Tuesday, 30 August 2016

Don't Knock Alternatives For Neuropathy! You Never Know!

Today's short post from themighty.com (see link below) says a great deal in a short piece of text. it's true what she says: if nothing is helping, you'll end up trying just about anything to make life with neuropathy just that little bit easier and if that falls under the category of 'alternative' therapies or supplements then so be it - if it works...don't knock it. Now of course, you should get professional advice; especially if you have other conditions and take other medications but neuropathy is one of those diseases where the patient is at the forefront of the research because the research throughout the  decades just hasn't thrown up anything that truly works in reducing nerve pain for all. So millions of people across the world, are trying this, that and the other remedy because they've heard it benefits some people (this blog is full of them) but gradually, one or more supplements gain a widespread reputation of having an effect and the snowball rolls. (Always avoid anything with the word 'cure' on the label though - it's a lie!) Eventually the science catches up and proves or disproves the theory. It may be risky but neuropathy patients are dogged folk and god loves a trier!!
 




Why I Don't Roll My Eyes at Alternative Treatments Anymore
By Michele Kleinmann Contributor I write about Chronic Pain
 
I used to secretly (OK, sometimes not so secretly) roll my eyes at people who poured money into alternative therapies or swore by specific diets or vitamins. If there wasn’t robust medical literature to back something, I wasn’t buying it. That is, until I found myself buying miso soup on a 100-degree day for the potential benefits of seaweed on my neuropathic pain (as advised by my acupuncturist). Or until I found myself falling asleep every night to my pain relief hypnosis app. Or until I found myself calling the compounding pharmacist, who I’m on a first-name basis with, to ask whether he had any calf-liver pills. That must have been a sight — me standing on a busy street corner yelling into my phone, “C-A-L-F liver, like the cow.” Ultimately, I didn’t proceed with that one, but that’s beside the point.

The point is, I now understand that when you’re desperate for pain relief, you’ll try just about anything. That’s not to say that I don’t still immediately go to PubMed or “Doctor Google” to research whatever has been proposed to me (once a skeptic, always skeptic-ish), but I’m a whole lot more willing to try things. I don’t care if the relief I might find is only due to the placebo effect. The placebo effect can be powerful and, at this point, I say bring it on.

Moving forward, I will try my best to refrain from judging others’ regimens, however strange they may seem. I will instead hope that they are getting relief from whatever it is that plagues them. And I ask that next time you see me buying copious amounts of blueberry juice while on the phone with my acupuncturist, you do the same (hope I get relief, not buy blueberry juice).

https://themighty.com/2016/08/why-i-dont-judge-alternative-pain-relief-treatments-anymore/

Monday, 29 August 2016

Neuropathy Pain: Dealing Or Squealing?

Today's post from painnewsnetwork.org (see link below) is another advice post about learning to live with your condition but it's still a valuable one because there may be ideas here that you hadn't considered when trying to deal with your own daily grind with neuropathy. Even one good new idea can improve the quality of your life, so although some people become sniffy about what they see as clichéd advice, it's always worth reading because that 'hey' i hadn't thought of that' moment is just around the corner and you may have less pain as a result.

Pain Companion: How to Live Better With Nerve Pain
By Sarah Anne Shockley, Columnist August 23, 2016

I’ve lived with severe nerve pain for the past eight years and have, through trial and error, found simple ways to help reduce and quiet it down on a daily basis.

Some of these methods may be obvious if you already live with nerve pain. I include them all here because I know that it certainly would have served me well to have had this information early on, instead of having to work it all out for myself.

The first thing I learned was to think about my situation differently. For a long time, I thought about my nerve pain as its own thing, separate from me. It was something I didn’t want to have around, as if it was its own entity. It was me against the pain.

I’ve come to understand that my nerve pain is an aspect of my body, and possibly myself, that is so raw, so irritated, so sensitive and so volatile that it does not serve to try to make it get better.

My nerves in pain don’t want to be poked or prodded or touched or manipulated into wellness. Even alternative treatments seem like too much to handle. I am a strong believer in acupuncture, but the idea of needles when my nerves are already screaming is not something I want to contemplate. Sometimes even light massage is too much.

When I began to accept the pain as part of my whole life experience, not something that could be extracted or aimed at and annihilated, I began to see that my approach to easing it was going to have to be much more holistic.

I found the best way to do that was to work with creating more well-being in the body around the nerve pain.

Often, I found that trying to deal directly with my nerve pain actually made it worse, but this indirect approach, over time, was much more effective in helping to ease it.

Here are some methods to help the body feel the best it can around the pain:

Relax and de-stress as much as possible. Limit interaction with things that would normally “get on your nerves,” such as stressful situations, toxic people, crowded stores, and rush hour traffic.

Stay on an anti-inflammatory diet and try to avoid inflammatory situations that activate fright, tension, or adrenaline rushes, such as argumentative people or being argumentative yourself.

Get more rest and sleep by staying calm. Make doing less a priority. You might use herbal teas, such as chamomile, to help with sleep or read yourself to sleep while listen to relaxing music. Avoid staying up late on the internet.

Choose activities that not only suit your physical limitations, but also soothe the mind and soul, such as meditation, listening to beautiful music, singing, walking in nature, talking with loved ones, and reading inspiring words.

Spend time every day in nature walking and focusing your attention on the soothing feeling of the air on the skin, the breeze, the sunlight, and the sound of birds. Bare feet on the ground or in sand can be exquisitely soothing to the nerves.

Take long soaks in bath salts or products using aromatherapy. Let your body relax into the warmth and the delicious smells.

Keep moving in any way you can that doesn’t exacerbate the pain. It’s important to keep the blood and oxygen flowing to keep your muscles from stiffening up and adding to the pain. Stagnant blood and stagnant energy do not help you heal.

Aside from helping your body feel better physically, I also recommend taking care of yourself emotionally. Here are some pointers:

Find the little pleasures and things you enjoy and appreciate. Don’t wait for the pain to leave before you enjoy yourself and your life. Find the places that don’t hurt and revel in them. If there aren’t any, look beyond your body and find the things you can take pleasure in around you, including nature, the creative arts, the community, and your family.

Don’t try to turn your life off to avoid feeling pain. Don’t close down your ability to laugh or have fun. This is still your life. It is the only one you have. Make the most of it, even if you have to include pain in the equation. Just let it be there. Even invite it along.

Be kinder to yourself. Create a self-love routine around taking care of your body and your emotions. Wash yourself with soothing hands. Buy things that have soothing smells, not sharp chemical odors. Indulge your need for more softness and kindness in your life. Wear clothes that feel soft against your skin. Talk to yourself using soothing words. Give yourself a break more often.

Finally, consider making friends with your painful nerves. Talk to them kindly. Tell them it’s safe to calm down. Tell them that you’re paying attention to your body and you’re doing the best you can to heal.

Let them know that you hear them, you honor them and you respect what they have to say to you through the pain. Understand that they are in alarm mode right now, but you have heard them, and it’s okay to tone it down a little. It’s okay to let their message be carried to you a little more softly, a little more quietly.

I think one of the tricks to working with nerve pain is to understand that we have one central nervous system that lives throughout the body. Even if we are feeling nerve pain mostly in the face, neck or hands, it relates to and affects the entire nervous system and therefore the entire body.

I believe we can positively affect nerve pain in any part of the body by treating the whole body with calming, soothing, relaxing, and restoring activities and approaches. I’ve found that they work. And anything we can do to bring the pain down a notch or two is well worth it.

Sarah Anne Shockley suffers from Thoracic Outlet Syndrome, a painful condition that affects the nerves and arteries in the upper chest. Sarah is the author of The Pain Companion: Everyday Wisdom for Living With and Moving Beyond Chronic Pain.

Sarah also writes for her blog, The Pain Companion.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

http://www.painnewsnetwork.org/stories/2016/8/23/pain-companion-how-to-live-better-with-nerve-pain

Sunday, 28 August 2016

Erythro­melalgia (EM): A Rare Hand And Foot Disorder

Today's post from independent.co.uk (see link below) is the story of a woman with a rare but extremely alarming condition called erythro­melalgia (EM), which is difficult to diagnose but is relevant to neuropathy sufferers because the symptoms can so easily be confused with other disorders, especially nerve damage. The point is that many neuropathy patients are (rightly) obsessed with their feet and hands and anything alarming that appears can press the panic buttons. However, not all foot conditions, redness, swelling ,pain etc are neuropathic in nature as this case shows. It's vital that you report unusual symptoms to your doctor but don't assume that this is yet another mean variation of what you know you already have. Great sympathy goes out to this lady but foot awareness is important, especially if you have nerve damage problems already.


Woman's 'foot infection' diagnosis turns out to be a rare genetic disorder with no cure Sandra G Boodman 2016
 
Melissa Bogner suffered with excruciating pain for months before a doctor finally diagnosed her with a very rare and poorly understood condition

The 41-year-old management analyst for the Navy had grown accustomed to periodic bouts of neuropathy — numbness in her hands and feet — the apparent legacy of a severe allergic reaction to a drug she took in 2000 to treat a gynecological infection.

But this 2015 episode was different. Along with the sensation that her feet felt unusually warm, the skin on the second toe of her right foot looked inflamed. Weeks later, she noticed a small blister.

Bogner, who lives in Southern Maryland, initially shrugged it off. She figured that whatever was wrong would go away on its own.

[In looking for ‘zebra,’ doctors are stumped by toddler’s painful legs, rash and bleeding gums]

“I didn’t go to the doctor because it didn’t hurt,” she recalled. But eight months later, Bogner would learn that her foot problems were classic signs of a condition that was neither temporary nor trivial.

“It’s been life-altering,” Bogner said of the diagnosis. Summer, a time of year Bogner once eagerly anticipated, has become the season she finds hardest to endure. To cope with her new reality, she has sought to channel her energy into a self-help group for people diagnosed with the little-known malady.
A fungal infection?

At first, Bogner tried to largely ignore the problem, assuming that her shoes were to blame. Changing footwear didn’t help. Sometimes her toe would itch and feel tingly. At other times, the redness seemed to lessen, but it never disappeared entirely.

In April, when she took her son to an urgent care center for treatment of a skateboarding injury, she asked the doctor what he thought might be wrong with her toe. He told her it looked like a fungal infection and suggested she try an over-the-counter remedy. Bogner took his advice but discovered that the ointment irritated her toe. Instead of clearing up, there were signs that the redness was spreading to her third toe.

At the time, Bogner was preoccupied with more pressing medical problems. During a three-day hospitalization for a hysterectomy, she asked doctors about her toe. They were reassuring; if it was serious, Bogner said they told her, the problem would affect all her toes, not just one or two.

By the end of May, her toes were still inflamed and her feet felt so hot that she routinely removed her shoes while she was sitting down. Bogner consulted her primary-care doctor. He, too, suspected a fungal infection and prescribed a potent cream containing a corticosteroid in the hope that it would quell inflammation.

In fact, Bogner said, the cream, which she used for about a month, exacerbated the problem. What had been a small blister “blew up into a cyst on the top of my toe,” she said. The sensation of heat and the tingling were undiminished.

“I thought, ‘When is this toe going to give me a break?’ ” Bogner recalls.

Spreading redness

Melissa Curley Bogner suffered with excruciating pain for many months before a doctor finally diagnosed her with a very rare and poorly understood condition. (Deirdra O'Regan/The Washington Post)

Next stop was a podiatrist, whom Bogner saw in June. By then, three toes on her right foot sometimes turned crimson and the problem seemed to be affecting her left foot as well. The podiatrist was concerned that although Bogner did not have diabetes, her toe discoloration might signal a vascular problem that was impeding circulation in her legs. She sent Bogner to a cardiologist.

Testing by the cardiologist found nothing to account for the skin discoloration or tingling, such as peripheral artery disease. “I thought, ‘I’m back to square one,’ ” Bogner recalled. By this time, the problem had spread from her toes to the rest of her feet.

Increasingly alarmed, Bogner said she “began obsessively Googling ‘burning red feet.’ ” One possibility was a condition called small fiber neuropathy, a form of peripheral neuropathy that can cause a burning sensation and severe foot pain.

Another option was erythro­melalgia (EM), a rare and poorly understood disorder; the term literally means “red limb pain.” First described in 1878, the condition is characterized by red, hot and painful extremities, usually the feet and less commonly the hands. In some patients, the ears or face are affected.

Some EM cases are caused by a genetic mutation, while others are the result of a blood disorder, including thrombocytosis, which occurs when the body produces too many platelets, disrupting normal clotting. But many people develop EM for no discernible reason. There is no cure for the disorder, which causes abnormalities in the way blood vessels dilate and constrict. Symptoms range from constant and extremely painful to intermittently bothersome; treatment largely consists of drugs to blunt the pain from flares and to help patients sleep, and of functional measures such as avoiding heat and elevating the legs.

Numbers are imprecise, but EM is estimated to affect about 1 in 100,000 Americans, many of them white women who develop the condition in middle age, although some people are affected as children. “I thought, ‘I can’t believe that I’m that 1 in 100,000,’ ” Bogner recalled, fearing that in fact she was.

Desperate for guidance, Bogner called the National Organization for Rare Disorders, a Connecticut-based clearinghouse and advocacy group that provides information about more than 1,200 conditions, including several of the possibilities Bogner had found. A staff member suggested she print out the information about EM, which most closely matched her symptoms, and take it to the neurologist she had seen over the years for treatment of her neuropathy. She was also advised to take pictures of her red feet during a flare to show the neurologist.

Ahmed Kafaji, a neurologist who practices in St. Mary’s County, saw Bogner in early July.

Her hands, he recalled, looked fairly normal but felt hot. When she showed him cellphone pictures of her feet, their appearance was consistent with EM, which he had seen previously once or twice in his career. Kafaji said he also noted that the skin on Bogner’s hands seemed somewhat coarse, which is consistent with EM.

“If doctors haven’t seen a case, it’s often misdiagnosed as eczema or allergies,” he said. As a result, some patients go from doctor to doctor without an accurate diagnosis.

Kafaji said he was concerned that Bogner might have an underlying blood or autoimmune disorder. So the following month, Bogner drove to Johns Hopkins Hospital in Baltimore, where she sought a second opinion and testing to rule out other abnormalities.

Blood tests ruled out cancer, Lyme disease, various auto­immune or bone-marrow problems, and a genetic mutation known to cause EM. After seeing two neurologists, a rheumatologist and a hematologist, Bogner was told that she had primary idiopathic EM — meaning the cause was unknown.
'A dreadful season'

The definitive diagnosis plunged Bogner into the despair that can accompany the wrenching adjustment required to live with a disabling, possibly permanent, condition.

While EM can improve, or even largely disappear, that doesn’t happen often.

A study of 168 patients treated at the Mayo Clinic between 1970 and 1994 found that 10 percent reported that their EM resolved after an average of nearly nine years. Of the others, about one-third reported that it worsened and one-third that the problem improved but did not disappear. The rest reported no change.

Bogner’s condition has not improved. She takes medicines to help her sleep and to try to blunt the worst of the flares, which can last from five minutes to all day.

“The heat can be like submerging your toes into burning water,” she said. When her ears are affected, “it feels like my head is on fire.”

Avoidance is a key strategy; she stays out of the summer heat and sun, which can trigger a flare, and remains in air-conditioned settings as much as possible. Last week, she and her family ventured north for their first vacation in Maine.

“Summer is a dreadful season,” she said. Trips to the pool or beach are now out of the question. Alcohol and spicy food can trigger a flare, so Bogner largely avoids both, but misses having a glass of wine with friends.

She holds out hope that there will be more effective treatment in her lifetime. “Doctors don’t understand the depression that goes along with this,” she said.

Involvement in an online group has been her most important source of support, Bogner said, and has enabled her to feel less isolated and lonely and to help others in similar or more difficult circumstances.

“We talk people off the ledge,” she said. “Our bond is very strong.”

http://www.independent.co.uk/life-style/health-and-families/health-news/foot-infection-diagnosis-turns-out-to-be-a-rare-genetic-disorder-a7205341.html

Saturday, 27 August 2016

A Day With Severe Nerve Pain

Today's post from themighty.com (see link below) will be an instantly recognisable story for many people living with severe neuropathy. In this case, the cause is diabetes but almost all nerve pain patients will be nodding their heads in agreement with what she says. Worth a read, if only to assure you that you're not alone.
 
The Pain I Feel in a Day With Diabetic Neuropathy
By
Pamula Floyd 08/16/16 I write about Diabetic Neuropathy
 
According to the American Chronic Pain Association, there are at least 26 million Americans living with diabetes. And more than one in five of those have diabetic nerve pain, also known as diabetic neuropathy. I am one of them.

As much as I try to correct my diabetes, the damage it’s done to my nerves is irreversible. It has forever impacted my ability to sleep, exercise, walk, work and engage in everyday activities.

Throughout the course of a day I can experience everything from burning, stabbing, stinging, jabbing, numbness or tingling, prickling or pins and needles, electric shock-like or shooting pain, and extreme tenderness and sensitivity to touch. And this is with pain medication. Can you imagine the descriptions I would use if I didn’t take pain medication?

I have to be careful with what materials I put on my feet. Some days I can wear shoes, other days there is no way in hell. As for socks, the insides of them must feel like rayon. When I shop for socks, I have to put my hand inside them to feel if they are soft enough. If they don’t feel like silk or rayon, then I don’t get them.

The same can be said of my bed sheets. I’ve definitely had to pay attention to thread count as well as the choice of material. Anything too rough can aggravate my feet and interrupt my sleep.

The neuropathy in my feet has gotten so bad that I recently discovered that I broke my big toe and the bridge that goes across my toes. And I have no idea how. What I find funny about this is that people without neuropathy can’t fathom the idea of breaking your foot that bad and not remembering how. For me, it took two weeks before I sought medical attention because I was used to my feet aching. And occasionally they swell. So I was as surprised when the doctor said that I had broken my foot. This is just one of the downfalls of having diabetic nerve pain.

And since the sensation in my feet has disappeared quite a bit, I also have trouble walking. Sometimes I can’t feel when I place my feet on the ground. This becomes scary when I am walking down stairs. It’s also one of the reasons why I will forever wear flat shoes. I can’t even wear clogs because I can’t feel my toes enough to be able to keep them on. They just flap right off my feet. My gait has changed, and my adult children say that I walk funny. Especially when I try to walk fast. I can’t walk fast. My feet won’t let me. Between the neuropathy in my feet and the fibromyalgia in my legs, there will be no more running or power walking for me. Not without me falling flat on my face.

I often lay awake at night and wonder where it all went wrong. Was it because I had gestational diabetes during my two pregnancies? If so, then why didn’t the doctors drill into my head that I needed to watch out for diabetes immediately? Then again, maybe they did. Maybe I didn’t listen because people in their 20s tend to think that they’ll live forever without a scratch or a bump. And maybe it was just meant to be. Whatever the reason, I’m doing my best to try and keep my diabetes under control. As for the neuropathy, I will continue to listen to what my body tells me and act accordingly. But if you’re reading this and you’re newly diagnosed with diabetes, then I beg you to take it seriously. You don’t want to wake up 20 years from now and realize you have difficulty walking. It’s not a good feeling.

https://themighty.com/2016/08/symptoms-of-diabetic-neuropathy-pain/

Friday, 26 August 2016

What A Neuropathy Patient Deserves From His/Her Doctor

Today's very good post from blog.aapainmanage.org (see link below) written by a doctor, contains advice for both doctor and patient when it comes to chronic pain conditions like neuropathy. The doctor needs to look at far more than the current symptoms the patient presents and the patient can read this article and reasonably expect that the doctor carries through with most of the suggestions here, in order to come to the best possible diagnosis. It's not rocket science but you'd be amazed at how many stories emerge of doctors who diagnose and prescribe drugs, based on their ten minute time slot with the patient and nothing else. Neuropathy (nerve damage) needs a far more structured approach than this and the patient who has often been in pain and discomfort for months and even years already deserves a proper holistic approach. There is no cure for neuropathy and the current treatments and drugs leave a lot to be desired in terms of success. Most often it's a case of 'suck it and see' but given the huge numbers of people with neuropathy across the world, patients deserve better. This article goes some way to addressing the problem and is well worth a read.

Strategies for Evaluating the Patient with Chronic Pain
Written by W. Clay Jackson, MD, DipTh, Vice President of the Board, Aug 16, 2016

A comprehensive evaluation of the patient with chronic pain is rarely straightforward, and it begins with the recognition that a complete cure is unlikely. The patient’s pain experience may be complicated by numerous factors, including lack of an obvious pathological cause, concomitant anxiety and depression, and a downward spiral of inactivity and lowered self-esteem. Often, medications used to treat the pain may themselves cause side effects that contribute to the patient’s reduced function.

The skillful clinician will work with the patient, incorporating time-efficient tools to determine a treatment plan that combines a variety of modalities and may or may not include the use of opioids. With chronic pain patients, the evaluation is key: Failure to identify all the factors that contribute to the pain can lead to ineffective treatment, further deterioration, and mutual frustration, not to mention legal and regulatory consequences. A seasoned clinician listens carefully to validate the patient’s pain without allowing elaborate descriptions to derail the timing and purpose of the visit. For most patients with persistent pain, the goal of treatment is not the complete relief of pain, but rather improvements in the patient’s physical and mental functioning that result in an improved quality of life as he or she takes increasing responsibility in his or her own therapy. Patient and clinician may be a traveling a long and bumpy road, but the outcome can be meaningful and beneficial for both.

The Assessment Process

There are numerous guidelines for managing the patient with chronic pain (1-4). Having a routine for the evaluation ensures that relevant data are captured. The clinician should evaluate and document the patient’s pain history including the nature, location, intensity, and duration of the pain; current and prior pharmacological and nonpharmacological treatments; factors that worsen or improve the pain; underlying or coexisting conditions; and (importantly) the effect of the pain on the patient’s life. An assessment of function should include the impact of the pain on the patient’s family and social life, employment, and sleep, and provide a baseline for follow-up evaluations. The clinician should also be alert to signs that the patient is minimizing or maximizing the subjective reports of the pain or, in cases of cognitive impairment, lacks the proper resources to describe it (3).

As the noted clinician Sir William Osler stated, it is more important to consider what kind of patient has the disease, rather than what kind of disease the patient has. The treatment of the patient with chronic pain proves time and again the truth of of his aphorism. Thus, I include questions about depression, anxiety, posttraumatic stress disorder, and other factors that might impact pain, including stress levels at home or at work. I consider the patient’s capacity for chemical coping, or the likelihood of using pain medication to cope with life’s stresses. And, of course, any evaluation that may lead to a trial of opioids should include an assessment of the patient’s risk for opioid misuse, but it also should include a qualitative assessment of the patient’s goals. What are the patient’s functional goals? How does the patient define functionality? What are simple, concrete things the patient wants to do in the next 30 days? How can treatment help the patient reach her goals?

When reviewing the pharmacological history, I attempt to ascertainwhether the pain is a part of the history or consumes the history. I ask which medications has the patient tried: nonsteroidal anti-inflammatory drugs (NSAIDs), serotonin norepinephrine reuptake inhibitors (SNRIs), nerve cell membrane stabilizers (anticonvulsants), and/or opioids. I like to think of these as the four pharmacologic pillars of pain relief, which often yield salutary results when used in combination. Is the patient equally balanced on all four pillars, or is he leaning on just one?

A comprehensive evaluation may take some time, but several strategies can be used to work within the time constraints of the office visit, especially in primary care practice. A comprehensive questionnaire can be filled out by the patient before the initial appointment, providing key historical information even before the patient enters the exam room. Self-reporting pain scales and screeners, such as the Brief Pain Inventory (BPI) (5), also can help consolidate information and maximize the time before the visit. I often bring the patient back in a week or two, or see the patient more frequently in the beginning of the treatment plan, to continue the initial evaluation. When dealing with a pain patient who may be considered difficult because he has lost the ability to cope with life, it is tempting to try to rush the evaluation. But most such patients have complex issues and histories that require a commitment on the clinician’s part to take the time to unravel them.

The clinician should perform a focused physical examination based on the patient’s history and carry out appropriate diagnostic testing. Quantitative measurements of the patient’s capacity for successful opioid treatment can be obtained from urine drug screens, electronic databases, and standard tools for risk stratification, such as the Opioid Risk Tool (6) and the revised version of the Screener and Opioid Assessment for Patients with Pain (SOAPP-R) (7). In addition, the Sheehan Disability Scale (8) and the WHO-5 (9) are very helpful to assess functionality and wellness (a predictor of resiliency). The PHQ-9 (10) is a useful scale for depression, which often co-exists with chronic pain and will impact the patient’s care.

Treatment Considerations

The patient-clinician relationship is best viewed as a collaborative partnership; whereas patient demand should not determine the choice of a therapy, it should inform the choice. Many patients want to combine complementary and alternative medicine options with pharmacological therapy, and the assessment will help determine which therapy will provide greatest benefit. If the patient has issues with gait and balance, for example, physical therapy can improve functionality and decrease the potential for falls. We would also recommend other strategies such as fall-proofing the home, and learning ‘tricks’ for safe and less painful walking. For patients with localized neuropathic pain, dry needling techniques may be effective. Massage, either alone or combined with topical treatments such as NSAID-based gel, may ease musculoskeletal and soft tissue pain.

Most complex pain patients will be taking multiple medications, so I try to maximize their effectiveness during treatment. For example, switching a patient who is already taking a selective serotonin reuptake inhibitor (SSRI) to an SNRI will often provide additional analgesia. I try to prescribe treatments that will ‘multitask;– give multiple therapeutic effects from one molecule. Another example: if lack of sleep is an issue, I usually give gabapentinoids at night. Of course, opioids may also be required, if the risk/benefit ratio is appropriate, and non-opioid therapies alone have failed.

Treating patients with chronic pain can be challenging, but I have developed strategies for dealing with some of the frustrations. I talk with my colleagues, keep up to date with legislation and CME, and, most importantly, I trust my clinical judgment–especially when I am confident that my evaluation has been comprehensive and has involved collaborating with the patient. I am comfortable treating my patients with chronic pain, even when they become angry and disagree with the treatment decision. Because I have laid the proper groundwork, I view this not as a treatment failure, but as an opportunity to strengthen the therapeutic relationship.

References 

 
Irving G, Squire P. Medical evaluation of the chronic pain patient. In: Fishman SM, Ballantyne JC, Rathmell JP, eds. Bonica’s Management of Pain. 4th Baltimore, MD: Lippincott Williams & Wilkins; 2010:208-223.
Fishman SM. Responsible Opioid Prescribing: A Physician’s Guide. Washington, DC: Waterford Life Sciences; 2007:13-29.
American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009;57(8):1331–1346.
Chou R, Fanciullo GJ, Fine PG, et al., for the American Pain Society- American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-130.
Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med. 1994;23(2):129-138.
Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the Opioid Risk Tool. Pain Med. 2005;6(6):432–442.
Butler SF, Fernandez K, Benoit C, Budman SH, Jamison RN. Validation of the revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R). J Pain. 2008;9(4):360–372.
Leon AC, Olfson M, Portera L, Farber L, Sheehan DV.. Assessing psychiatric impairment in primary care with the Sheehan Disability Scale. Int J Psychiatry Med. 1997;27(2):93-105.
Bech P. Measuring the dimensions of psychological general well-being by the WHO-5. QoL Newsletter. 2004;32:15-16.
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613.

This story originally appeared in The Pain Practitioner, Spring 2014.

http://blog.aapainmanage.org/strategies-evaluating-patient-chronic-pain/

Thursday, 25 August 2016

Coping With Neuropathy: Nobody Said It Would Be Easy!

Today's post from foxnews.com (see link below) is one which the cynics amongst you will hate and the optimists will love. However, if you disregard the slightly glib/new age titles for each tip, the content is very useful, if not essential, for people living with long-lasting nerve pain. It's true, we have to work on our own mindsets to achieve anything like a positive outlook about neuropathy - it's a never-ending grind and often, however positive you try to be, your body will stubbornly refuse to cooperate. Nevertheless some of the ideas here may help you feel better on any given day and for that reason alone, they're worth publishing. Try not to let cynicism take over because cynicism leads to depression and worse pain.

12 healthy ways to cope with a chronic illness
By Julie Revelant Published March 21, 2016

In 2007, Tami Stackelhouse, then 35, was diagnosed with fibromyalgia, a chronic condition that caused pain throughout her body, brain fog and extreme fatigue.

“I remember thinking, ‘If I could just close the door, turn off the lights and lie down on the floor of my office, I would be asleep immediately,’” Stackelhouse, of Tigard, Oreg., said.

Eventually her condition worsened, even forcing her to quit her job as a customer service manager, file for disability and spend day after day lying on the couch.

After months of searching for answers and working with her doctor, a turning point came when she found a health coach who helped her change her diet, find ways to be more active, reduce stress and get enough sleep.

“One of the things we came up with was a mantra of ‘Every day that I do what I need to do, I’ll feel a little bit better,’” she recalled.

With supportive family members and friends by her side, along with meditation, journaling and prayer, Stackelhouse found strength she needed to pull through each day until her symptoms subsided.

And in the process, she learned how to be kind to herself.

“Changing my attitude towards myself was the number one thing that made it all happen,” she said.

Receiving a devastating diagnosis or dealing with a chronic condition is no easy feat. In fact, studies show that approximately one-third of people with chronic illness also deal with depression.

The good news however, is that if you have a chronic illness, there are some simple strategies you can do to feel strong, calm and positive.

1. Don’t blame yourself— or your body.

When you’re diagnosed with a chronic illness, it’s common to view your body as the enemy or feel angry and blame yourself as though it’s your own weakness that is preventing you from healing.

Try to see the illness as the enemy instead and recognize that your body is working as hard as it can to support you even it’s sick, said Toni Bernhard, the Davis, Calif.-based author of “How to Live Well with Chronic Pain and Illness: A Mindful Guide.” Bernhard has been living with a chronic illness for 15 years.

“Everyone struggles with his or health at some point in their lives and to blame yourself only adds mental stress and suffering on top of the physical difficulties you’re already facing,” she said

2. Use Google wisely.

Information is power, but if you’re obsessive by nature, you’ll get stuck, said Carolyn Daitch, Ph.D., an internationally-renowned psychologist in Farmington Hills, Mich. and author of “The Road to Calm Workbook: Life-Changing Tools to Stop Runaway Emotions.”

It’s OK to research reputable sources about your illness but if it’s causing you anxiety, put a time limit on it or ask a friend or partner to help you weed through all of the information and narrow down what’s important and relevant.

3. Find acceptance.

“If you spend your time denying where you are and being angry about it, it keeps you from taking constructive steps to make things better for yourself,” Bernhard said.

Instead of looking too far into the future, think about what you can do now, within your limitations, to be happy. And say to yourself, “I don’t like it, I don’t want it, but I can handle it,” Daitch said.

4. Focus on the positives.

When all else feels hopeless, it can be hard to stay positive, but it’s important to build “positive expectancy,” or a belief that things will get better, Daitch said.

When you know the illness is short term, it’s much easier to do, but even if you’re facing a long-term illness, you can still come up with things to focus on so you’ll stay positive.

5. Be kind to yourself.

Instead of putting yourself down when things get hard, be understanding and compassionate with yourself. Think about what you might say to someone else in need and use the same kind words when you speak to yourself.

6. Assess your support network.


Family and friends might feel uncomfortable or afraid of your illness. What’s more, some may not have the patience to deal with the unpredictable nature of your life, while others may not want to believe that you’re sick especially if you look perfectly healthy.

Although you can certainly try to educate them about your condition, if they can’t be supportive for you like you wish they were, forgive them and wish them the best if you decide to part ways.

“Holding bitterness and anger in your heart just makes you feel worse,” Bernhard said.

7. Practice mindfulness.

Mindfulness and meditation are effective ways to stay present and restore a sense of calm. In fact, meditation reduces anxiety, fatigue and pain in women undergoing breast cancer biopsies, according to a recent study in the Journal of the American College of Radiology.

To start a meditation practice, notice the thoughts, feelings and sensations in your body, but don’t fight or judge them. Instead, imagine them floating away like balloons.

“Although the goal is not necessarily for it to have it go away, indeed, if you move into the kind of calm, curious detachment, it usually does soften,” Daitch said.

8. Visualize health.

Visualization and guided imagery are powerful ways to calm the body and the mind. Try this: imagine your body as a symphony with many sections and instruments. Although one instrument might need to be tuned, focus on the healthy parts and say to yourself, “There’s strength within. There’s a part of me that’s strong and it can help other parts,” Daitch said.

9. Ask for a hug.

Studies show that sharing a hug with a loved one can help lower blood pressure, ease stress and boost oxytocin, the love hormone. What’s more, hugging may even prevent stress-induced illness, a recent study in the journal Psychological Science found.

10. Get support.

 
Reach out to other people you can confide in, those who have dealt with a chronic illness and/or find strength in public figures who inspire you. Don’t be afraid to ask for help either, whether it’s a friend who can help run errands or cook meals for you or a mental health counselor you can talk to on a regular basis.

11. De-stress.

Walking, yoga, aromatherapy and humor are all great ways to reduce stress and restore a sense of calm and well-being.

12. Set boundaries.

It’s natural for family members and friends to offer unsolicited advice or words of wisdom, but if it’s unwelcomed it can make you upset. Recognize that whatever they offer comes from a place of love and instead of reacting simply say, “Thank you, I’ll think about it.”

Julie Revelant is a health journalist and a consultant who provides content marketing and copywriting services for the healthcare industry. She's also a mom of two. Learn more about Julie at revelantwriting.com.


http://www.foxnews.com/health/2016/03/21/12-healthy-ways-to-cope-with-chronic-illness.html

Wednesday, 24 August 2016

Quality Sleep For Nerve Pain Patients

Today's post from spine-health.com (see link below) is a really useful one for the vast majority of neuropathy patients who have more pain and therefore more problems, with sleeping at night. One of the features of neuropathy, is that the pain and discomfort can be worse at night. Nobody seems to be quite sure why this happens but it does and can reduce the quality of people's lives considerably. Consistent sleep deprivation leads to a gradual running down of the body's ability to get through the day and that's without taking the pain itself into consideration. Constructive articles with useful links like this one are therefore always welcome. Even if you don't follow through on all these tips, maybe one or more will help you gain more quality sleep and as most neuropathy patients know, quality sleep is like gold dust!

7 Sleeping Tips for Patients with Chronic Pain
By Stephanie Burke |

Pain doesn't end when the sun goes down. Studies show a majority of those with chronic pain have trouble falling asleep or staying asleep.

Unfortunately, poor sleep can make pain worse—so pain and insomnia can set a damaging cycle into motion that makes it harder and harder to find pain relief or a good night's sleep.

See Chronic Pain and Insomnia: Breaking the Cycle

Smart sleep practices known as good sleep hygiene can help you get a better night's rest.


Learn more: Practicing Good Sleep Hygiene


The first step in breaking this cycle is to talk with your doctor and make sure you have a multi-disciplinary approach to treating the pain itself. Even if the physical cause is not treatable or is unknown, there are treatments for the pain available, including medication and cognitive behavioral therapy.

See 11 Chronic Pain Control Techniques

You don't have to focus on pain treatments alone before you treat insomnia though—in fact, they're best tackled together.

We've compiled some sleep tricks that seem to help many of our Spine-health Forum members:


1. Only go to bed when you are tired

Do not allow yourself to toss and turn in bed. This only makes things worse, and usually you'll end up stressing out about the fact that you're not sleeping.

If you can't fall asleep within 20 or 30 minutes, get out of bed and engage in something that makes you tired.

Once you figure out your optimum bed time, do your best to keep a regular sleep schedule.

See Sleep Aids for People with Chronic Pain

2. Cool the room

Simply cracking the window in cold weather or turning up the air conditioner a little more is a great way to make the room temperature colder and to have deeper and more restorative sleep.


3. Check your bedroom "equipment"

Ask yourself these questions: 

 
Does my mattress provide me with enough lumbar support? Check out these mattress guidelines.

How does my pillow support my neck? Is it too high or too firm? Read these suggestions for pillow support and comfort.

What position is most comfortable when sleeping? Am I relaxed on my back, side, or am I curled up? How do I feel when I wake up in the morning after having slept in these positions?

Certain sleeping positions are recommended for different types of pain.

For example, patients with pain from osteoarthritis are advised to sleep in the fetal position (on their sides, with knees curled up), while patients with degenerative disc disease may prefer to sleep on their stomach. Those with hip pain may achieve relief by placing a pillow between the knees.

4. Drink herbal tea


Avoid coffee after dinner and minimize or exclude caffeinated soda and other stimulants like alcohol and nicotine.

Chamomile tea is an excellent choice to help you relax.


5. Work up a sweat

While many people with chronic back and neck pain worry that exercising will only exacerbate their pain, the opposite is actually true: Being active often decreases pain.

Engaging in regular exercise, stretching, and strengthening programs can promote the body's natural healing process and make you feel better both physically and mentally. And, as a bonus, it will make it easier to fall asleep at night.


6. Write down your worries

Why is it that when your head hits the pillow, all your worries become so intense? To cope with this phenomenon, try "forced worrying." Before you go to bed, take 15 minutes or so to write down your worries. Then put the list away and tell yourself that your time to worry for the day is over.

If you find yourself in bed worrying about other things, keep a notebook and pen nearby and write these down as well.


7. Visualize something peaceful

With your mind free of worry, gently close your eyes and think of something tranquil and relaxing. Consider incorporating a sound relaxation machine or even aromatherapy.

What helps you get a good night's rest? Find out what our community members think in our Sleep Forums.


Learn more:
Natural Remedies and Herbal Supplements as Sleep Aids


Modern Ideas: The Gate Control Theory of Chronic Pain

Related Articles

Practicing Good Sleep Hygiene

Sleep Aids for People with Chronic Pain

How to Evaluate a Mattress

Psychological Approaches for Insomnia

Related Videos




Video: What is the Best Mattress for Back Pain?

Mattress comfort can help patients recover from their back pain. Learn how to choose the best mattress to avoid back pain.





Best Pillows for Neck Pain or Back Pain Video

Knowing which pillow to use when you have neck pain can make your days easier and the recovery time shorter.





Pillows and Positions for Easing Neck Pain Video

Explore the process for selecting a correct support pillow and which body positions may help alleviate neck pain during sleep or during waking activities.

http://www.spine-health.com/blog/7-sleeping-tips-patients-chronic-pain

Tuesday, 23 August 2016

Better Sensory Testing Leads To Better Diagnosis And Better Treatment For Neuropathy Patients

Today's fascinating post from nature.com (see link below) looks at a Danish study that has shown that current drug treatments for neuropathy can be effective if targeted at specific symptoms. That means that diagnoses have to be much better and much more accurate than they currently are. The researchers, affiliated with the German Research Network on Neuropathic Pain (DFNS) have devised a standardized battery of assessments known as quantitative sensory testing (QST). This basically groups patients according to their specific neuropathic symptoms. At the moment, it's a case of a wet finger in the air to see which way the wind is blowing and then diagnosing neuropathy with little reference to a patient's specific pain symptoms and then applying the range of drugs we're all familiar with, in the hope that something will work. Perhaps there's little wonder that failure is a common result of such an approach. By examining a patient's responses to a series of tests, the nature of their pain can be better identified and therefore, theoretically, better treated. This all makes sense but as we all know, cost is a vital component of any testing and treatment regime and more detailed testing is going to cost more, especially if skin biopsies are brought into the equation. Then there's a question of time. The handling doctor is often under pressure to establish a diagnosis and initiate treatment as quickly as possible, not least from the patient him/herself, who has already been suffering for some time before reaching this stage. It's going to take a sea-change of attitude from medical authorities and insurance companies to bring about detailed testing and patient grouping but reading this article does suggest it's in our best interests as neuropathy patients.

Neuropathy: A name for their pain
Michael Eisenstein Nature 535,S10–S11(14 July 2016)doi:10.1038/535S10a Published online 13 July 2016
 

People with neuropathic pain have struggled to find relief with conventional drugs. Researchers are investigating whether more meaningful pain classifications could help.

Two years ago, with little fanfare, neurologist Søren Sindrup reported the results of a successful clinical trial1. On the face of it, it was a modest success story. Instead of coming up with a wonder drug, Sindrup and his team repurposed an existing medication. Nevertheless, some pain researchers consider the trial a potential game-changer — one that marked a turning point in how researchers think about neuropathic pain.

This type of chronic pain arises from damage to the nerves that sense, transmit or process information about environmental stimuli. It can result from numerous initial insults, including spinal cord injury, diabetes and chemotherapy. Patients have generally been grouped on the basis of this initial trauma. But Sindrup, who is at Odense University Hospital in Denmark, and his colleagues took a different approach. They used diagnostic work-ups to cluster patients by their symptoms. This allowed the researchers to home in on a cohort that was more likely to respond to treatment. This is a huge step forward in an area where clinicians have struggled to help their patients. “The drugs we have relieve 50% of pain in somewhere between 1 in 4 and 1 in 7 of the patients we treat,” says Andrew Rice, a pain researcher at Imperial College London. “That's for the best drugs — and that's not very good.”
 

Part of
Nature Outlook: Pain

A growing number of pain researchers think that improvements can be found by analysing symptoms for clues about the underlying nerve damage. Neurologist Giorgio Cruccu of Sapienza University in Rome draws a comparison with another area of neurology. “There is no universal treatment for epilepsy,” he says. Instead, “it depends on the type of seizures”. Pain is a challenging medical target — doctors gain much of their insight from patients' reports rather than from external observations. But clinicians are attempting to devise more-sophisticated diagnostic tools to give the field a quantitative edge — and perhaps usher this patient population into a new era of evidence-based treatment.


Testing your patients

“There were hints in the literature that there are different mechanisms at work.”

Pain is initially recognized through peripheral sensors in the skin known as nociceptors, which react to potential sources of injury such as heat or mechanical trauma. Nociceptors send signals through specialized nerve fibres to the spinal cord, and from there to the brain (see page S2). Disruption to any part of this process can trigger enduring discomfort, although the severity and sensations experienced — burning or shock-like pain, numbness or tingling — can vary widely depending on the nature of the underlying damage. Not all injuries result in the same pain symptoms. For example, people with post-herpetic neuralgia (which can result after an outbreak of shingles) often have spontaneous pain that resembles an electric shock, but some experience allodynia — pain as a result of benign physical contact, such as clothing rubbing against skin. Over the past two decades, clinical researchers have come to appreciate that this variety of symptoms offers a way to understand how pain works. “There were hints in the literature that there are different mechanisms at work across various neuropathic pain entities, where patients have the same 'origin' of pain, but a different pain mechanism,” says Christoph Maier, a pain specialist at University Hospital Bergmannsheil in Bochum, Germany. “Today, we know this idea is correct.”

If these symptoms do represent different underlying mechanisms, that would help to explain why people in the same patient group respond differently to the same drugs — and that might have implications for treatment. “We have tried to develop a classification that is based on symptoms, which may give some indirect clue about the pain mechanism,” says Nadine Attal, a neurologist at Versailles Saint-Quentin-en-Yvelines University in France. Over the past decade, several questionnaires have been developed, including painDETECT and Douleur Neuropathique 4, which help to distinguish pain associated with nerve injury from that brought on by other causes, and the more detailed Neuropathic Pain Symptom Inventory (NPSI), for further subclassification of patients. These can be completed by patients in minutes, and have proved to be a reliable way to assess the nature and intensity of their pain.



Christoph Maier

Left to right, a whisker-like fibre, pin prick and thermal stimulus are used to test pain sensitivity as part of the quantitative sensory testing protocol.

But questionnaires do not objectively measure pain, nor can they zero in on the factors that trigger it. To provide such insights, Maier and other researchers affiliated with the German Research Network on Neuropathic Pain (DFNS) have devised a standardized battery of assessments known as quantitative sensory testing (QST). The QST protocol includes components such as hot and cold probes, to determine whether pain is triggered by thermal stimuli, and thin, whisker-like filaments that are applied to the skin to assess sensitivity to touch. “If you have somebody with allodynia, that small filament would feel painful,” says Ian Gilron, an anaesthesiologist at Queen's University in Kingston, Canada. QST can help researchers to measure the response of different types of sensory nerve, including both the small fibres that detect painful stimuli and the large ones that transmit information about movement and vibration. Although QST enables clinicians to measure and monitor pain symptoms, it is a labour-intensive process that requires extensive training. Furthermore, the variability in pain response across or even within individuals means that QST is better suited to identifying subgroups in a population than for diagnosing individuals.

Skin biopsies taken from the area of pain can provide a more detailed picture of what is happening at the tissue level. “You can demonstrate the loss of small fibres by directly counting how many free nerve endings can be found in the epidermis,” says Cruccu. He also advocates the use of tests that directly measure how well individual nerves function. Such techniques, says Cruccu, “provide objective measures unpolluted by cognitive biases”. Although this type of neurophysiological testing can reveal the nature of nerve damage, it requires costly, specialized equipment and expertise — and some of the more cutting-edge tools have yet to be validated for clinical use.


In search of subgroups

Researchers are still deciding how to rewrite the diagnostic rule book, but preliminary studies support the idea that a deeper assessment of pain symptoms can lead to more effective care. For example, in Sindrup's clinical trial1, although the team recruited patients with diverse neuropathic traumas, it used QST to identify common characteristics that might predict drug efficacy. The researchers found that people with nerves that had become hyper-responsive to temperature or physical probing — the 'irritable nociceptor' phenotype — were more than three times as likely to have pain relief from the anticonvulsant drug oxcarbazepine as those who had the non-irritable phenotype. This response also makes mechanistic sense: Sindrup and colleagues noted that oxcarbazepine blocks the sodium channel proteins that are responsible for nerve signalling, which could well be hyperactive in patients with irritable nociceptors.

This study is one of the few to select patients up front on the basis of pain characteristics, but others have applied similar techniques retrospectively. By using QST and skin-biopsy data collected during a trial of botulinum toxin A, which inhibits the firing of pain nerves, Attal and her colleagues found that people with both allodynia and a higher density of epidermal pain-sensing fibres were more likely to benefit from this treatment2. And a team led by Didier Bouhassira, a colleague of Attal's at Versailles, is preparing to report a study that re-examined data from 1,200 patients who previously participated in unsuccessful clinical trials for a heavily studied neuropathic pain drug. These findings offer hope for improved patient–drug 'matchmaking', whereby symptom profiles inform smarter trial design and help doctors to prescribe the treatments that are most likely to be effective.

Integrating data sets from multiple diagnostic approaches offers a way to improve this process. One such effort, by neurologist Roy Freeman at the Beth Israel Deaconess Medical Center in Boston, Massachusetts, and colleagues, analysed QST and NPSI data from past clinical trials to identify four distinct patterns of pain symptoms that seem to correlate in different groups of patients3. These profiles could be developed into 'fingerprints' for specific types of neuropathic injury by, for instance, connecting specific pain triggers such as pressure or cold with manifestations of pain such as stabbing or tingling sensations.

Researchers hope that such correlations will reveal information about the roots of pain pathology. A large European patient registry maintained by the DFNS and the public–private organization the Innovative Medicines Initiative (IMI) is enabling a more thorough hunt for such patterns. “It contains about 4,000 patients,” says Maier, who manages the data set as part of the IMI's Europain project. “It includes somatosensory profiles, clinical data, QST data, microscopy and skin-biopsy data and, in some cases, genetic data.”

Despite having only a handful of trials to serve as proof of concept, several consortia — including the US-based Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) — are planning on using these phenotyping tools in clinical trials. For now, most of the enthusiasm is coming from the academic sector; pharmaceutical companies expect much stronger evidence before taking on the additional cost. There is also the likelihood that more refined testing will shrink the patient population that drug companies can target with new analgesic drugs. “Instead of getting an approval for all of post-herpetic neuralgia, for example, they'd get one just for post-herpetic neuralgia with allodynia,” Rice says.

Nevertheless, according to Cruccu, a growing number of trials now use the quick questionnaires as a cost-effective fail-safe. Even if, overall, a trial seems unsuccessful, the availability of these data could enable a later search for specific subgroups in which efficacy can be demonstrated. Maier says that findings such as those from Sindrup's trial suggest that many 'failures' may be masking successes: small numbers of patients whose positive response to a drug is drowned out by the sea of people whose pain is poorly matched to the therapy being tested.

For now, the diagnostic tools available give only basic signposts for clinicians who treat people with neuropathic pain. But, given the dearth of effective treatments, even modest gains could have an outsized impact — especially once a next generation of analgesics enters the pipeline. “If there was a way to know who was most likely to respond to a drug and really focus on that in a clinical trial,” says Rice, “that would be magic.”

References


References•
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Demant, D. T. et al. Pain 155, 2263–2273 (2014).
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Attal, N. et al. Lancet Neurol. 15, 555–565 (2016).
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Freeman, R., Baron, R., Bouhassira, D., Cabrera, J. & Emir, B. Pain 155, 367–376 (2014).
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Michael Eisenstein is a freelance science writer based in Philadelphia, Pennsylvania.


http://www.nature.com/nature/journal/v535/n7611_supp/full/535S10a.html

Monday, 22 August 2016

Medical Cannabis For Nerve Pain: What Doctors Must Decide

Today's post from journalofethics.ama-assn.org (see link below) is an advisory article for doctors considering whether to prescribe medical cannabis for their neuropathic patients in severe pain. The article comes from 2013 and you probably don't need reminding that the case for medical marijuana use for chronic pain has become significantly stronger since then. It's an interesting and well-balanced article that will give us an insight into what considerations doctors must take before prescribing it but may also give you a little more confidence in deciding whether its a safe and/or desirable option in your own particular case. Worth a read.
 

Medicinal Cannabis and Painful Sensory Neuropathy
Igor Grant, MD
Virtual Mentor. May 2013, Volume 15,

Painful peripheral neuropathy comprises multiple symptoms that can severely erode quality of life. These include allodynia (pain evoked by light stimuli that are not normally pain-evoking) and various abnormal sensations termed dysesthesias (e.g., electric shock sensations, “pins and needles,” sensations of coldness or heat, numbness, and other types of uncomfortable and painful sensations). Common causes of peripheral neuropathy include diabetes, HIV/AIDS, spinal cord injuries, multiple sclerosis, and certain drugs and toxins. Commonly prescribed treatments come from drugs of the tricyclic and selective serotonin reuptake inhibitor (SSRI) antidepressant classes, anticonvulsants, opioids, and certain topical agents. Many patients receive only partial benefit from such treatments, and some either do not benefit or cannot tolerate these medications. The need for additional treatment modalities is evident.

Animal studies and anecdotal human evidence have for some time pointed to the possibility that cannabis may be effective in the treatment of painful peripheral neuropathy [1]. Recently, the Center for Medicinal Cannabis Research (CMCR) at the University of California [2] completed five placebo-controlled phase II clinical trials with smoked or inhaled cannabis [3-7]. Another study reported from Canada [8]. Patients included people with HIV neuropathy and other neuropathic conditions, and one study focused on a human model of neuropathic pain. Overall, the efficacy of cannabis was comparable to that of traditional agents, somewhat less than that of the tricyclics, but better than SSRIs and anticonvulsants, and comparable to gabapentin (see figure 1).


img1


Figure 1. Common analgesics for neuropathic pain.


*to achieve a 30% reduction in pain.

Number needed to treat (NNT) = 1/(E-P), where E is the proportion improved in experimental condition and P is the proportion improved on placebo. Example: If 60% “improve” (according to a given definition) in the experimental condition, while 30% “improve” in the placebo condition, then NNT = 1/(.6-.3) = 3.3. Data adapted from Abrams et al. [3] and Ellis et al. [4].

The concentrations of tetrahydrocannabinol (THC) in these studies ranged from 2 to 9 percent, with a typical concentration of 4 percent resulting in good efficacy. Side effects were modest and included light-headedness, mild difficulties in concentration and memory, tachycardia, and fatigue. Serious side effects (e.g., severe anxiety, paranoia, psychotic symptoms) were not observed. Mild cognitive changes resolved within several hours of drug administration.

While these were short-term trials with limited numbers of cases, the data suggest, on balance, that cannabis may represent a reasonable alternative or adjunct to treatment of patients with serious painful peripheral neuropathy for whom other remedies have not provided fully satisfactory results. Because oral administration of cannabinoids (e.g., as dronabinol, marketed as Marinol) can result in inconsistent blood levels due to variations in absorption and first-pass metabolism effects, inhalational (or potentially sublingual spray, e.g., nabiximols, marketed as Sativex) administration remains preferred to oral administration.

Cannabis as a smoked cigarette, while demonstrating efficacy, poses a number of challenges, inasmuch as it remains illegal under federal law, even though it is permitted in an increasing number of jurisdictions on physician recommendation. Figure 2 provides a schematic approach for physician decision making in jurisdictions where medicinal cannabis is permitted [9]. See figure 2 


http://journalofethics.ama-assn.org/2013/images/img2oped1-1305.jpg

This decision tree suggests key points that a physician should consider in making a determination. In the case of a patient assumed to have persistent neuropathic pain, the first determination to be made is that the patient’s signs and symptoms are indeed consistent with a diagnosis of neuropathy. Assuming a patient does not respond favorably to or cannot tolerate more standard treatments (e.g., antidepressants, anticonvulsants) and is willing to consider medicinal cannabis, the physician proceeds to compare risk and benefit. Among these considerations is whether the patient has a history of substance abuse or a serious psychiatric disorder that might be exacerbated by medicinal cannabis. Even the presence of such a risk does not necessarily preclude the use of medicinal cannabis; rather, coordination with appropriate substance abuse and psychiatric resources is necessary, and, based on that consultation, a risk-benefit ratio can be formulated. In patients for whom the ratio appears favorable, the physician should discuss modes of cannabis administration including oral, smoked, or vaporized. Once risks and benefits are evaluated and discussed with the patient, cannabis treatment may commence as with other psychotropic medications, with attention being paid to side effects as well as efficacy. Attention must also be paid to possible misuse and diversion, which can then trigger a decision to discontinue the treatment.

In summary, there is increasing evidence that cannabis may represent a useful alternative or adjunct in the management of painful peripheral neuropathy, a condition that can markedly affect life quality. Our society should be able to find ways to separate the medical benefits of making a treatment available to improve lives when indicated from broader social policy on recreational use, marijuana legalization, and unsubstantiated fears that medicinal cannabis will lead to widespread cannabis addiction [10-12].

References
Joy JE, Watson Jr SJ, Benson JA, eds. Marijuana and Medicine: Assessing the Science Base. Washington, DC: National Academies Press; 1999.
Center for Medicinal Cannabis Research. http://www.cmcr.ucsd.edu.
Abrams DI, Jay CA, Shade SB, et al. Cannabis in painful HIV-associated sensory neuropathy: A randomized placebo-controlled trial. Neurology. 2007;68(7):515-521.
Ellis RJ, Toperoff W, Vaida F, et al. Smoked medicinal cannabis for neuropathic pain in hiv: a randomized, crossover clinical trial. Neuropsychopharmacology. 2009;34(3):672-680.
Wallace M, Schulteis G, Atkinson JH, et al. Dose-dependent effects of smoked cannabis on capsaicin-induced pain and hyperalgesia in healthy volunteers. Anesthesiology. 2007;107(5):785-796.
Wilsey B, Marcotte T, Deutsch R, Gouaux B, Sakai S, Donaghe H. Low-dose vaporized cannabis significantly improves neuropathic pain. J Pain. 2013;14(2):136-148.
Wilsey B, Marcotte T, Tsodikov A, et al. A randomized, placebo-controlled, crossover trial of cannabis cigarettes in neuropathic pain. J Pain. 2008;9(6):506-521.
Ware MA, Wang T, Shapiro S, et al. Smoked cannabis for chronic neuropathic pain: a randomized controlled trial. CMAJ. 2010;182(14):E694-E701.
Grant I, Atkinson JH, Gouaux B, Wilsey B. Medical marijuana: clearing away the smoke. Open Neurology J. 2012;6:18-25.
Kleber HD, DuPont RL. Physicians and medical marijuana. Am J Psychiatry. 2012;169(6):564-568.
Harper S, Strumpf EC, Kaufman JS. Do medical marijuana laws increase marijuana use? Replication study and extension. Ann Epidemiol. 2012;22(3):207-212.
Grant I, Atkinson JH, Gouaux B. Research on medical marijuana. Am J Psychiatry. 2012;169(10):1119-1120.

Igor Grant, MD, is a professor and executive vice chair of the Department of Psychiatry and director of the HIV Neurobehavioral Research Program (HNRP) at the University of California, San Diego School of Medicine. Dr. Grant is the founding editor of the Journal of the International Neuropsychological Society and founding co-editor of the journal AIDS and Behavior.

http://journalofethics.ama-assn.org/2013/05/oped1-1305.html

Sunday, 21 August 2016

Nerve Damage Complications From Diabetes Mustn't Be Underestimated

Today's post from tudiabetes.org (see link below) is the story of a diabetes patient living with neuropathy (amongst other things) who is forced to lose a toe and it offers a salutary lesson in the consequences of certain life choices. The important thing is to avoid becoming diabetic in the first place but hey, that's easier said than done. Can't preach here but sometimes reading someone else's account of their medical history can shake you up a little and maybe persuade you to change a few things to make your health picture a little less alarming. The risk of losing parts of your feet due to neuropathic complications is all too real for some patients.


This little piggy
Roger212 Aug 3rd 2016

Diabetes Complications and other Conditions

I have never been a 'good' diabetic. Compliance with rules is just not in my nature. I was diagnosed in 1967, at the age of 18, after I had gone into hospital
for a relatively minor surgery. Two weeks after that diagnosis, I was
launched back into the world, scared and not completely sure of what
came next. The nurses had taught me all about doing injections, and I
had a shiny glass syringe and a box of one-time use needles. I also
had a diet booklet from the dietician, prescribing a 2,000 calorie
diet. Two thousand calories? Come on, I was a teenager. I ate 2,000
calories for breakfast.

Diabetes ended my plans for a military career, but I had finishing high school and getting into University to worry about, so I took my 16 units of Lente
insulin daily, avoided sweets and did pretty much what I wanted. In
those days we couldn't test for blood sugar, so we had to test for
urine sugar until the 90s. My tests always showed 4% or higher, the
highest a test could go. I saw my GPs mostly, although once in a
while they would send me to hospital for “stabilization.”

In my thirties I went through a period of heavy drinking. I don't know if it's coincidence, but it was at this time I lost the sight in my left eye. I went back
and forth between the right eye and the left eye for a few years, but
was blind in both eyes for only a week. I recovered most of my
eyesight through laser and a couple of actual eye surgeries, and a
very, very good ophthalmologist. This cost me a job, as my company
decided “your position is no longer required.” Yeah.


Skip ahead a few years, and I'm in my fifties, now equipped with human insulin and a blood glucose meter. My blood glucose management is better, but still not
good. In around 2005, I had my first foot infection. It involved my
left big toe and first toe, and they turned black. Due to the good
offices of the surgeon my GP sent me to, These toes recovered nicely,
and in six months or so looked as if they had never had a problem.

For several years I had recurring infections in toes on both feet. The usual course of events was that my toe or toes would turn black, and after antibiotics and frequent dressing changes they would slowly recover. I quickly knew
all of the staff at the wound clinic by their first names, and they
treated me wonderfully, and still do today.

So, at this point I had racked up neuropathy, nephropathy, retinopathy, cataracts, heart disease, a strange condition that gives me vertical double vision, mild liver and kidney problems, and arthritis. That last one may not
be due to diabetes, as it runs in my family. Oh! Oddly enough, I
suffer from depression, although I am medicated and able to hold it
at bay, but I don't smile much.

My last toe problem occurred in 2013 on a trip, at Heathrow airport. I was travelling with my daughter who was on a business trip to Paris and London. She noticed blood on the floor when I came out of the bathroom in the
morning. My right big toenail had become detached, and we dealt with
it with some bandaids my daughter had, and bought some supplies when
we got to Paris. I limped through the rest of the trip, and got back
to the wound clinic, where the doctor saved me again.
I continued to go to the wound clinic monthly for medical pedicures. They handed that job off to a podiatrist who shares office space with the clinic. At one of these pedicures, in March this year, the podiatrist discovered a
sore on the end of my middle right toe.

So now it was back to the wound clinic for antibiotics and dressing changes. After two months, I brought up the possibility of an amputation, as we seemed to be getting nowhere with the toe. Furthermore, I was having considerable
pain from the toe. The doctor wanted to wait awhile, but in June
X-rays revealed that the bones in the toe were fully infected. So we
agreed on an amputation, and set the following Wednesday, June 22, as
the date.

I had thought the process of amputation would require some fanfare – a hospital stay, hospital food, pretty nurses, all that. However, it was done in the
clinic, on the same cot I lie on for dressing changes or pedicures.
The doctor took off the dressing, wiped the toe down and gave me some
local anaesthetic. Then, while we chatted back and forth, he
cheerfully removed the toe. No pain, no fuss. I saw the toe go into a
specimen jar, and called out, “Wait, wait! I've changed my mind!”

The doctor said, “Ya want me to put it back? Too late!” and we all had a laugh. They are used to me at the clinic. In a matter of minutes the wound was
bandaged, and I walked out of the clinic with a note to come back at
7:30 the following morning. I had walked into the clinic at 7:25, and
walked out at 7:50, less one toe, but the pain from the toe was gone,
and stayed gone.

Along with my family and friends we came up with a bunch of jokes about only being able to count to 19, having difficulty playing “This little piggy.” After
all, do you drop the one that had roast beef, or the one that had
none, or go to the fourth toe and say “This little piggy had tofu,”
because then the next little piggy wouldn't want any, and could go
“Wee, wee...” oh, never mind!

All jokes aside, it isn't easy to give up a toe. It seems like a small thing, and I recognized the necessity, but when it got down to the crunch, I felt saddened. I
have known for fifty years that something like this could happen.
Thank God that I have made it this far without going blind, as has
happened to people I know. I also know people who have lost legs.
Some of those have subsequently lost their lives, so I know it could
be worse, and could get worse. But as I mentioned, I suffer from
depression, and am beginning to do a lot of sitting around with time
to think.

The wound appears to be healing well, and it seems by mid August it will be healed. This
should allow me to return to my activities such as woodwork,
swimming, walking and maybe even riding my bicycle, but two weeks ago
the doctor showed me X-rays that show the second toe is infected in
the bone, and therefore must go, too. So, the piggy that stayed at
home is to be evicted.


This did not improve my mood. It puts my recovery off until late September, and cancels any thoughts I may have had of doing much this summer. I spent a week with my daughter recently, and had to do my own dressing changes,
which is something I am unwilling to repeat. I should be able to
dance at my daughter's wedding on October 1 if nothing else goes
awry. I thought at one time that removing the toe would be the end of
the problem for now, but of course that is not true. I now have to
deal with the possibility of losing half a foot, and after that, half
my lower leg.


I try not to sit around dwelling on the problem or its infinite possibilities. There are things I can do, and I do them. I am trying to be careful about my
bgs, and waiting for the day when the doctor says, “There, Roger!
You're all healed. You don't have to come back here any more.” That
will be the best present I could have.

I said at the outset that I have not been a 'good' diabetic, but I'm still here after 50 years.

I know I have done things wrong during the course of this whole
thing, and I don't need to hear about it. The thing a diabetic
doesn't need to hear when faced with complications is, “You could
have prevented this if....” This is just my experience of losing a
toe. Whether you see it as inspiration or cautionary tale is up to
you. I hope you have gained something from it.

LATE BREAKING NEWS!

Just before submitting this, I saw the doctor at the clinic, and he thinks my second toe may get better, so we are holding off removing it until it gets a chance to improve. So, the second piggy has a stay of execution. We'll wait
and see.

Roger N. Tulk (Roger212)
 
http://www.tudiabetes.org/forum/t/this-little-piggy/55179