Painful Peripheral Neuropathy

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Hi Folks,

I received an email from a potential patient last night and as she is complaining about burning and excruciating pain, which is one of my pet hates and weaknesses :bang:, i thought i'd seek some advice before she comes in for a consult. this is her email:

Dear Byron Starkey

I would very much like to come and visit you in your rooms as I am suffering with terrible feet condition and if you will take the time to read this letter, I would be most grateful.

I have been experiencing excruciating pains in both feet for 3 years now and I have been diagnosed with Peripheral Neuropathy. I have seen a Neurologist and an Endroconologist and have even been to the pain clinic in hope of curing my condition. I was unable to get any relief from any of these specialists and I am presently taking Lyrika twice daily which was recommended by my GP but even this is not helping? I take Trepline at night as well as a sleeping tablet and I still have no relief from the constant pain and even with the little sleep that I manage to get I am moaning in my sleep continuously. The constant burning and pain in my feet keeps me awake most of the time and I get very little sleep. The pain is constantly there and it is affecting my life both physically and mentally. It feels like some one is pricking me all over the pads and toes with hot pokers and my feet burn all the time.

I am really desperate to get some kind of relief and to be pain free - do you think you will be able to help me? I am neither a doctor nor a specialist but surely there must be a cure of some sort that can help?

As you can see by reading my email, I am very desperate for help and to have a quality of life. The lack of sleep and constant pain is really depressing and I sincerely hope that you are able to help.

Please can you give me your opinion on this matter?

Thank you.

I look forward to hearing from you.

Kind regards.

M.d.P



So guys, give me your opinion.... where to from here?
She has not said that she's diabetic, i don't know about her circulatory status, footwear that she wears, previous surgeries, allerigies or other meds she may be taking.

Any help would be greatly appreciated!

Cheers:drinks
Byron

 

Re: Peripheral Neuropathy

Welcome to the club. I have been fighting a similar problem for 20 years. But about 55 years ago, the nerves in the bottom of my feet were damaged but only hurt when standing or walking. But then the pain became chronic and started to move up my legs, eshpecially teh calve are. Sort of like charlie horse pain there. I was then diagnosed as having periphersl neuropathy as I had high arches. But no genetic link was found so the neuropathy was of the acquired type and related to the nerve damage in my feet, similar to diabetics. Just this year, another neurologist had a skin biopsy done and it came back as severy small fiber neuropathy. For the past 20 years, I went thru various meds from Motrin, Naproxin, and the Tramadol of 2 each 50 mg 4 times a day worked quite well until about 2 years ago. Then I added Gapentin to my list and I take 1800 mg per day now along with the tramadol. I am functional most of the time now, but still have some bad days. I am not a diabetic

 

Re: Peripheral Neuropathy

I doubt you can offer this patient much to work with.

As you know, there are multiple causes for painful peripheral neuropathy. Given this patient is seeing an endocrinologist, then it is highly likely they have Type 1 or 2 diabetes. Strict control of blood glucose levels is therefore essential, as wide fluctuations (particularly up to 20mmol/l) will aggravate the situation. Tight conrol reduces symptoms in most situations.

Unfortunately there is little that can be done to 'cure' painful PN. Most treatments are aimed at reducing the impact of the symptoms on quality of life. Lyrica, gabapentin, amitriptylline and other tricyclic and SSRI antidepressants are the usual mainstay of care. Sometimes it resolves spontaneously.

However, don't 'assume' that diabetes is the only issue at hand. There is a wide differential diagnosis list for PN - look up 'DANG THERAPIST' for a list of possibilities.
If you can get the right people involved (neurology, pain clinic) then this will be the most helpful path to follow.

LL

 

Re: Peripheral Neuropathy

check the medication with your own eyes, double check the advice and that its been adhered to, rule out other diagnosis, try pain clinic, only other options with limited sucess but worth a try acupuncture (from a pod or chinese expert). opsite spray left to build up for 6 weeks at least,.... try physio colleagues....its a toughie not least for the sufferer

 

Re: Peripheral Neuropathy

Hi Byron,

If this patient presented to me, I would apply Opsite to both feet from the base of the toes to the malleoli. Use Fixomul or similar to secure the proximal and distal adges, and some around the heel and ball of the foot (higher wear areas). The fixomul just keeps the Opsite on. When you apply the Opsite, use slight tension. Get the patient to leave on for one week. Call them a week after that to see how they got on. This may (or may not - doesn't work for everyone) reduce / eliminate the paraesthesias. Some get relief only while its on then the paraesthesias return on removal. Others get long term relief even once removed. Its easy to do and worth a try in my opinion.

If that failed, I would try acupuncture, I have had some success with this, again though, doesn't work with everybody.

Plus the other things mentioned in the posts above.

Good luck.

Rebecca

 

Re: Peripheral Neuropathy

Topical capsciacin, Opsite etc are usually only useful for superficial allodynia type PN. Deep lancinating symptoms are not typically helped with these approaches.

I have had limited success with these over the years, and patient compliance is usually troublesome. Lyrica appears to be the drug of choice these days...

LL

 

Hey Guys,

Thank-you so much for all your opinions, the patient will probably see me sometime next week and i'll keep you updated on the progress!

Cheers
Byron

 

I have been using a topical application of Neurogen:

http://www.purebodysolutions.com/Merchant2/merchant.mvc?page=PC/CTGY/OB

In my non responsive clients. This has mixed results but has worked in numerous clients with severe neuropathic pain where most oral drugs have failed.

regards

 

The patient MDP (Byron Starkey) presents with difficult symptoms of painful peripheral neuropathy. This raises several questions:small fiber vs large fiber? Have contributing causes such as diabetes, hypothyroidism, anemia, Lumbar nerve compression, tarsal tunnel syndrome, interdigital neuoma been ruled out?? Lumbar MRI?? Labwork including ANA? In my practice, we see patients with neuropathies and roughly 60% have underlying cause (we refer for neuro consult, EMG, NCV), and 40% idiopathic. Generally our approach (prior to the Lyrica-Gabapentin-Cymbalta options) is topical treatment ( + oral where indicated). Topical treatment of Neurogen has been suggested and has been very promising in our experience. Placement of this can be either over the tarsal tunnel-deep peroneal-sural nerves and/or over the interdigital spaces. Also, we have utilzed various combinations of topical comp0unded PLO gel + Lidocaine, Ketoprofen, Ketamine - again small areas of treatment TID and monitorig for skin irritation. Generally well tolerated. Also topical Biofreeze, EMLA (small surface areas), topical Lidoderm 5% small patch over a few "hot spots" are some other approaches. Small fiber neuropathy , especially in diabetic patients and confirmed by 3 mm skin punch biopsy has shown some clinical symptomatic improvement according to recent work by Allen Jacobs DPM and Mackie D.P.M. --they found some lessening of paresthetic symptoms with oral Metanx (L-methylfolate) taken once or twice daily which has been our finding as well. Other oral approaches for neuropathy have been Benfotiamine, alpha lipoic acid. John A Senneff has published a series of 3 books on neuropathy which may be useful.

I believe it is important to determine etiology(ies) if possible, and rule out "double crush" from tarsal tunnel etc. Address biomechanics if contributory. Go after specific anatomic areas or nerve "trunks" with topicals. Not trying to be exhaustive in this post, just putting forth a few ideas for thought/discussion. All the best in 2010.

 

Hi Guys, difficult problem - painful peripheral neauropathy. Just a thought - have had patients using many of the quoted treatments. Some patients don't like the heavy drug therapies due to their side effects . This is especially true if the person is elderly and living alone. The opsite has worked for a time in some cases. Have recently been trying a TENS (Circulation Booster) to reduce symptoms to help sleeping in one idiopathic PN patient. Must also agree that exercise in the afternoon seems to help aswell. Has Anyone else tried the TENS to control symptoms? There are some research papers suggesting that it can take up to six months to show improvements. Any comments?

 

Folks
re painful neuropathy in diabetes and LL's post - is there actually evidence that improved glycaemic control leads to reduction of symptoms, especially in the short term? Clearly there are countless reasons why glycaemic control should be optimised, especially terms of avoidance of neuropathy in the first place. I've come across instances of where patients' glycaemic control has improved dramatically over a short period and this has triggered painful symptoms. I'm not doubting that in order to facilitate a reduction in symptoms in the long run then glycaemic control is an important factor, just that i'd temper expectations of a reduction in blood glucose levels and their variance leading to any perceptible improvement in symptoms in the initial months. Experience suggests it takes a very long time.


Cheers

 

benfotiamine has reduced pain level .Have used solo or in combo with lyrica . patients appreciate the lack of side affects or drug interaction.

 

Byron,
If it was me I would run new pathology ( if they did not have recent ones), this way you can rule out other nasties. As you would do with all of your patients a circulatory examination of the feet, including all of her pulses could be a start. Rule out Family history..are the soles of her feet smooth and with no blemishes, I would ascertain how her activies of daily living comprise of...Of course rule out diabetes...maybe it could be incorrect footwear...Is the Patient obese - (without being nasty)...does she do anything to help herself ...other than complaining such as regular gentle exercise... and I would also exclude all other connective tissue disorders.. and lastly review her medications thoroughly - prescribed or non prescribed and do we take other drugs or substances.... Hoping this helps
Rescued.

 

I recently had a patient who complained of terrible cramps and burning sensations in her feet and legs when trying to sleep.
I wasnt sure of the burning sensations and attributed it to some form of peripheral neuropathy associated to her diabetes.
I suggested dry needling of some foot muscles and gastroc/soleus to try and help with the cramps.
She came back 2 weeks later and had been able to sleep without the burning sensation and cramp free for the 1st week. She was beginning to feel some burning again but not as bad as previously. So I dry needled her again and will await the outcome

 

Sorry to hijack the these
Am

 

Sorry to hijack the thead
Any where to learn dry needling in Melbourne ? Short course etc

 

Press Release:
How does exercise affect nerve pain?
Experiments show exercise-related reductions in neuropathic pain and inflammatory mediators

 

Press Release:
Putting a block on neuropathic pain before it starts
Liposomes packed with local anesthetic could block the nerve signals that reprogram pain centers and cause chronic, debilitating pain

 

Hey Byron - Janine from Hillcrest

Also rule out heavy alchohol usage (not necessarily alcoholism) and Vit B/folic acid deficiency.

I have also had a few cases of this so-called "idiopathic PN". I start off small by asking them to exercise more and to use something like ReCharge Your Feet (available in Dischem). I also give them a little blurb about which foods to eat more of in order to increase their vit B/folic acid content in their diets. IF they are willing to go through the pain of vit B injections, i ask them to go for a Neurobion injection once a week until the acute symptoms have settled down, thereafter only once a month.

I am also a believer in holistic healing such as tissue salts, acupuncture and reflexology.

See you at the next get together!