of Massage Therapy. Rheumatology. 2003;42 (9):1101–1106. PubMed #12777645. PainSci #54834.

Is massage safe? Researchers attempted to answer that question. Four databases were reviewed; all articles which reported adverse effects of any type of massage therapy were looked at. In the end, 20 reports were looked at. “The majority of adverse effects were associated with exotic types of manual massage or massage delivered by laymen, while massage therapists were rarely implicated.”

The conclusion was that, while not entirely risk free, “serious adverse events are probably true rarities.” BACK TO TEXT
Posadzki P, Ernst E. The safety of massage therapy: an update of a systematic review. Focus on Alternative and Complementary Therapies. 2013;18(1):27–32. PainSci #53974.

OBJECTIVE: To update a systematic review evaluating the safety of massage therapy.

METHODS: A literature search was carried out using four electronic databases for the period December 2001 to May 2012. All articles reporting adverse effects of massage therapy were retrieved. Adverse effects relating to atypical massage, aromatherapeutic massage oil or ice were excluded. No language restrictions were applied. Data were extracted and evaluated according to predefined criteria.

Seventeen case reports and one case series were published since our previous review. The reported adverse effects comprised acute paraplegia and abdominal distension, bladder rupture, bilateral cerebellar infarction, cervical lymphocele, cervical cord injury, cervical internal carotid and vertebral dissection, chylothorax, haematuria, interosseous nerve palsy, myopathy, perinephric haemorrhage, rhabdomyolysis, severe headache, blurred vision, paraesthesia and focal motor seizures. In the majority of the reports, a cause–effect relationship was certain or almost certain. Serious adverse effects were most commonly associated with massage techniques applied to the neck area.

Evidence suggests that massage may occasionally lead to moderately severe adverse effects. BACK TO TEXT

Several dozen at least who experienced minor negative effects and a lighter wallet. I recall only about dozen or so having really poor experiences, mostly aggravated chronic pain. Only a handful of those were obviously significantly injured by massage. But those were sad cases. BACK TO TEXT

Woolf CJ. Central sensitization: Implications for the diagnosis and treatment of pain. Pain. 2010 Oct;152(2 Suppl):S2–15. PubMed #20961685. PainSci #54851.

Pain itself often modifies the way the central nervous system works, so that a patient actually becomes more sensitive and gets more pain with less provocation. That sensitization is called “central sensitization” because it involves changes in the central nervous system (CNS) in particular — the brain and the spinal cord. Victims are not only more sensitive to things that should hurt, but also to ordinary touch and pressure as well. Their pain also “echoes,” fading more slowly than in other people.

For a much more detailed summary of this paper, see Central Sensitization in Chronic Pain. BACK TO TEXT

Lai MY, Yang SP, Chao Y, Lee PC, Lee SD. Fever with acute renal failure due to body massage-induced rhabdomyolysis. Journal of Nephrology, Dialysis and Transplantation. 2006 Jan;21(1):233–4. PubMed #16204282. PainSci #54301. BACK TO TEXT

Grant AC, Wang N. Carotid dissection associated with a handheld electric massager. South Med J. 2004 Dec;97(12):1262–3. PubMed #15646768. BACK TO TEXT

Tanriover MD, Guven GS, Topeli A. An unusual complication: prolonged myopathy due to an alternative medical therapy with heat and massage. South Med J. 2009 Sep;102(9):966–8. PubMed #19668045. BACK TO TEXT

Aksoy IA, Schrader SL, Ali MS, Borovansky JA, Ross MA. Spinal accessory neuropathy associated with deep tissue massage: a case report. Arch Phys Med Rehabil. 2009 Nov;90(11):1969–72. PubMed #19887226. BACK TO TEXT

Thursday, 23 June 2016

Are There Non-Opioid Alternatives For Nerve Pain?

Today's post from (see link below) is an important one because it highlights the dilemmas facing doctors and patients alike when it comes to medicating severe neuropathic pain. The situation at the moment is clear: there is a global (but mainly North American) outcry at the use and abuse of opioid-strength medications and this has triggered a frantic search amongst the scientific community for non-opioid medications that are both strong and effective enough to combat nerve pain at its worst. This article is directed at trainee doctors and nurses and examines the problem in a sensible and well-balanced way and for that reason it's very interesting for neuropathic patients who have no option at the moment but to use the only means available for suppressing their pain and that is the opioid family of medications. It may seem a little technical but it will provide you with so much information about the thinking behind nerve pain drug prescription.

Non-Narcotic Options for Pain Relief with Chronic Neuropathic Conditions
Donna V. Wright, MS, RN, FNP
Journal for Nurse Practitioners. 2008;4(4):263-270.

Neuropathic pain is a misunderstood, usually inadequately treated condition. This article discusses the types of pain, mechanisms of pain, diagnosis, and rationale for treating neuropathic pain. The importance of working with patients to achieve their functioning goals is also addressed.

Tom Jacobson, a bail bondsman, is not getting adequate pain relief from hydrocodone/acetaminophen 10/500 (Lortab) four times a day. He is suffering from chronic low back pain with peripheral neuropathy secondary to a motor vehicle accident. He knows that his back pain is a long-term condition (with chronic pain, the recommended daily dose of acetaminophen is 2000 mg to minimize the risk of liver damage; therefore, increasing his daily doses is not an option). He has tried the generic equivalent with less acetaminophen and with less than satisfactory results. He does not want to take the next step up the pain ladder to oxycodone/acetaminophen (Percocet) at this time. He knows that in South Carolina, by changing his prescription to a schedule II medication, he will be required to obtain a new prescription monthly and that his nurse practitioner can no longer prescribe independently of her physician preceptor (in 29 states, prescription of scheduled drugs requires physician collaboration.)[1] This increase in required medical supervision and possible change of caregiver can be a deterrent for some patients. The most important consideration for Tom is the nature of his work. He does not believe that he can function effectively in his role unless he feels "totally in control." The nature of narcotic medications makes this a concern.

To better understand some of the mechanisms of neuropathic pain, a review of the types of pain, the mechanisms, the diagnosis, and the treatment of neuropathic pain is in order. Cadden describes three types of pain: acute, chronic, and acute on chronic.[2] Tom is experiencing chronic pain, which simplifies his care. When chronic pain sufferers have acute pain as well as chronic pain, they are at risk for undertreatment of pain. Table 1 reviews terms used to describe pain. There are basically three ways to treat pain: alter the central pain perception (inhibit mechanisms of pain perception in the dorsal horn of the spinal cord"'how most narcotics work), modify the pain source, and block transmission of pain impulses by modulating the transmission of the pain impulse.[2] The last mechanism is the area in which we will focus.

"Chronic neuropathic pain is the net result of sensory input greater than the central inhibitory response" the uniqueness of chronic neuropathic pain is that its multiple etiologies share a common pathway."[5] The pain signal is processed via the dorsal horn of the spinal cord and transmitted in the central nervous system (CNS). After an injury, the healing process may be altered and actually increase rather than decrease the pain response. The development of dendritic growth (neuroplasticity) can increase the number of alternate neural pathways, which may actually increase the sensitivity to pain. These alternate pathways may have an accumulation of Na+ channels that become "leaky" and fire spontaneously or with very little provocation. "Neurons fire, or spontaneously produce electrical impulses on a regular basis" they may fire more or less slowly depending on whether or not they are excited or inhibited from firing by various types of chemicals called neurotransmitters" naturally occurring chemicals i.e. substance P, glutamate and aspartate excite neurons responsible for pain transmission" drugs that block the action of these substances diminish our awareness of pain. Our body's narcotic chemicals in the brain and the spinal cord inhibit the transmission of pain impulses."[6] By decreasing the rate of impulse firing, these chemicals can help modulate the pain response. The chemicals or neurotransmitters involved are commonly affected by anticonvulsants, antidepressants, neuroleptics, and antiarrythmics (ie, betabockers, sodium channel blockers, acetycholinesterase inhibitors) ( Table 2 , Table 3 ). This very simplified explanation helps provide rationale for the diagnostic criteria and the management of neuropathic pain.

The initial goals for diagnosis according to Gilron[8] include: rule out treatable conditions (ie, a neoplasm), confirm the diagnosis of neuropathic pain, and identify the clinical features (ie, insomnia) that help individualize treatment. Neuropathic pain is most frequently diagnosed by history and examination. A common presentation would be a level of pain intensity that is disproportionate to the injury received. There may be a history of sensory disturbance (numbness, abnormal sensations, itching, burning, pricking) that worsens as the day progresses. This pain pattern may initially follow a dermatonal distribution but can begin to deviate as neuronal plastic changes advance. The development of new "leaky" neural pathways (neuroplasticity) after an injury can set the stage for development of chronic burning or electric (tingling, shocking, jolting) sensations. These overly sensitive pathways can become "exquisitely painful" or sensitive to sensations that are normally not considered painful (allodynia). Other manifestations of neuropathic pain are dysesthesia, altered or abnormal sensations, paresthesias, or hyperalgias. These pains can occur spontaneously due to regrowth connections to sympathetic nerve fibers or can be evoked. It may become difficult for the sufferer to perform his or her usual daily activities.

It is important to determine which medications or treatments have been attempted. Acetaminophen and nonsteroidal antiinflammatories (NSAIDs) are usually not effective. Concurrent alcohol or substance use and abuse issues can complicate treatment. This delayed symptomology combined with a tendency for the pain path to follow a dermatonal distribution meet the diagnositic criteria for neuropathic pain.[9]

On physical examination, disturbances in light touch, response to pin pricks, vibration, and proprioception may be noted. Sensory disturbances may be beyond the discrete nerve territory. There may be pain with a straight-leg raise exam, which suggests irritation of a lumbar root; Phalen's test or Tinell's sign may be positive (usually indicates carpal tunnel). Deep tendon reflexes may be abnormal. A skin examination may show temperature, color, and hair growth changes, along with abnormal sweating.[8] Stimulus-evoked hypersensitivities may be present and can occur in areas that have loss of sensation. "The symptoms most associated with neuropathic pain were dysesthesias, evoked pain, paroxysmal pain, thermal pain, autonomic complaints, and descriptions of the pain as being sharp, hot or cold, with high sensitivity."[10] It is common for there to be a relatively modest demonstration of clinical neurological deficits or an essentially normal examination.[10]

Confirmatory diagnostics include computed tomography (CT) scans and magnetic resonance images (MRIs) that may show compromised nerve root pathways and structural damage; electromyography and nerve conduction studies, which can show the extent of neuroplastic changes; quantitative sensory testing (QST "' measures sensory thresholds for pain, touch, vibration, and temperature); and three-phase nuclear medicine bone scans that may help diagnose complex regional pain syndrome (CRPS).[10] During the diagnostic phase, a physiatrist (a physician who specializes in physical and rehabilitation medicine) can be an invaluable ally who can perform and interpret many of these examinations as well as suggest other diagnostic tests that might be appropriate.

Once the diagnosis has been confirmed, the practitioner may want to consider using conservative nonpharmacologic treatment options. These options can be crucial if the patient has a history of alcohol and/or substance abuse. Consider the physical conditions and activities that may increase pain. Watch the patient walk, move, and transfer. Large wallets, improper shoes (especially heels and boots), inappropriate canes and walkers, and gaits that favor one leg or another can increase neuropathic pain. Also, evaluate physical activities that may be exacerbating pain. Riding lawnmowers, all-terrain vehicles, and post-hole diggers are among the common culprits.

Physical therapy may be an appropriate referral for gait training; to determine the need for assistive devices; to determine whether use of a TENS (transcutaneous electrical nerve stimulation) unit would be appropriate; to initiate the use of massage, therapeutic exercises, cold, heat, hydrotherapy, electrical stimulation, or light therapy; to improve the general physical condition and reduce stress levels;[9] or to assist with the development of a set of guidelines for patient activity. A physiatrist may not only be able to assist in confirming the diagnosis but also in performing nerve blocks (injection of an anesthetic to "deaden" a specific nerve pathway), facet injections (use of a corticosteroid to decrease inflammation around a nerve root), and in recommending appropriate physiologic therapies.

The other specialists that you may wish to consult include a pain clinic referral[9] (a facility supervised by a physician, usually an anesthesiologist, who specializes in pain management) for nerve blocks and other injections; a chiropractor[9] (a practitioner who uses spinal manipulation to treat disorders of the nervous system); or a homeopath[9] (a practitioner who uses a system of therapeutics based on the theory that "like cures like"). Due to the emotional impact of chronic pain, a referral to a behavioral therapist may be appropriate. This therapist may suggest various therapies to improve the patient's coping level, reduce stress, and raise the pain threshold, which include relaxation, biofeedback, distraction, or attendance at a support group.[9] "Early referrals for nerve blocks and injections can promote the effectiveness of physiotherapy and pain rehabilitation."[8] While you hate to discourage activity with chronic pain, management of pain requires that the patient achieve a balance between activity and rest.

What pharmacologic options are available for the nurse practitioner who wants to help his or her patients maintain their functional levels? "Pharmacologic interventions follow the guidelines of the three-step analgesic ladder for pain control as developed by the World Health Organization (WHO). Step 1: Mild pain is usually treated with aspirin, acetaminophen, or nonsteroidal antiinflammatories (NSAIDs).[11] This is usually not an appropriate treatment level for neuropathic pain. Step 2: "Step 2 of the WHO three-step ladder includes mild opiates" along with the adjuvant medications."[9] In this instance, the nurse practitioner may be delaying or minimizing the use of stronger opiods (i.e. morphine) which are reserved for moderate-to-severe pain (Step 3 of the WHO ladder). This combination can decrease the incidence of side effects and increase the functional level of patients. Which medication is best? Table 4 suggests options. However, the bottom line is "how functional is your patient with this medication?" Current guidance is that for neuropathic pain, "tricyclic antidepressants are the initial drugs of choice" .amitryptyline, nortriptyline, imipramine, or desipramine." "Second line medications are anticonvulsants that include phenytoin, carbamazepine, and valproic acid" . (they) are especially helpful in cases of neuralgia and paresthesia."[15] Atypical anticonvulsants have had a role in neuropathic pain treatment, ie, gabapentin (Neurontin). The Food and Drug Administration (FDA) also has recommendations based on research.

Antidepressants should be used with caution in patients whose psychiatric history is unknown. A patient with an undiagnosed bipolar disorder can be placed in a hypomanic state or in a state of rapid cycling subsequent to initiation of an antidepressant.[15] Tricyclic antidepressants, ie, amitriptyline (Elavil) have been used as an adjunctive in treatment of neurogenic pain. They are believed to inhibit reuptake of serotonin and norepinephrine. Amitriptyline has multiple drug effects and antiarrythmic effects. Dosing this medication at bedtime can help reduce the impact of sedation. It is a pregnancy category D.[15] It is investigational for adjunctive analgesia with phantom limb pain, migraine, diabetic peripheral neuropathy, peripheral neuropathy pain, and post herpetic neuralgia.[14] Doxepin (Sinequan) works similarly to amitriptyline but with more sedation. Its pregnancy category is NR.[15] Nortriptyline can be used for chronic severe neurogenic pain.[14] Desipramine is investigational for severe neuropathic pain.[14] Imipramine has been used for severe neuropathic pain but has a seizure risk with high therapeutic dosages.[14]

Other antidepressants used for pain control include venlafaxine (Effexor), which potentiates neurotransmitter activity in the CNS, especially serotonin and norepinephrine with weak potentiation of dopamine. This medication should not be discontinued abruptly. It is a pregnancy category C.[15] Duloxetine (Cymbalta) works similarly to venlafaxine. It was the first medication to have FDA approval for diabetic peripheral neuropathy. With duloxetine, you must use caution with severe renal and hepatic disease. It is a pregnancy category C (Lilly insert). With any medication that increases serotonin levels, be aware of the risk of serotonin syndrome. This is especially true when "triptans" (medications used to prevent migraines) and SSRIs (selective serotonin reuptake inhibitors) are used together.[13]

Anticonvulsants have been considered second line for neuropathic pain. One of the most commonly used drugs is gabapentin (Neurontin). It is believed to be a competitive and reversible inhibitor of acetycholinesterase, which decreases the available acetycholine for nerve impulse transmission. The dosage needs to be reduced if the patient has altered renal function. It is a pregnancy category C.[15] It is considered an investigation drug for neuropathic pain and prevention of migraines. It has been approved for treatment of post herpetic neuralgia (PHN). It can be dosed up to 1800 mg/day in three divided doses.[14] Pregabalin (Lyrica) has obtained FDA indications for post herpetic neuralgia, diabetic peripheral neuropathy, and primary fibromyalgia syndrome. It is believed to be a GABA analog that reduces calcium dependent release of several neurotransmitters. The dosing for pregabalin is more linear than that of gabapentin (Pfizer insert).[13]

Another anticonvulsant, carbamazepine (Tegretol) is commonly used for trigeminal neuralgia and restless leg syndrome. It reduces the post tetanic potentiation of synaptic transmissions (it possibly depresses activity in the nucleus ventralis anterior of thalamus, thus decreasing polysynaptic responses).[14] This medication is well known for its multiple drug interactions, especially with warfarin, tricyclic antidepressants, and monamine oxidase inhibitors. It is a pregnancy category D.[15] Valproic acid (Depakene) acts by increasing levels of GABA, an inhibitory transmitter. It may also improve membrane stability by affecting the potassium channel. It has been used for prophylaxis of migraine headache.[14] Concerns include decreased hepatic function, multiple drug interactions, and that it is pregnancy category D.[15] Phenytoin (Dilantin) has also been indicated for neuretic pain"'migraine, trigeminial neuralgia, Bell's palsy. This medication acts by stabilizing neuronal membranes by decreasing the influx of sodium ions across the cell membranes in the motor cortex during generation of nerve impulses. Concerns include hydantoin hypersensitivity, slowed cardiac conduction, and hepatic dysfunction. This medication is also a pregnancy category D.[15] It is considered investigational for trigeminal neuralgia.[14] In theory, any anticonvulsant could be used as an adjuvant. However, be wary of medications not commonly used for pain control. In my practice, the drug Gabitril (tiagabine) has precipitated seizures in nonepileptic patients and should not be used "off label." In fact, an FDA alert was issued February 28, 2005 discouraging off-label use of this medication due to seizure risk in nonepileptics.[13]

Other medications that can be used include skeletal muscle relaxants, ie, lioresal (Baclofen), which has a twofold effect. It inhibits transmission of monosynaptic and polysynaptic reflexes and it causes muscle relaxation. It has indications for analgesia and trigeminal neuralgia. This medication should not be withdrawn abruptly.[15] Its function is related to GABA with CNS depressant effects. It is investigational for trigeminal neuralgia, prevention of migraines, and neuropathic pain.[14] Chloroxazone (Parafon forte) modifies the central perception of pain through its sedative effects. Possible side effects can include angioedema and anaphylaxis.[15]

Do not overlook topical analgesics. In fact, some authors suggest that topical lidocaine should be the first pharmacologic intervention.[8] The three classes most commonly used include[5]:

Local anesthetics "' lidocaine and mexiletine (Mexitil) interfere with the exchange of sodium in the sodium channel. (Some patients find Biofreeze effective at decreasing pain.)

Formulations containing antiinflammatories

Topical capsaicin "' depletes substance p and decreasing transmission of pain impulses.

Consider having a compounding pharmacist tailor topical medications. Consult with the pharmacist regarding the specific compounds and their concentration. Table 5 provides a reference for discussion. Topicals are ideal when patients desire decreased side effects and decreased liver involvement.

Another consideration when choosing an adjuvant is the associated conditions that interfere with pain management. Has the patient recently started on a "statin" for lowering cholesterol levels? Does the patient also suffer from arthritis, muscle spasms, restless leg syndrome, insomnia, diabetes mellitus, or depression? Sometimes treating other conditions allows medications for chronic pain syndromes to work more effectively. Comorbidities may point to appropriate adjuvants. Tricyclic antidepressants are helpful if insomnia is a concern. Baclofen has been known to help with neuropathic pain due to its neurotransmitter and CNS effects. "Steroids have been and continue to be administered by multiple routes for complex regional pain syndrome therapy."[12] Methylprednisolone (Medrol dose pak) is an antiinflammatory and immunosuppressant that can provide significant relief when inflammation is present. It is not for long-term use.[15] "Nonsteroidal anti-inflammatory drugs, physical therapy, accupuncture, antidepressants, and antiepileptics have been used as adjunctive treatment for chronic low back pain."[12] Clonidine (Catapress) stimulates the alpha andrenergic receptors in the CNS, which inhibits the sympathetic vasomotor center and decreases nerve impulse transmission, thus decreasing pain. Side effects include bradycardia and hypotension. This medication has been used for post herpetic neuralgia and restless leg syndrome.

"Pain management requires ongoing evaluation, patient education and reassurance. Diagnostic evaluation of treatable underlying conditions (eg, spinal cord compression, herniated disc, neoplasm) should occur concurrently with pain management."[8] For many patients with neuropathic pain, the nurse practitioner who has developed a comprehensive plan of care and has a strong network for referrals can be the most appropriate primary care provider. However, severe intractable pain may require referral to a pain clinic or neurosurgeon (if significant damage is identified during diagnostic studies). In most cases, "treatments with the lowest risk of adverse effects should be tried first."[8]

There is both an art and a science to pain management. Rowbotham states that the "Treatment of complex regional pain syndrome is largely empirical."[12] Sometimes trial and error is the best guide with any neuropathic pain. Both the practitioner and the patient need a willingness to try various options. If "pain is whatever the person experiencing the pain says it is, existing whenever the patient says it does,"[17] perhaps optimal functioning can be defined similarly. Can optimal functioning be defined as being achieved when the patient can satisfactorily perform at their chosen activity level? My bail bondsman, Tom, is a case in point. After multiple trials, he started using pregabalin as an adjuvant. His pain was more controlled, he felt as if he was "in control," and he became better able to function without excessive sedation. An unqualified success. 

There is both an art and a science to pain management. Rowbotham states that the "Treatment of complex regional pain syndrome is largely empirical."[12] Sometimes trial and error is the best guide with any neuropathic pain. Both the practitioner and the patient need a willingness to try various options. If "pain is whatever the person experiencing the pain says it is, existing whenever the patient says it does,"[17] perhaps optimal functioning can be defined similarly. Can optimal functioning be defined as being achieved when the patient can satisfactorily perform at their chosen activity level? My bail bondsman, Tom, is a case in point. After multiple trials, he started using pregabalin as an adjuvant. His pain was more controlled, he felt as if he was "in control," and he became better able to function without excessive sedation. An unqualified success. 

References (click to open)
Journal for Nurse Practitioners. 2008;4(4):263-270. © 2008 Elsevier Science, Inc.

Wednesday, 22 June 2016

Is Depression A Natural Result Of Neuropathy?

Today's post from (see link below) asks the question as to whether depression and anxiety are a natural response to neuropathy? Some may respond with 'Duh! You try living in constant pain and with restricted movement and see how you feel!' but it may not be as simple as that and this article pushes for better awareness by both patient and doctors, so that depression as a result of nerve pain doesn't go untreated. It's pretty logical really; the better you feel mentally, the better you will be able to deal with neuropathy symptoms but so many patients are left to flounder and sink deeper into anxiety problems that eventually become worse than the cause itself. Worth a read and if you feel you are really depressed by your condition, seek help; there's no shame attached; nobody should be surprised that you're suffering mentally but you may save yourself a lot of grief later.

Managing Neuropathy, Anxiety, and Depression
By Cindy Tofthagen, PhD, ARNP, AOCNP, FAANP

Anxiety and depression—two unique conditions that often co-exist—are common responses to chronic illnesses such as neuropathy that deserve attention and need to be screened for and managed [1]. Left untreated, these conditions can slow the treatment of each other and worsen physical and psychological disability, thus increasing neuropathy’s burden and making its management even more of challenge. Depression is described as prolonged sadness and loss of enjoyment in life. Anxiety is usually a result of fearfulness regarding possible future events and the uncertainty surrounding those events.

Neuropathy’s Link to Depression and Anxiety

People with neuropathy may experience anxiety, depression, or both at different times. Uncertainty regarding the underlying cause of neuropathy, loss of functional ability, pain, and concern about how the neuropathy will progress are all part of coping with neuropathy that can cause anxiety and/or depression.

Studies have shown that medical costs associated with caring for people with neuropathy, who concurrently have anxiety, depression, or both are higher than for those who do not. You are also more likely to go to the emergency department or be hospitalized if you are anxious or depressed. [2] The more painful your neuropathy is, the more likely you are to experience anxiety and/or depression. Neuropathic pain symptoms may seem worse during the night, causing you to lose sleep, and this can worsen both the anxiety and the depression as well as the symptoms of neuropathy [3]. Feeling that you have little control over your symptoms, not being able to participate in activities you normally enjoy, and changes in your social life may contribute to anxiety and depression [4].

The COPE Problem-Solving Approach

As with any chronic illness, it is important to learn how to take control of your symptoms. The acronym C. O. P. E.—representing strategies for taking back control and proactively managing your disease—stands for:




E-expert information

The COPE problem-solving approach was developed to help patients with cancer and their caregivers manage symptoms at home, [5] but it can also be used to manage other chronic diseases such as neuropathy as well as its comorbidities. I have shared this approach with the Tampa, Florida-based neuropathy support group I coordinate to help patients and their family members and friends; I also use it in my own life. You have probably used the COPE problem-solving approach in your own life without realizing it.

A Case History

Sue has neuropathy and after a series of evaluations and tests, her neurologist was unable to identify the underlying cause. Sue has been attending a local neuropathy support group for a few months; she met a woman at a recent meeting who just learned that she has a progressive and life-threatening illness. Sue starts to worry and become anxious that since she has many of the symptoms described by the woman she met, she too may have a similar illness.

Sue could use the COPE problem-solving approaches to manage her anxiety as follows: 

Creativity: Sue could think back to the times in her life when she may have been anxious and recollect how she took back control of the situation and what she did to get through it. She could also try talking to others who have had anxiety for ideas about how they overcame their feelings.

Optimism: Thinking about things from a positive perspective has been shown to improve coping and reduce stress in people with chronic illnesses [6, 7]. Instead of dwelling on the possibility that Sue might have a life-threatening illness, Sue could use optimism to send herself positive messages. E.g., “Besides having neuropathy, there is no reason to think that I have a life-threatening illness;” or “I can cope with anything that comes my way;” or “I can do all things with the strength that God gives me, or that I have within myself.” 

Planning: What plans could Sue make to help relieve her anxiety? Sue recognizes that her anxiety seems to increase when she is alone or when she is idle. She could plan to spend more time visiting with family and friends. She could also plan a new home decorating project so that when she has time alone, she can spend it thinking about her project instead of worrying and getting anxious. Additionally, Sue could plan to consult with her neurologist again to ask him his opinion of the seriousness of her illness and any additional questions she might have.

Expert information: In addition to consulting with her neurologist, Sue could also plan to partner with a counselor or a psychologist for additional help with coping. Looking up information on methods to alleviate anxiety may also be helpful as long as they come from reliable sources.

Neuropathy affects your ability to live and work the way you once could. As such, treatment strategies should address all the areas of your life that are affected by neuropathy as well as the co-existing conditions such as anxiety, and depression. You will need a multidisciplinary approach to care and so partnering with the right team of health care providers is key. You will also find support from patient advocacy organizations such as The Neuropathy Association and from outreach to your peers via support groups.

Jain, R., et al., Painful diabetic neuropathy is more than pain alone: examining the role of anxiety and depression as mediators and complicators. Current diabetes reports, 2011. 11(4): p. 275-84.
Boulanger, L., et al., A retrospective study on the impact of comorbid depression or anxiety on healthcare resource use and costs among diabetic neuropathy patients. BMC health services research, 2009. 9: p. 111.
Gore, M., et al., Pain severity in diabetic peripheral neuropathy is associated with patient functioning, symptom levels of anxiety and depression, and sleep. Journal of pain and symptom management, 2005. 30(4): p. 374-85.
Vileikyte, L., et al., Diabetic peripheral neuropathy and depressive symptoms: the association revisited. Diabetes Care, 2005. 28(10): p. 2378-83.
Bucher, J., P. Houts, and T. Ades, The Complete Guide to Family Caregiving2011, Atlanta: American Cancer Society.
Chesney, M.A., et al., Coping effectiveness training for men living with HIV: results from a randomized clinical trial testing a group-based intervention. Psychosom Med, 2003. 65(6): p. 1038-46.
Carver, C.S., M.F. Scheier, and S.C. Segerstrom, Optimism. Clinical psychology review, 2010. 30(7): p. 879-89.

Tuesday, 21 June 2016

Pain And The Nervous System: How It All Works (Vid)

Today's fantastic YouTube video gives us a science/biology lesson without insulting our intelligence. It's undoubtedly aimed at medical students and neurologists but experienced neuropathy patients will be able to follow this with considerable interest. If you've ever done any research on your neuropathy, you will have come across many of the terms he uses but maybe haven't been able to place them in context. It may be worth having a Google page open at the same time, so that you can quickly look up words you don't understand. Dr John Campbell explains how pain is generated, how it works; how the nervous system deals with it and how various treatments work or don't as the case may be and you'll be amazed at how it all seems to relate to your own burning, tingling, nerve damage. Really! I'm not kidding! It may not seem like it but this highly complex subject suddenly seems relevant to your own symptoms. It's a long video (40 minutes) but absolutely worth dipping into because you'll learn so much and be able to picture what's happening in your own body.

Pain 2, Pathways, peripheral, spinal cord and brain
Dr. John Campbell
Published on 29 Nov 2013

Monday, 20 June 2016

Gastroparesis: An Autonomic Neuropathy Stomach Problem

Today's post from (see link below) looks at a specific symptom of autonomic neuropathy (nerve damage where the involuntary functions of the body are affected) that many neuropathy patients may suffer from but have no idea what it is and why it happens. It's called Gastroparesis and basically means that, due to nerve damage in the digestive system, food either stays too long in the stomach, or is not properly digested, leading to a whole raft of problems. One of the problems is that the tests for this are not pleasant, some might say 'invasive' and I would hazard a guess that most doctors won't take the trouble to carry them out because there are so many other possible causes of the symptoms that first come to mind. Read this short article and if you think you may fall into this category, be as persuasive as you can in getting yourself tested. Autonomic neuropathy is one of the worst forms of nerve damage to diagnose because it can affect so many bodily functions at the same time but that doesn't mean that it shouldn't be taken seriously.

Posted by Dr. Leonel Porta

Autonomic Neuropathy is one of the most common types of Neuropathy in diabetics. As the name implies, the autonomic nervous system is responsible for monitoring the functioning of the organs that act largely unconsciously and regulates bodily functions such as the heart rate, digestion, and respiratory rate.

When stomach function is impaired due to this nervous complication in diabetes, Gastroparesis (a condition in which your stomach cannot empty itself of food in a normal fashion) occurs. Today, we will focus on how to know if you have Gastroparesis and which tests will help the doctor diagnose this diabetic complication.

In DiabeTV we’ve talked about Gastroparesis and its complications, however, it is important to remember that Gastroparesis is a condition that consists of a delayed gastric emptying, that is, the stomach takes too long to empty its contents. What causes this? It’s caused by a damage to the vagus nerve, which controls the movement of food through the digestive system.

When a diabetic patient has complications such as Autonomic Neuropathy which are affecting the vagus nerve, the muscles of the stomach and intestines do not work properly, so that the movement of food is stopped or delayed. Remember, that when blood glucose levels remain raised for a prolonged time, damage occurs to the blood vessels that carry oxygen and nutrients to the nerves. Also, chemical changes can occur within nerves which alter their structure and function.

Some of the many symptoms that give indications of Gastroparesis, are nausea, vomiting of undigested food, poor appetite, weight loss, premature feeling of fullness when eating, bloating, heartburn, gastroesophageal reflux, and stomach spasms.

The tests that the doctor carry out to diagnose Gastroparesis are varied and depend on the severity of symptoms and conditions of the patients. These include:

Barium X-Rays: This test consists of an X-ray done after drinking a substance (barium) that allows the anatomy of the small intestine to be hightlighted and outlined. The presence of a blockage in any part of the small intestine will result in the accumulation of the barium solution which shows the gastric delayed emptying.

Gastric Emptying Scan: this is a nuclear medical test that shows whether the solid and liquid foods remain for too long in the stomach caused by a lowered emptying rate. The patient ingests a radiolabeled test meal food and by using a scanning technique the rate of gastric emptying is measured.

Gastric manometry:
This is a test to measure the electrical and muscular activity of the stomach during the digestive process. For this test, an endoscope is inserted through the mouth into the stomach. This provides information about the strength and frequency with which the stomach muscles contract under fasting or feeding conditions.

Upper Gastrointestinal Endoscopy:
this examination allows an screening of several causes Gastroparesis which appear as symptoms. Under an anesthesia a thin flexible probe is introduced via the mouth into the stomach. The endoscope allows an inspection of the upper gastrointestinal tract, looking for possible ulcers, swelling, tumors, hernias, or other abnormalities. If necessary, samples for biopsies may be taken.

Like the upper endoscopy, an ultrasound or a blood test will allow your doctor to rule out other possible causes of delay in gastric emptying, different from Autonomic Neuropathy.

Treatments for Gastroparesis include the use of insulin, oral medications, changes in the diet, and modifying eating schedule. In more severe cases, feeding tubes orally or intravenously insertes can be used. Gastroparesis associated with diabetes is an entirely preventable complication. The priority of all diabetic patients should always be to control their blood glucose levels. Only then they will avoid unnecessary complications and ensure their own welfare.

Sunday, 19 June 2016

Strategies To Get Through The Day With Neuropathy

Today's post from (see link below) provides some wise words for those people struggling with neuropathy on a daily basis. Sometimes it's the pressure from other people that makes you over-extend and do more than is good for you and sometimes it's the pressure of the relentless symptoms that can make life so miserable that it's difficult to see a way forward. This article may help you form a strategy to deal with all that. It's realistic and not too 'new age' or clichéd and provides some genuinely helpful tips on living with a chronic illness. Worth a read but putting it into action won't be easy.

Pacing: The Chronically Ill Person’s Best Friend
Toni Bernhard J.D. Turning Straw Into Gold Posted Jun 15, 2016

Five effective strategies for pacing when you’re sick or in pain

Pacing refers to spacing out your activities during the day so that you’re able to stay within the limits of what your body can handle without exacerbating your symptoms. Another way to think of it is that pacing is a way to keep you inside your "energy envelope"—the envelope that contains your energy stores for any given day.

First, an admission: Even though pacing may be the single best “treatment” for me, I have a love-hate relationship with it. On the one hand, I love pacing because it keeps my symptoms from flaring. On the other hand, I hate pacing because it keeps me from doing everything I want to do.

To complicate matters, I’m much better at pacing when I’m at my best, as opposed to when I’m at my worst. This means that when I’m feeling intensely sick or in pain, I tend to ignore pacing and overdo things which, of course, only exacerbates my symptoms. Why in the world would I do this? Because doing things distracts me from my symptoms. In other words, activity keeps me from tuning in to how my body feels. Of course, this always backfires. The time comes when my body imposes itself on the situation and tells me in no uncertain terms: “That is enough for now.” Then, when I do give in and lie down to rest, I have to deal with feeling worse due to all that extra activity. When will I learn?

This tendency of mine is the exact opposite way that “pacing failure” is usually described. It’s usually described as overdoing it when you’re feeling good, and then having to pay for it later, often by being confined to bed for a time. This is called the “push and crash cycle.” I can do that too, but in this complicated relationship I have with pacing, I could call my tendency to overdo it when I’m already feeling terrible a “crash and crash cycle”!

I’m pretty sure I’m not alone in doing this.

The odd thing is that I’m generally a very disciplined person, so because pacing takes discipline, you’d think I’d be good at it. But I’m not. I admit that one reason for writing this piece is self-interest: I need to work on my pacing skills and writing about it will inspire me to do so.

Here are some ideas for pacing that have worked for me when I’m being “good” and following them: 

1. Alternating activity with rest.

This is the essence of pacing.

In my experience, the best way to do this is to write out a schedule for the day that incorporates rest in between each activity you want or have to do, be it mental or physical. This way, you’re dividing your activities into manageable chunks of time.

Here’s the secret to success with this: if you don’t stick to your schedule exactly, don’t abandon it. This is a common mistake. When I was teaching, I recommended that students create a schedule during finals period in which they set out what subjects they’d study on any given day and time. Then I gave them this final piece of advice: “Stuff happens that can keep you from sticking precisely to your schedule. Don’t throw it out. Revise it and start from your new spot.”

This approach to scheduling has helped me tremendously since becoming chronically ill. For example, if I put on the schedule for the morning, “10:00-10:30: work on blog post,” but then wind up working until 11:00, I revise the schedule and move on with the day. Simply having that schedule in front of me keeps me from deviating from it too much. Without set time-frames, I’m likely to lose track of time and work for several hours straight; then of course, I have to suffer the consequences. Some people find it helpful to set a timer; when it goes off, they know it’s time to stop the activity and rest for a while. 

2. Slowing down when performing tasks.

I tend to do things quickly. This causes my heart to begin racing and it can even make me dizzy. Slowing down is an excellent way to pace. And so, when I catch myself going faster and faster, for example, when I’m folding laundry or doing the dishes, I consciously tell myself to slow down. Not only do I save energy this way (and so I’m pacing), but I enjoy the task much more.

3. Following the 50% rule.

With this pacing tool, given how you feel on a particular day, you decide what you can comfortably do and then only do 50% of it.

One reason this is a great strategy is that I tend to overestimate what I can comfortably do, so this keeps me safely within my energy envelope. I also recommend that you think of that unexpended 50% as a gift you’re giving yourself to help you feel less sick and in less pain. 

4. Using a metaphor to help allocate available energy.

Many of you are familiar with the “spoon theory” by Christine Miserandino and find it very helpful. Here’s a link to it: The Spoon Theory.

I use a “marbles in a bowl” metaphor because it works better for me. When I wake up in the morning, depending on how I feel, I imagine that I have a certain number of marbles in a bowl. They represent the available energy I have for that day. It might be 50 marbles on a good day…and 10 marbles on a bad day.

Then, before I start an activity, I estimate how many marbles it will use up and subtract that number from my total. When there are no more marbles in my bowl, it’s time to “shut down” for the day. Initially, I had a lot of success with this strategy. Unfortunately, several years ago I stopped doing it. (Note to self: start thinking about marbles again!)

Don’t forget that mental and emotional activity use up marbles too. In fact, stress is a marble gobbler. For this reason, if an unexpected source of stress arises, you may suddenly find your bowl empty. That’s the time to make a commitment to rest as much possible for the remainder of the day.

5. Using a pedometer or a heart rate monitor.

These are inexpensive devices. A pedometer counts the number of steps you take in a day. A heart rate monitor keeps track of how fast your heart is beating. Once you figure out your limits—how many steps you can take or how high your heart rate can become before you feel the energy draining out of you—you keep your eye on the pedometer or the heart-rate monitor; when they get to a certain reading, you know it’s time to rest.

The reason I’m not using either at the moment is that, in my case, I can overdo things without taking a single step, for example, working too hard on my writing even though I’m reclining on the bed. Nevertheless, I know from others that these two devices can be valuable pacing tools.


A final word. Expect the unexpected, meaning that no matter how carefully you’ve planned your day for perfect pacing, as John Lennon wrote: “Life is what happens while you’re busy making other plans.” Stuff happens that may keep you from sticking to your pacing goals. When that happens, don’t abandon your pacing plans and don’t blame yourself for getting off-course (that’s a useless waste of your limited energy). Instead, revise your schedule and then try again. In an earlier piece, I referred to this as keeping a “Try Mind.”

Saturday, 18 June 2016

Are Opiods Going To Kill Neuropathy Patients?

Today's short post from (see link below) raises more questions than answers as far as this blog's concerned and doesn't necessarily appreciate the nature of chronic nerve pain. Any article that suggests: "For less severe (nerve) pain, many over-the-counter medications, such as ibuprofen or naproxen, may be as effective as an opioid" has to be suspect because it just can't be true. Neuropathy patients are prescribed opioid drugs for their pain when all else has failed and to suggest that over-the-counter analgesics may be just as effective, shows lack of understanding of how nerve pain works on the brain and nervous system. That said, any article that threatens opioid users with a much increased risk of death has to be taken seriously,  read and examined. It feels like an article that is written in response to the current 'crisis' with medication overdose problems and Professor Ray doesn't leave any doubt as to which side of the fence he sits on. He states: "We found that the opioid patients had a 64 percent increased risk of death for any reason and a 65 percent increased risk of cardiovascular death," but doesn't deliver the scientific evidence or context behind their findings. Should we be worried about this sort of headline? Of course we should but then we need to know how the conclusions have been reached. If you are a neuropathy patient in severe pain and having to rely on opioids to dampen that pain, then I suggest you have another talk with your prescribing doctor or specialist if you're worried. 99% of opioid users don't want to be taking opioids but have no choice and they take their medication with the greatest care and will do anything to avoid becoming addicted or harming themselves. They form a partnership with their doctors and their medication use is controlled and checked regularly to avoid any problems. The 1% who don't are the ones behind the current prescription drug hysteria...sledgehammer to crack a nut much!!!

Opioids increase risk of death when compared to other pain treatments 
Date:June 14, 2016 Source:Vanderbilt University Medical Center

Long-acting opioids are associated with a significantly increased risk of death when compared with alternative medications for moderate-to-severe chronic pain, according to a Vanderbilt study released today in JAMA.

Not only did long-acting opioids increase the risk of unintentional overdose deaths, but they were also shown to increase mortality from cardiorespiratory events and other causes.

Lead author Wayne Ray, Ph.D., and colleagues with the Vanderbilt Department of Health Policy studied Tennessee Medicaid patients between 1999-2012 with chronic pain, primarily back and other musculoskeletal pain, who did not have cancer or other serious illnesses.

Researchers compared those starting a long-acting opioid to those taking an alternative medication for moderate-to-severe pain.

Alternative medications included both anticonvulsants -- typically prescribed to prevent seizure activity in the brain, treat bipolar disorder or neuropathic pain -- and low doses of cyclic antidepressants, which are taken for depression, some pain and migraines.

"We found that the opioid patients had a 64 percent increased risk of death for any reason and a 65 percent increased risk of cardiovascular death," said Ray, professor of Health Policy at Vanderbilt University School of Medicine.

"The take-home message for patients with the kinds of pain we studied is to avoid long-acting opioids whenever possible. This is consistent with recent Centers for Disease Control and Prevention guidelines. This advice is particularly important for patients with high risk for cardiovascular disease, such as those with diabetes or a prior heart attack."

If a long-acting opioid is the only option for effective pain relief, patients should start with the lowest possible dose and only gradually increase it, he said.

The study group had a collective 22,912 new episodes of prescribed therapy for the medications, with 185 deaths in the long-acting opioid group and 87 deaths in the control group.

Long-acting opioid users had 69 excess deaths per 10,000 users. In other words, for every 145 patients who started a long-acting opioid, there was one excess death.

"We knew opioids increase the risk of overdose. However, opioids can interfere with breathing during the night, which can cause heart arrhythmias," Ray said.

"We were concerned that long-acting opioids might increase cardiovascular death risk, which is what we found. Because most patient populations have more cardiovascular deaths than overdose deaths, our finding means that prior studies may have underestimated the harms of long-acting opioids."

Ray said the findings add urgency to measures to restrict long-acting opioid use to those for whom benefits outweigh harms.

"Data are limited as to the best medicine for the kinds of pain we studied, such as back pain, although for pain involving the nerves, the non-opioids may be better," Ray said. "For less severe pain, many over-the-counter medications, such as ibuprofen or naproxen, may be as effective as an opioid."

Story Source:

The above post is reprinted from materials provided by Vanderbilt University Medical Center. Note: Materials may be edited for content and length.

Journal Reference:
Wayne A. Ray, Cecilia P. Chung, Katherine T. Murray, Kathi Hall, C. Michael Stein. Prescription of Long-Acting Opioids and Mortality in Patients With Chronic Noncancer Pain. JAMA, 2016; 315 (22): 2415 DOI: 10.1001/jama.2016.7789

Friday, 17 June 2016

Hands And Feet Tingling And Burning? Read On

Today's post from (see link below) is a post that will help you if you've suddenly realised that the strange symptoms you've been feeling may well signal a more serious problem. Despite the tens of millions of patients all across the world, there's still a widespread public ignorance about neuropathy and when your doctor first mentions it, you'd be forgiven for looking glassy eyed and rushing for the dictionary (or Google) when you get home. This article, plainly and accurately gives you a heads up as to what's going on in your body but it's only a start. After reading this you need to do your own research (this blog is a good place to start) and prepare a list of questions for your doctor you can't find the answers to yourself. It's a disease of contradictions, where everybody reacts differently to treatments; perhaps not surprising when you realise that there are over 100 different types and over 100 different causes. That said, you have to start somewhere and knowledge is definitely power when it comes to neuropathy. Don't despair: eventually you'll find something that helps control your symptoms but be prepared for a bumpy road!

Tingling hands: What you need to know about peripheral neuropathy
By: Audra Kolesar Winnipeg Health Region Wave, May / June 2016

What is peripheral neuropathy?

Peripheral neuropathy is a term used to describe problems with the nerves of the peripheral nervous system. It is also called nerve palsy.

What is the peripheral nervous system?

The peripheral nervous system is the term used for all of the nerves outside the brain and spinal cord. Peripheral nerves transmit information from the brain and spinal cord to every other part of the body. They connect your brain and spinal cord to your muscles and allow you to move your muscles. They also conduct sensations such as pain, temperature, and touch to your brain. The nerves connecting to internal organs that allow you to do things like breathe and digest food are also part of the peripheral nervous system.

How does peripheral neuropathy occur?

Peripheral neuropathy has many different causes. Anything that interferes with the function of a nerve can lead to neuropathy. Some common causes are:
Direct injury to the nerve, such as a sports injury.
Pressure on a nerve caused by repetitive use (such as carpal tunnel syndrome), improper use of crutches, or an abnormal growth, such as a tumor.
Diseases such as diabetes, arthritis, lupus, or alcoholism.
Infections (usually viral, for example, infections by the herpes virus).
Exposure to poisons.
Some medicines, such as some cancer medicines.
Lack of vitamins, such as vitamin B-12, or minerals.

What are the symptoms?

The symptoms of peripheral neuropathy depend on which nerves are damaged.

Nerves that help you move your muscles are called motor nerves. If motor nerves are damaged, you may have muscle weakness or you may not be able to move the muscles controlled by the damaged nerves.

Nerves that conduct sensations, such as touch, are called sensory nerves. When these nerves are affected, you may have numbness, tingling, pain, or extreme sensitivity to touch.

The nerves controlling internal organs are called autonomic nerves. Symptoms caused by damage to these nerves depend on what organs are affected.

For example, you may have vision problems if the nerves to your eyes are involved. Problems with other nerves may cause dizziness, leaking of urine from the bladder, or digestion problems, such as constipation or diarrhea.

How is it diagnosed?

Your health-care provider will ask about your symptoms and medical history, and will examine you. You may have a nerve conduction test to check the function of specific nerves. You may have other tests.

How is it treated?

The goals of treatment are to manage the condition causing the neuropathy and to relieve symptoms. The treatment depends on the cause. For example, if the problem happens after an injury, depending on how severe the injury is, the neuropathy may go away on its own and not need any specific treatment. If it is caused by a disease, such as diabetes or lupus, the treatment is focused on better control of the disease. If the cause is a vitamin deficiency, your provider may prescribe vitamin supplements.

The symptoms of neuropathy can be treated with medicines, such as:
Non-prescription pain relievers such as acetaminophen, aspirin, or ibuprofen.
Prescription NSAIDS (nonsteroidal anti-inflammatory drugs).
Medicines that can be put on the skin and numb the skin (lidocaine) or cause irritation (capsaicin).
Medicines for seizures that also can treat pain, such as gabapentin (Neurontin).
Antidepressant medicines that can help relieve pain.

Some of the other possible treatments for nerve pain are:
Biofeedback (a way to control your body's responses with your mind) or relaxation methods.
Electronic nerve stimulation devices.
Shots of local anesthetics, steroids, or other medicines to block pain signals or decrease inflammation.
In severe cases, surgery to cut the nerve causing the pain.

How long will the effects last?

Peripheral neuropathy caused by an injury usually lasts from a few days to several weeks, depending on the injury. Neuropathy due to diabetes and other chronic diseases tends to not go away completely, but it may improve with treatment of the disease. Neuropathy caused by a viral infection is less predictable. It may or may not go away with time.

How can I help prevent neuropathy?

It can be hard to prevent neuropathy caused by injury. But you can reduce your risk of neuropathy by taking steps to manage your condition. For example, if you have a condition that requires medication, follow your health-care provider's advice and take your medicines as prescribed. It also helps to lead a healthy lifestyle - exercising and eating a balanced diet that includes fruit, vegetables, whole grains, and lean meat to give you enough vitamin B-12.

Can you tell me more about neuropathy caused by diabetes?

Health-care professionals have been studying diabetic neuropathy for many years, but they do not yet understand how diabetes damages the nervous system. However, they do know that some people can prevent the development of neuropathy by keeping their blood sugar under control.

If a person does develop diabetic neuropathy, how is it treated?

Diabetic neuropathy is treated in several ways:
Muscle weakness is treated with support, such as splints. Physical therapy can also help with exercises for the weak muscles. Exercises can be also used to strengthen other muscles that have not weakened.
As with other cases of neuropathy, pain-killing drugs or cream can be applied to the skin to help pain during the night. Medicines can be used to treat nausea, vomiting, and diarrhea.

It is important to remember that injuries can be a serious problem for people with diabetic neuropathy. That's because the condition makes it harder to feel if something is hot or sharp. Diabetes also makes it harder for injuries to heal. People with diabetic neuropathy should be extra careful to avoid burns, cuts, and other injuries. Foot care is especially important, as a small injury or ingrown toenail can lead to long-term complications if you do not catch it quickly.

Can I help prevent diabetic neuropathy?

The best way to help prevent diabetic neuropathy is to:
Control your diabetes. Try to keep your blood sugar at a normal level.
Do not smoke.
Maintain normal blood pressure.
Exercise regularly, according to your health-care provider's recommendation.
Limit the amount of alcohol you drink because it can cause neuropathy, too.
Eat a healthy diet with fruits and vegetables (some vitamin deficiencies can cause neuropathy).
Keep your checkup appointments with your health-care provider.

Audra Kolesar is a registered nurse and manager with Health Links - Info Santé, the Winnipeg Health Region's telephone health information service.

The information for this column is provided by Health Links - Info Santé. It is intended to be informative and educational and is not a replacement for professional medical evaluation, advice, diagnosis or treatment by a health-care professional.