Someone emailed requesting a blog on peripheral neuropathy. It is particularly long and tedious to read if you do not suffer with this condition, but those who do may find some of the information applicable or valuable. Please let me know if this is the case or if you have anything to add which has helped you with your symptoms, particularly if PN is idiopathic.
The chronic experience of tingling, burning or pain in your hands, toes, feet or legs, or no feeling at all, can be very frustrating, especially in temperature extremes. Approximately 20 million people have some form (over 100 types) of this condition where, in simple terms, there is a disruption in signaling between the central nervous system and body. Depending on whether the autonomic, motor and/or sensory nerves are involved, people will present with different or most of the following symptoms: The 1st or autonomic type may experience nausea, difficulty swallowing, blood pressure issues (i.e., orthostatic hypotension), incontinence, digestive upsets and vertigo or the 2nd (motor) with muscle atrophy, cramping and weakness and decreased reflexes, and 3rd (sensory) with paresthesia, uncoordination (lack of position sense), or pain. Possible causes: Often in the past, one may have experienced some kind of traumatic injury (mechanical, thermal or chemical) or an infection (viral or bacterial) or there is an existing endocrine or metabolic disorder such as diabetes or liver disease. Chronic exposure to the following could lead to nerve damage: Insecticides and solvents, specific pharmaceuticals, alcohol abuse, and heavy metal exposure, (including The Jimi Hendrix Experience, Metallica, or Alice Cooper….sorry, couldn’t resist). Severe edema of the extremities can also exert undo pressure on the peripheral nerves. Cardiovascular disease, hypothyroidism or autoimmune diseases (lupus, rheumatoid arthritis) may be underlying factors which may lead to nerve damage. Kidney disease can allow toxins to build over time which could damage the nerves. Most often the symptoms equally affect both sides of the body, which is referred to as polyneuropathy.
Chronic inflammatory polyneuropathy is caused by damage to the myelin sheath (vs degeneration of the axons) of the peripheral nerves and is closely related to Guillain-Barre syndrome. One can also have damage to both the axon and myelin sheath. Usually prednisone is the drug of choice along with the use of immunosuppressant medications.
Treatment modalities: Other than prednisone or the use of other drugs, there are several remedies which can give temporary relief. Physiotherapy can aid all types of PN through compensatory strategies which may improve muscle strength and mobility and minimize the shrinkage of muscles and tendons. Some of the specific treatments include thermal modalities, soft-tissue techniques, electrical stimulation, spinal and peripheral mobilizations, vibration platforms, ultrasound, balance systems and force plates, functional activities, near infrared phototherapy and individualized exercises. These treatments are used to help alleviate symptoms. If the underlying cause is diabetes or another health issue which can be quickly addressed, then there is hope of reversing the disease if caught in very early stages.
I found an old study which discussed topical thermal modalities used to improve local circulation and metabolism, neuromuscular and tendon function, and nociception, where pain receptors (nociceptors) may respond to tissue damage. Local topical heat application is more accepted by the patient than cold application, but the cold application had greater potential for restoration if used short term. Application of heat, for example, increases metabolic activity, which increases circulation, but the downside is that is can exacerbate inflammation; the cold application had the opposite effect. Cryotherapy has a cooling action on the tissues and is commonly used for injuries or maintaining hair growth during chemotherapy by decreasing the amount of drug reaching the nerves during infusion. Used in small areas for a short period, it can increase circulation, but will decrease blood flow if used in large areas of the body. For the most part, cryotherapy uses a probe which is inserted into tissue next to the affected nerve which is causing pain. The freezing inactivates the primary nerve which relieves the irritation; this is not indicated for neuropathy, in general, but more for neuromas and pinched nerves. Low Level Light Therapy or Cold Laser Therapy can also increase blood flow to tissues, as well.
Another treatment called anodyne monochromatic infrared photo energy, usually performed at home, was not shown to improve the quality of life, sensory neuropathy or nerve conduction when used over a 3 month period. This infrared light therapy can, however, possibly increase blood flow to the areas and stimulate nerve function. Many people feel it has helped them, so it wouldn’t hurt to try this modality of treatment (minimum of 25 sessions) since it is approved by the FDA and most insurance companies and has no major side effects if used properly.
Soft Tissue Therapy uses massage or manipulation of muscles and fascia in order to stretch and relax muscle fiber and tissue structures. Once an assessment is performed, the therapist will define the trigger points and target those areas in order to alleviate pain, swelling and tight hypertonic muscles, all which increase circulation to the areas.
Medications used most often for PN are antidepressants (amitriptyline, doxepin, nortriptyline or imipramine), anticonvulsants (such as gabapentin and pregabalin), anti-arrythmia meds (mexiletine) and as a last resort, narcotics. Serotonin and norepinephrine inhibitors, such as duloxetine and venlafaxine may ease the pain, particularly if you are a diabetic. Topical applications of lidocaine or capsaicin can be used for localized pain. Foot braces or orthopedic shoes may help compensate for gait disturbances. Acupuncture, meditation, reflexology, yoga and massage have also been shown to provide relief.
If there is an underlying condition such as an autoimmune system disorder which causes neuropathic symptoms, then medications such as prednisone, cyclosporine, mycophenolate and azathioprine may help. Relief from demyelinating polyneuropathy could come in the form of intravenous immunoglobulin and plasma exchange, also. Transcutaneous electrical nerve stimulation (TENS) delivered daily for 30 minutes may help. If no relief is found, then discontinue after one month. Of course, physical therapy can improve weak muscles, as can surgery for nerve pressure or impingement.
The use of whole body vibration therapy caught my eye since I had never heard of it before for PN. A case study with a diabetic patient utilized this therapy after failed trials with pharmaceuticals and interventional pain management. Each session consisted of 4 bouts of 3 minute vibrations. The outcome measures after 4 weeks showed a significant acute pain reduction with no side effects. Its main function is to relax and stimulate the musculo-skeletal and nervous systems, which in turn may relieve neuropathic pain in the extremities.
The Mayo Clinic mentions that Alpha Lipoic Acid has been used for years in Europe as a therapeutic adjunct for PN. Begin with a low dose (100 mgs) and increase over time to 600 mgs. per day. Diabetics must watch for hypoglycemic episodes while increasing the dosage. Alpha Lipoic Acid is known to protect the microcirculation to the nerves. These extremely small microcirculatory blood vessels deliver oxygen and nutrients while the mediators of dilation (nitric oxide, prostaglandins and hydrogen peroxide) aid in dilation within subcutaneous adipose tissue. Impairment of nitric oxide, in particular, has been attributed to increased vascular oxidative stress, which contributes to endothelial dysfunction, closely related to neuropathy and foot ulceration. Another study suggested that ALA has therapeutic potential in diabetics who have depleted antioxidant defenses. As an aside, being obese significantly increases the risk of sensory type neuropathy and decreased compound muscle action, possibly due to a metabolic alteration. ALA has been noted to improve neuropathic deficits and is important to cellular energy production plus it helps to reduce oxidative by-products which can be harmful to cells.
Evening Primrose Oil has shown promise, as has the amino acid Acetyl-L-Carnitine for neuropathic conditions. Omega 3 Fatty Acids (fish or flaxseed oils) may reduce inflammation and increase blood flow to the extremities. Certain B vitamins are also recommended, particularly if chemotherapy can induce the neuropathy. Pyridoxine (B6) taken in a 25 – 100 mg. dose may provide some relief with most types of neuropathy. Also check blood levels of vitamin B 12 to make sure it is within the normal range.
Benfotiamine is an interesting fat soluble form of thiamine (vitamin B1) in that is aids in blocking the biochemical pathways by which high blood glucose can damage cells within the body. With the highest doses of 320 mgs per day, a study showed an overall beneficial therapeutic effect on neuropathy status with significant improvement in pain and vibration sensations and current perception threshold (becoming aware of sensory nerve conduction and function integrity) on the peroneal nerve, a branch of the sciatic nerve supplying movement and sensation to the lower limbs. Benfotiamine may also aid in the lowering of advanced glycation end products (AGE) which can damage proteins, such as collagen, the major structural protein in connective tissue which is easily susceptible to damage. Test tube studies showed that benfotiamine prevented AGE formation in endothelial cells cultured in high glucose and improved kidney function with those in end-stage renal failure. A trial with diabetics suffering with neuropathy experienced a significant improvement in nerve conduction velocity from the feet with no adverse effects.
Research has shown that a low-fat, high fiber vegan diet is helpful and in one study brought pain relief to 81% of diabetic participants. Many were able to reduce both their diabetes and blood pressure medications. Otherwise a healthy diet should consist of low fat meats and dairy products, vegetables, fruits, whole unprocessed grains, nuts and seeds, and legumes, unless you are sensitive to any particular foods.
As you can see, it took many days to pull from a large number of research sources and I tried to cover every conceivable angle which hopefully included some information which will be useful to you. It is a difficult condition, but many have alleviated some of their pain using one or several of these treatments.
-Jane Alise
References: (Some are out-of-sequence, but easy to correlate from text. Need to get this out and it’s not a graduate research paper, thank goodness. So glad those days are over.)
~National Institute of Neurological Disorder & Stroke. Article, NINDS Chronic Inflammatory Demyelinating Polyneuropathy, found at http://ninds,nih.gov.
~Hoitsmas, E., Reulen, J. P. H., deBaets, M., Drent, M., Spaans, F. C., & Faber, G. C. (2004). Small fiber neuropathy: A common and important clinical disorder. Journal of Neurological Sciences, 227 (1): 119 – 130. doi:10:1016j.jns.2004.08.12
~Dana Farber Institute, “Alleviating Peripheral Neuropathy Symptoms.” Found at http://www.dana-farber.org/Health-Library/Alleviating-Peripheral-Neuropathy-Symptoms.aspx.
~The Foundation for Peripheral Neuropathy.
~Nannerman, D. (1991). Thermal modalities heat and cold. A review of physiologic effects with clinical applications. American Association of the Occupational Health Nurse, 39 (2). 70-75.
~Lavery, C. A., Murdock, D. P., Williams, J., & Lavery, D. C. (2007). Does anodyne light therapy improve peripheral neuropathy in diabetes? A double-blind, sham-controlled, randomized trial to evaluate monochromatic infrared photoenergy. Diabetes, Care, 31 (2). 316-321.
~Peripheral Neuropathy Information Page: National Institute of Neurological Disorders and Stroke article found at: http://www.ninds.nih.gov/disorders/peripheralneuropathy/peripheralneuropathy.hm.
~Hong, J., Barnes, M., & Kessler, N. (2013). Case study: use of vibration therapy in the treatment of diabetic peripheral small fiber neuropathy. Journal of Bodywork and Movement Therapies, 17 (2), 235 – 238.
~http://www.mayoclinic.org/diseases-conditions/peripheral-neuropathy/basics/alternative-medicine/con-20019948.
~Heitzer, T., Finckh, B., Albers, S., Krohn, K, Kohischutter, A., & Meinertz, T. (2001). Beneficial effects of alpha-lipoic acid and ascorbic acid on endothelium-dependent, nitric oxide-mediated vasodilation in diabetic patients: Relation to parameters of oxidative stress. Free Radical Biology Medicine, 31 (1), 53-61.
~Robinson, A., & Grizelj, I. (2015). Visceral adipose microvascular function in morbid obesity; A pathway to disease. Microcirculation, 22 (1). Found at http://microcirc.org.
~Miscio, G., Guastamacchia, G., Brunani, A., Priano, L.,Baudo, S., & Mauro, A. (2005). Obesity and peripheral neuropathy risk; A dangerous liaison. Journal of Peripheral Nervous System, 10 (4). 354-358.
~Winkler, G., Pal, B., Nagybeganyi, E., Ory, I., Porochnavec, M., & Kempler, P. (1999). Effectiveness of different benfotiamine dosage regimens in the treatment of painful diabetic neuropathy. Drug Research Journal, 49 (3), 220 – 224.
~Nannerman, D. (1991). Thermal modalities: heat and cold. A review of physiologic effects with clinical applications. American Association of the Occupational Health Nurse, 39 (2). 70 – 75.
~Lavery, L. A., Murdoch, D. P., Williams, J., & Lavery, D. C. (2007). Does anodyne light therapy improve peripheral neuropathy in diabetes? A double-blind, sham-controlled, randomized trial to evaluate monochromatic infrared photoenergy. Diabetes Care, 31 (2). 316 – 321.
Peripheral Neuropathy Information Page: National Institute of Neurological Disorders and Stroke article found at: http://www.ninds.nih.gov/disorders/peripheralneuropathy/peripheralneuropathy.hm.
~DINE study (Dietary Intervention for chronic diabetic NEuropathy pain)