What Do We Know About Chronic Pain

Today's post is the third in a series from 4therapy.com (see link below), which looks at the psychological aspects of having neuropathy and other forms of chronic pain. This one looks at pain itself, what it does and why it happens. It also considers various options for tackling pain in the future - a very useful guide to understanding your pain.

A Pain Primer: What Do We Know About Pain?
Source: National Institute of Neurological Disorders and Stroke

We may experience pain as a prick, tingle, sting, burn, or ache. Receptors on the skin trigger a series of events, beginning with an electrical impulse that travels from the skin to the spinal cord. The spinal cord acts as a sort of relay center where the pain signal can be blocked, enhanced, or otherwise modified before it is relayed to the brain. One area of the spinal cord in particular, called the dorsal horn, is important in the reception of pain signals.

The most common destination in the brain for pain signals is the thalamus and from there to the cortex, the headquarters for complex thoughts. The thalamus also serves as the brain's storage area for images of the body and plays a key role in relaying messages between the brain and various parts of the body. In people who undergo an amputation, the representation of the amputated limb is stored in the thalamus.

Pain is a complicated process that involves an intricate interplay between a number of important chemicals found naturally in the brain and spinal cord. In general, these chemicals, called neurotransmitters, transmit nerve impulses from one cell to another.

There are many different neurotransmitters in the human body; some play a role in human disease and, in the case of pain, act in various combinations to produce painful sensations in the body. Some chemicals govern mild pain sensations; others control intense or severe pain.

The body's chemicals act in the transmission of pain messages by stimulating neurotransmitter receptors found on the surface of cells; each receptor has a corresponding neurotransmitter. Receptors function much like gates or ports and enable pain messages to pass through and on to neighboring cells. One brain chemical of special interest to neuroscientists is glutamate. During experiments, mice with blocked glutamate receptors show a reduction in their responses to pain. Other important receptors in pain transmission are opiate-like receptors. Morphine and other opioid drugs work by locking on to these opioid receptors, switching on pain-inhibiting pathways or circuits, and thereby blocking pain.

Another type of receptor that responds to painful stimuli is called a nociceptor. Nociceptors are thin nerve fibers in the skin, muscle, and other body tissues, that, when stimulated, carry pain signals to the spinal cord and brain. Normally, nociceptors only respond to strong stimuli such as a pinch. However, when tissues become injured or inflamed, as with a sunburn or infection, they release chemicals that make nociceptors much more sensitive and cause them to transmit pain signals in response to even gentle stimuli such as breeze or a caress. This condition is called allodynia -a state in which pain is produced by innocuous stimuli.

The body's natural painkillers may yet prove to be the most promising pain relievers, pointing to one of the most important new avenues in drug development. The brain may signal the release of painkillers found in the spinal cord, including serotonin, norepinephrine, and opioid-like chemicals. Many pharmaceutical companies are working to synthesize these substances in laboratories as future medications.

Endorphins and enkephalins are other natural painkillers. Endorphins may be responsible for the "feel good" effects experienced by many people after rigorous exercise; they are also implicated in the pleasurable effects of smoking.

Similarly, peptides, compounds that make up proteins in the body, play a role in pain responses. Mice bred experimentally to lack a gene for two peptides called tachykinins-neurokinin A and substance P-have a reduced response to severe pain. When exposed to mild pain, these mice react in the same way as mice that carry the missing gene. But when exposed to more severe pain, the mice exhibit a reduced pain response. This suggests that the two peptides are involved in the production of pain sensations, especially moderate-to-severe pain. Continued research on tachykinins, conducted with support from the NINDS, may pave the way for drugs tailored to treat different severities of pain.

Scientists are working to develop potent pain-killing drugs that act on receptors for the chemical acetylcholine. For example, a type of frog native to Ecuador has been found to have a chemical in its skin called epibatidine, derived from the frog's scientific name, Epipedobates tricolor. Although highly toxic, epibatidine is a potent analgesic and, surprisingly, resembles the chemical nicotine found in cigarettes. Also under development are other less toxic compounds that act on acetylcholine receptors and may prove to be more potent than morphine but without its addictive properties.

The idea of using receptors as gateways for pain drugs is a novel idea, supported by experiments involving substance P. Investigators have been able to isolate a tiny population of neurons, located in the spinal cord, that together form a major portion of the pathway responsible for carrying persistent pain signals to the brain. When animals were given injections of a lethal cocktail containing substance P linked to the chemical saporin, this group of cells, whose sole function is to communicate pain, were killed. Receptors for substance P served as a portal or point of entry for the compound. Within days of the injections, the targeted neurons, located in the outer layer of the spinal cord along its entire length, absorbed the compound and were neutralized. The animals' behavior was completely normal; they no longer exhibited signs of pain following injury or had an exaggerated pain response. Importantly, the animals still responded to acute, that is, normal, pain. This is a critical finding as it is important to retain the body's ability to detect potentially injurious stimuli. The protective, early warning signal that pain provides is essential for normal functioning. If this work can be translated clinically, humans might be able to benefit from similar compounds introduced, for example, through lumbar (spinal) puncture.

Another promising area of research using the body's natural pain-killing abilities is the transplantation of chromaffin cells into the spinal cords of animals bred experimentally to develop arthritis. Chromaffin cells produce several of the body's pain-killing substances and are part of the adrenal medulla, which sits on top of the kidney. Within a week or so, rats receiving these transplants cease to exhibit telltale signs of pain. Scientists, working with support from the NINDS, believe the transplants help the animals recover from pain-related cellular damage. Extensive animal studies will be required to learn if this technique might be of value to humans with severe pain.

One way to control pain outside of the brain, that is, peripherally, is by inhibiting hormones called prostaglandins. Prostaglandins stimulate nerves at the site of injury and cause inflammation and fever. Certain drugs, including NSAIDs, act against such hormones by blocking the enzyme that is required for their synthesis.

Blood vessel walls stretch or dilate during a migraine attack and it is thought that serotonin plays a complicated role in this process. For example, before a migraine headache, serotonin levels fall. Drugs for migraine include the triptans: sumatriptan (Imitrix®), naratriptan (Amerge®), and zolmitriptan (Zomig®). They are called serotonin agonists because they mimic the action of endogenous (natural) serotonin and bind to specific subtypes of serotonin receptors.

Ongoing pain research, much of it supported by the NINDS, continues to reveal at an unprecedented pace fascinating insights into how genetics, the immune system, and the skin contribute to pain responses.

The explosion of knowledge about human genetics is helping scientists who work in the field of drug development. We know, for example, that the pain-killing properties of codeine rely heavily on a liver enzyme, CYP2D6, which helps convert codeine into morphine. A small number of people genetically lack the enzyme CYP2D6; when given codeine, these individuals do not get pain relief. CYP2D6 also helps break down certain other drugs. People who genetically lack CYP2D6 may not be able to cleanse their systems of these drugs and may be vulnerable to drug toxicity. CYP2D6 is currently under investigation for its role in pain.

In his research, the late John C. Liebeskind, a renowned pain expert and a professor of psychology at UCLA, found that pain can kill by delaying healing and causing cancer to spread. In his pioneering research on the immune system and pain, Dr. Liebeskind studied the effects of stress-such as surgery-on the immune system and in particular on cells called natural killer or NK cells. These cells are thought to help protect the body against tumors. In one study conducted with rats, Dr. Liebeskind found that, following experimental surgery, NK cell activity was suppressed, causing the cancer to spread more rapidly. When the animals were treated with morphine, however, they were able to avoid this reaction to stress.

The link between the nervous and immune systems is an important one. Cytokines, a type of protein found in the nervous system, are also part of the body's immune system, the body's shield for fighting off disease. Cytokines can trigger pain by promoting inflammation, even in the absence of injury or damage. Certain types of cytokines have been linked to nervous system injury. After trauma, cytokine levels rise in the brain and spinal cord and at the site in the peripheral nervous system where the injury occurred. Improvements in our understanding of the precise role of cytokines in producing pain, especially pain resulting from injury, may lead to new classes of drugs that can block the action of these substances.

http://www.4therapy.com/life-topics/chronic-pain/pain-primer-what-do-we-know-about-pain-2860

About Homeopathic Medicines

Regarding action of the medicines: Unlike other systems of medicine, Homeopathy doesn’t act through blood after digestion of the drug materials. It acts through nerve endings in the tongue. It reaches the brain and works from a higher level. So avoid taking anything in your mouth for 10 minutes before and after taking your medicine i.e. you should take medicine with a clean tongue (tasteless). For example, if you take coffee or tea, the taste of it will remain for 15-20 minutes, so you should avoid taking medicines during that period. The strength of the medicines will become low if they are not stored well. Homeopathic remedies should be stored away from strong light, strong temperature and strong smells. External application or treating externally by any means usually suppresses the condition and later it recurs with much intensity. You will understand this when you are cured easily with internal medicines.

Whether homeopathy medicines can be taken during pregnancy – Yes, since action of the medicines is not through blood, it won’t go to the womb.

Whether other system of medicines can be allowed to continue with Homeopathic medicines – Yes, it can be, since most of the other systems of medicine act through blood, whereas Homeopathic medicines act in the tongue where there are lots of sensory nerve-endings. The Homeopathic medicines dissolve in the tongue itself and won’t go up to the stomach to react with other remedies in the stomach.
Dietary restriction – Some people say you have to cut down on coffee, tea, spicy food, pepper, onion, garlic, smoking, drinks, flowers, scents, cream, etc., while taking Homeopathy. This is not true. These are things you cannot avoid in day-to-day life. If the medicine is correct, it will work to cure the condition in any kind of situation. But you cannot take sweets if you have diabetes, cigarettes if you have

respiratory complaints, alcohol in the case of liver complaints, spicy food if you suffer from ulcer, oily diet if it is hypertension, etc. So, it is unnecessary to worry about avoiding these unavoidable things in this modern world.
Can Homeopathy cure all diseases completely – Yes, but within its limitations. Each system has its own advantage and scope and Homeopathy is no exception. Within its limits, its performance is often remarkable. Irreversible or degenerative conditions where structural damages are more marked cannot be cured completely by Homeopathy. However, Homeopathy can play an important role in such cases by providing physical as well as psychological support which will aid the body in defending itself against the disease and further degeneration.
Diagnosis – Cure and comfort can be felt only by the patient and cannot be examined or diagnosed by doctor or lab findings. Homeopathy treats the patient’s symptoms in all ways, always. For selecting the right drug, it gives importance to the character of onset of symptoms, its aggravating or precipitating factors and characteristic symptoms of patient, exciting cause, thirst, sweat, shivering, appetite, sleep, stool habit, mental restlessness, relieving factors and associated symptoms.
Every patient has his/her own pattern of falling ill and will experience different sets of symptoms even for the same illness as per diagnosis. For example, some patients suffering from jaundice will have fever, vomiting, nausea, body itching, etc., but some others will have a different set of symptoms like loss of appetite, thirst, profuse sweating, weakness, constipation, etc. Here the selection of Homeopathic medicines will be different for the patients even though they suffer from jaundice. A well-selected remedy quickly supports the body mechanism and clears the complaints at the earliest.
Regarding investigations – No one can deny the importance of laboratory investigations in diagnosis and assessment of prognosis. It also helps in monitoring the betterment. Homeopathy doctors also use thermometer, stethoscope and BP apparatus, etc., which are all invention of physics and not a treasure to a particular system of medicine. Also a Homeopathy doctor will go in for ECG, EEG, ultrasound scanning, CT scan, MRI scan, and all blood and urine reports for diagnosing the complaints. Also blood values and other investigations, the elevated levels or structural changes found while scanning are only the effects of the diseases and not the disease itself. For example – An elevated level of total blood Eosinophil count and serum-Immunoglobulin, IgE, in blood are effects of the allergy conditions and they are not the cause for sneezing. Most people think that Eosinophilia is the ultimate cause of sneezing, but in real, it is not so.
Regarding prevention – Prevention is better than cure. Homeopathy has a greater advantage over other systems by treating the patient (not disease). It has the ability to prevent and control the progress of a disease. The earlier you treat, the better your chance of complete recovery. Since Homeopathy deals with improving immunity for eliminating the diseases, there won’t be any recurrences of the complaints.
Regarding side-effects – One of the most common reasons why people seek Homeopathic care, is the “cure will be permanent without side-effects” since it is very much refined. According to Newton’s universal law, every action has its own reaction. If it is true, if there is action, there should be reaction. Here in Homeopathy, since the medicines are administered in very minimal doses, we do not notice the reaction or adverse reactions which are also very minimal and unnoticeable.
For example, nowadays, in Allopathy medicines, people are often advised to use sleeping pills for sleeplessness. This sleeping pill will create artificial sleep on the drug day and produce sleeplessness the next day as its adverse action, obliging the universal law. Since people take pills at night regularly, the adverse action may not be noticed but its other adverse actions like depression and lack of concentration will be found in due course, after prolonged use. In contrast, in Homeopathy, substances which induce sleeplessness in large doses will be given to the patient in minute doses to sleep naturally, without any noticeable side-effects.
Regarding surgery – In advanced conditions, surgery is the only way. Homeopathy is not against surgery, if that is the case. But it can be avoided in many cases like piles, uterine masses, breast tumours, pleurisy, gallstones, kidneystones, etc, if it is properly diagnosed and treated before complications arise. For example, tonsillitis is not a pure surgical complaint which can be cured in 70-80 per cent of cases. Homoeopathy follows Nature’s rule, so it never admits removal as a cure. It takes healing as making healthy, not removing. Likewise piles, nasal polyp, kidney stones, etc., can be noticed to recur even after surgical manipulation. This is because surgery treats the effects of the disease rather than the disease itself.

Finally, regarding doctor & faith – Homeopaths may fail in curing the disease, but Homeopathy never fails, i.e., the cure depends upon the ability of the doctor to diagnose the case and select the right drug for the case. There is also a popular saying – Finally, it is faith that cures. Faith means faith in the doctor, medicine and cure. We have to accept this saying also, since occurrence, real causes, nature of complaints and its presentation and curing process are all still obscure and remain as unknown science.
In total, Homoeopathy is the fingerpost on the crossroads of healing which directs the way to SAFEST PERMANENT CURE.

for new hope

Dr. S. Chidambaranathan, BHMS, MD (Homeo)

Laxmi Homeo Clinic

24 E. New Mahalipatti Road

Madurai, TN 625 001

India

Tel:  +91-452-233-8833 | +91-984-319-1011 (Mob)

Fax: +91-452-233-0196

E-mail:  drcheena@yahoo.com

www.drcheena.com / www.drcheena.in

(Disclaimer: The contents of this column are for informational purpose only. The content is not intended to be a substitute for professional healthcare advice, diagnosis, or treatment. Always seek the advice of healthcare professional for any health problem or medical condition.)

What Your Doctor May Not Tell You About Neuropathy

Today's post from curediseases.pw (see link below) is very sensibly written and should appeal to all readers looking for just a little more information than their doctors are able to supply during a fifteen minute consultation. It addresses some of the myths surrounding neuropathy, many of them brought about because doctors just don't have the time to explain what's happening in any length. Time is the issue here...nobody is suggesting that doctors are being negligent...they just don't have the necessary time! The article fills in some of the blanks, with accurate and helpful information and you may well learn something you didn't know about this frustrating disease that's causing you so many problems. Worth a read.
 

11 Things Doctors Don’t Tell You About Neuropathy
November 19, 2016 ASHLEY

Have you ever learned a piece of valuable new information about neuropathy and thought to yourself, “I wish I would’ve known that when I was first diagnosed.” If you’re anything like me, this is a somewhat frequent occurrence. The reality is that while a lot has been (and is being) discovered about neuropathy in the scientific and medical communities, our understanding of it is an evolving process. Compared to a decade or two ago, we know considerably more now than we did – but even so, there is much that is yet to be fully understood about this silent but painful nerve condition.

As I look back on all I’ve learned about neuropathy over the years – from causes to treatments and everything in between – there is a lot I wish I’d been told about sooner. As with any battle against a chronic condition – knowledge is power. The more you know about your neuropathy – including its potential causes and the steps you can take to most effectively treat it and prevent it from spreading – the better your chances are of reducing your neuropathy related symptoms and preventing further nerve damage.

With that said, here are 11 things I wish I’d known about neuropathy when I was first diagnosed:

There are many potential causes – including medications

Some of the known causes of neuropathy include diabetes, chemotherapy, exposure to toxins, surgery, injury or trauma, vitamin B12 deficiency, excessive amounts of vitamin B6, autoimmune diseases, nutritional imbalances, excessive alcohol consumption and even medications. Knowing the cause of your neuropathy is one of the most important factors in determining how to treat it.



MORE: 7 Potential Causes of Your Neuropathy

In some cases, the cause of neuropathy will remain a mystery even after thorough testing and investigation. This is referred to as idiopathic neuropathy, meaning the cause is unknown. In most cases, however, doctors should be able to arrive at a cause (or number of causes).


Some Causes Are Reversible

One of the dreaded realities we often associated with neuropathy is that the damage is irreversible – that you’re stuck with the pain, tingling or numbness forever. While in many cases the damage and symptoms may last indefinitely, there are cases in which the damage may be reversible. This largely depends on the cause of your neuropathy and how quickly you catch it and take steps to reverse it (obviously, the earlier the better).

Among the causes in which damage has the potential to be stopped and even reversed are diabetes, vitamin B12 deficiencies, nutritional deficiencies, heavy alcohol consumption and medications. Of course, to have any hope of stopping or reversing the damage one must determine the cause of the damage and take immediate steps to remedy the problem.

For those with diabetes or nutritional deficiencies, managing blood sugar and improving diet is key to reversing the damage. Those with vitamin B12 deficiencies should work with their doctor to determine ways to eliminate the deficiency through diet or supplementation. Finally, those with neuropathy caused by alcohol or medications should restrict or eliminate the use of the substance causing the damage.

Nerve Damage Can Spread If Underlying Cause Isn’t Addressed

The peripheral nervous system is comprised of nerves running from the brain and spinal chord to other parts of the body. Damage to the peripheral nerves typically manifests itself first in our extremities – usually the hands or feet. What many neuropathy patients don’t realize is that over time these symptoms can spread to other parts of the body – including the arms, ankles, legs and more – if the underlying cause isn’t addressed. This is why both early detection and treatment are so critical. 

Look Out For Early Indicators of Peripheral Neuropathy

The earlier you can catch neuropathy the better your chances of preventing the symptoms from spreading. Some of the early signs of neuropathy to watch out for include:
Gradual numbness or tingling sensations in the feet or hands (which may spread into the legs and arms)
Sharp, stabbing pains
Intense burning pain
Extreme sensitivity to touch
Loss of balance or coordination
Muscle weakness, loss of motor skills
Restless Leg Syndrome (RLS)

Neuropathy Can Affect Muscle Control

Within the peripheral nervous system there are three types of nerves: motor, autonomic and sensory. While the most recognizable symptoms of neuropathy are related to the sensory nerves (i.e. pain, tingling and numbness) – nerve damage can manifest itself in other ways as well. When neuropathy damages the motor nerves, it disrupts the nerves ability to relay messages from the brain and spinal cord to various muscle groups. This can result in difficulties such as loss of balance, difficulty walking, loss of dexterity, cramps or spasms, muscle weakness and loss of muscle control.

MORE: What No One Tells You About Neuropathy & Muscle Control


Neuropathy Can Affect Autonomic Functions

Another group of nerves that can be affected my neuropathy is the autonomic nerves. The autonomic nervous system is a division of the peripheral nervous system that influences various internal organs such as the heart, stomach, liver, adrenal gland and more. Damage to the autonomic nerves disrupts the signals sent from the brain and spinal cord to these various organs – sometimes resulting in a disruption to the involuntary functions these organs are involved in.

MORE: Heartburn, Indigestion and 25 Other Symptoms You Didn’t Know Were Caused By Neuropathy

Here are the most common organs affected by damage to the autonomic nerves and the symptoms generally associated with them:


Pain Medications Only Mask the Pain

There are a number of prescription medications available to help cope with neuropathic pain. These medications have been a lifesaver for many sufferers (myself included) as they help take the edge off the pain and make it more manageable. Unfortunately, their purpose is simply to help mask the pain rather than help correct the underlying problem. In addition, there can be negative side effects associated with any prescription medication – so one must be aware of the risks.

MORE: Strategies for Fighting Neuropathy Without Prescriptions

Understanding that these prescription medications would not necessarily stop or reverse my nerve damage – but merely mask the symptoms – helped me to recognize the importance of trying various approaches to help address the underlying causes of my neuropathy. 

Natural Herbs & Supplements May Help

While prescription medications typically only mask the symptoms, nutritional supplements and herbs may help both relieve symptoms and address underlying causes. By addressing underlying causes or problems, they may help to slow or even stop the nerve damage from spreading. Some of the best supplements and herbs for nerve pain include:
Vitamin B12
Vitamin D
Magnesium
Alpha Lipoic Acid
CoQ10
Acetyl-l-carnitine

Vitamin B12 is especially important for nerve health. It helps build up and support the myelin sheath – a protective coating around the nerves that shelters them from damage and infection. Studies have shown that high doses of vitamin B12 can promote nerve regeneration of damaged nerves.

MORE: Top 10 Herbs & Supplements for Nerve Pain 
 
Alternative Therapies Can Help (but be patient)

Like a lot of people, I was hesitant about alternative therapies and skeptical about the promised results. However, alternative therapies have proven to be very beneficial in both helping me to manage my pain as well as improving my overall health. That said – there is no miracle therapy or treatment that is going to relieve my nerve pain overnight. I’ve found that with alternative approaches, the results are gradual – but they tend to be lasting results.

Alternative therapies for neuropathy range from low-impact exercises like yoga or tai chi to ancient practices like acupuncture. Here is a good list of popular approaches you may want to explore if you are suffering from neuropathy:
Acupuncture
Massage
Yoga
Tai Chi
Walking or stationary bike
Biofeedback
TENS therapy (Transcutaneous electrical nerve stimulation)

MORE: 10 Little Known Ways to Relieve Nerve Pain 
 
Diet Could Be Helping or Hurting Nerve Pain

Something else I wish I’d known was the impact that diet can have on the symptoms of neuropathy. There are certain foods that can aggravate nerve pain as well as ones that can help boost nerve health. Knowing which foods or ingredients fall into which category can make a big difference!

Among the foods that can make neuropathy worse are casein-based products (commonly found in dairy products), artificial sweeteners, gluten, added sugars and refined grains. When consumed excessively, alcohol can also harm the nerves and block the absorption of essential vitamins like B12.

MORE: 4 Nutrient Deficiencies That Are Killing Your Nerves

Foods that promote healthier nerves include ones rich in B-complex vitamins such as B12 & B2. Other important vitamins and nutrients for strong nerves include vitamin D, vitamin E, Magnesium and Zinc.
Joining a Neuropathy Support Group Can Help

They say that experience is the mother of all wisdom, so what better way to learn about neuropathy than to join others who have been living with it for years? Joining a support group or online forum can give you insights into living with neuropathy that you might not find elsewhere. They are also safe environments to ask questions and learn what experience others have had with various medications, treatments and therapies.

To find a support group near you, the Neuropathy Support Network has a useful support group search tool. In addition to local support groups, there are a handful of online support groups or forums. For finding information and support online, check out these 10 Resources Every Neuropathy Sufferer Should Bookmark.

Life with neuropathy can be painful, overwhelming and frustrating. As with anything, the more experience one has the more wisdom and insight he or she will gain into how to better cope with the hand that has been dealt. For me, the process has been gradual and frustrating (of course) – but I’ve learned many things that have resulted in small yet meaningful changes to make the road a little smoother. What things do you wish you had known about neuropathy when you were first diagnosed?

http://curediseases.pw/11-things-doctors-dont-tell-you-about-neuropathy/

A Possibly Useful Book About Neuropathy

Today's post from booksonthemove.com (see link below) is a notification of a book about neuropathy that may be useful for people living with the disease. You should note that the book is designed for doctors and medical clinicians who are likely to come into contact with the condition and may therefore be technical and not exactly easy-reading for the layman. However, in the interests of arming yourself with knowledge, it may be worth asking your library to order it. Knowledge is definitely power when it comes to nerve damage and this may be a valuable reference book for the patient as well as the doctor. Understanding your disease is a major step forward in learning to live with it.

Textbook of Peripheral Neuropathy
 

Textbook of Peripheral Neuropathy

ISBN:1936287102

Authors Peter Donofrio MD

Publisher : Demos Medical

Textbook of Peripheral Neuropathy is a practical but authoritative reference for clinicians in any medical specialty who are evaluating and treating patients with signs and symptoms of a peripheral neuropathy. Reviewing the full spectrum of clinically significant neuropathies, the book contains chapters on common and rare forms including mononeuropathy in the upper and lower extremities, mononeuritis multiplex, diffuse and symmetric polyneuropathies, brachial and lumbrosacral plexopathies, and spinal root disorders-disorders that can mimic diffuse and/or focal neuropathies, complicating diagnosis and evaluation. Coverage encompasses both inherited and acquired diseases, including neuropathies arising from physical injury, diabetes, alcoholism, toxins, autoimmune responses, nutritional defi ciencies, vascular and metabolic disorders, medication-induced neuropathies, and idiopathic conditions. The textbook provides an evidence-based approach to testing, differential diagnosis, and treatment, and should serve as a trusted resource for healthcare professionals confronting the many manifestations of peripheral neuropathy in clinical practice.

The chapters are written by internationally renowned expert contributors with deep clinical experience and contain numerous tables, fi gures, and algorithms providing clear diagnostic and management guidelines. Boxed Clinical Pearls and Key Points allow for quick access to pertinent information, making evaluation and review easy and rewarding.

Features of Textbook of Peripheral Neuropathy Include:
Practical yet comprehensive-an accessible “go-to” reference for clinicians
Covers all clinically relevant peripheral neuropathies
Clinical Pearls and Key Points are set off from the text for quick reference
Contains clear diagnostic and management guidelines from expert contributors
Structured chapters make it easy to find essential point-of-care information

http://booksonthemove.com/book-review/textbook-of-peripheral-neuropathy

What Can I Do About Pain Related Fatigue

Today's post from webmd.com (see link below) may seem like another simplistic self-help post, aimed at  the general public rather than those living with chronic pain but the fact is that many many people living with neuropathy are often desperately tired. Either from the constant pain, or from weakness caused by over-activity that others would see as normal, it doesn't really matter. The point is, what can we do about it, if anything? Some of the tips shown below may well be helpful for you but as long as you're aware of the problem, you're more likely to take steps to help it. One thing is sure; without regular and quality sleep periods, your whole day will be affected by tiredness - don't be ashamed to take naps when necessary and when your body tells you too. Far too many articles stress the need for exercise and activity and they are indeed helpful for neuropathy patients (however you may protest) but rest and recovery are equally important.
 

Why Am I So Tired?
WebMD Feature Reviewed by Jennifer Robinson, MD

Are you always tired? That’s no surprise in these tightly scheduled, overloaded times.

The good news is, it’s simpler than you might think to get your energy back. The trick is to figure out why you’re fatigued. Then you can learn what to do about it. 

5 Common Reasons for Tiredness

1. What you eat. A shot of caffeine and sugar can seem like quick fix when you need an energy boost, but it soon makes things worse. After your blood sugar levels spike, they crash. You end up more fatigued, not less.

A far better solution is a balanced diet full of fruits, vegetables, and lean protein.

“Most people feel like they're less tired if they eat a healthy diet," says J. Fred Ralston Jr., MD. He's a past president of the American College of Physicians. "Eating healthy also means you'll carry less weight, and obesity is a big contributor to fatigue.”

2. How much water you drink. Instead of that caffeine-filled, sugary drink, try a glass of water.

Mild dehydration affects your mood, and it makes you feel more tired, research shows. It can set in when you drink just a little less H20 than you normally do.

The Institute of Medicine recommends that men get about 125 ounces of water a day and women get 91 ounces. Those amounts include water from all foods and beverages.

3. How much you sleep.

Millions of Americans just don’t get the ideal 7 to 9 hours of snooze time. If you’re one of them, avoid caffeine, alcohol, and large meals in the hours just before bedtime. Turn off the TV and unplug the computer before you turn in. Also, go to bed at the same time each night and keep your bedroom quiet and dark.

4. How much you exercise. Studies show that when inactive people start to work out, they feel much less fatigue than those who stay idle. When you move more, you not only use more energy, you also have more on a daily basis.

Ralston recommends you start with 30 minutes of exercise at least 4 days a week. Be sure to finish at least 3 hours before bedtime, so you have time to wind down. After a month, you should notice improvement in your fatigue. Within 3 to 6 months, you should feel much better.

5. What you do to handle stress. Stress is a fact of life. Fatigue sets in when you have more than you can handle. The first step in changing the way you deal with stress is to figure out your body’s stress signals -- aside from feeling fatigued, you might be angry, headachy, tense, or unable to focus.

Once you know how stress affects you, you can teach yourself to control it. Proven ways to limit the toll stress takes on you include:

Short, regular periods of meditation
Talks with friends or family about your challenges
Regular breaks from work
Taking time for yourself
Could It Be Something Else?

If you’ve taken steps to address all five of the most common causes of fatigue and you still feel worn out, visit your doctor.

Chronic tiredness is linked to medical conditions including these:

Anemia, or a lack of iron in the blood, is a common cause of fatigue, and it's easy to check with a simple blood test, says Sandra Fryhofer, MD. She's an associate professor of medicine at Emory University.

"It's particularly a problem for women, especially those who are having heavy menstrual periods,” she says.

An iron-rich diet that's heavy in meats and dark, leafy greens can correct low levels of iron. Ask your doctor if an iron supplement might help, too. Other key nutrients that can hold off fatigue include potassium and vitamins D and B12.

Thyroid problems. Both an over- and an underactive thyroid can cause fatigue. A blood test can help a doctor gauge how well your thyroid's working.

Diabetes. People who have uncontrolled diabetes "just plain don't feel good," Fryhofer says. "If you feel draggy and you're also having blurred vision or lots of urination, you should get that checked with a blood test."

Depression. If your feelings of exhaustion are accompanied by sadness and loss of appetite, and you just can't find any pleasure in things you once enjoyed, you might be depressed. Don't keep it to yourself. Your doctor, or a therapist, can start you on the path back to feeling better.

Sleep problems. Many different sleep issues can keep you from feeling rested and energized. Talk to your doctor about a sleep evaluation, especially if you snore, since that could point to a condition called obstructive sleep apnea, which briefly stops your breathing several times a night. Like other sleep disorders, it’s treatable.

Undiagnosed heart disease. Ongoing tiredness can be a warning sign of heart trouble, Ralston says. “If you have trouble with exercise you used to do easily, or if you start feeling worse when you exercise, this could be a red flag for heart trouble. If you have any doubts, see your doctor.”

http://www.webmd.com/fitness-exercise/features/reasons-tired

Fluoroquinolones Another Warning About Nerve Damage

Today's post from stonehearthnewsletters.com (see link below) is another forceful article about the dangers of Fluoroquinolone, antimicrobial antibiotics (Levaquin, Cipro,Avelox etc) to nerve damage patients or even those who don't as yet suffer nerve damage. The evidence is now pretty much overwhelming that these antibiotics should be avoided or at least properly discussed with your doctor. Even the FDA has forced manufacturers to clearly state the dangers on their packaging. They can cause mitochondrial toxicity (simply put, they can attack the mitichondria, the energy powerhouses of nerve cells and essential for good working order) and if you already have neuropathy, make it considerably worse and if not, actually cause it. They are so widely prescribed that they're practically medical M&Ms but please talk over any prescription with your doctor or specialist, before taking them - there are alternatives available.
 

Levaquin, Cipro, Avelox May Result In Neurodegenerative Diseases 
Posted on September 2, 2014 by Stone Hearth News

HAMILTON, N.J., Sept. 2, 2014 /PRNewswire-iReach/ – Four years ago, Lisa was a physically active and healthy 45 year old. She would frequently unwind at the local gym after spending a long day on her feet teaching a class of energetic elementary school students. All of that changed dramatically when she took an antibiotic for a sinus infection. Lisa’s doctor prescribed the popular antibiotic, Levaquin, a drug she was told was safe. She became so disabled, she was unable to continue working. Lisa’s doctor was at a loss to explain the sudden onset of these painful, debilitating symptoms, particularly when they continued to worsen months after she had stopped taking the antibiotic.

Levaquin belongs to a class of antibiotics called Fluoroquinolones. Originally manufactured to treat serious, life-threatening infections, they have been increasingly used for minor infections and, in some cases, when no infection exists. A common misconception is that they are safe, despite several Black Box warnings, which include Central Nervous System (CNS) dysfunction and increased risk of tendon rupture. In August 2013, the FDA strengthened Levaquin’s warning to include the risk of Peripheral Neuropathy, which can be permanent.

While doctors have struggled to explain Fluoroquinolone Toxicity Syndrome, part of the explanation may be found in an April 17, 2013 FDA report which indicates Levaquin, Cipro, and Avelox may cause Mitochondrial Toxicity. This report, obtained through a Freedom of Information request, states that Mitochondrial Toxicity is implicated in serious, life-threatening neurodegenerative conditions, such as Parkinson’s, Alzheimer’s, and ALS.

Based on this 2013 FDA report, signed by an FDA Acting Division Director, Dr. Charles Bennett from the University of South Carolina, submitted a Citizen Petition to the FDA requesting a Black Box warning be added to the Levaquin label which would warn doctors and patients of the risk for Mitochondrial Toxicity.

Quinolone Vigilance Foundation (QVF), www.SaferPills.org, a non-profit, charitable organization that fosters, initiates, and funds research on Fluoroquinolone Toxicity, supports the Citizen Petition. Rachel Brummert, QVF Executive Director, herself injured by Levaquin in 2006, was diagnosed four years later with Neurosarcoidosis, a degenerative neurological disorder that is linked to Mitochondrial Toxicity. “The failure by the FDA and drug makers to adequately warn the public puts patients at an alarmingly high risk of developing life-threatening neurodegenerative disorders,” said Brummert. “We call on the FDA and drug makers to protect the American public and issue this important warning immediately.”

John Fratti, also damaged by Levaquin and is a staunch advocate for additional Black Box warnings, agrees with Brummert. “Doctors and patients should not have to obtain drug safety information through a Freedom of Information Act request. The boxed warning requested by the Citizen Petition is needed immediately.”

For Lisa, who still struggles with the aftermath of the damage caused by Levaquin, the requested Citizen Petition Black Box warning will come too late. It may, however, prevent others from suffering a similar fate.

Media Contact: Rachel Brummert, Quinolone Vigilance Foundation, 609-575-9839, rachel@saferpills.org

News distributed by PR Newswire iReach: https://ireach.prnewswire.com

SOURCE Quinolone Vigilance Foundation

http://www.stonehearthnewsletters.com/levaquin-cipro-avelox-may-result-neurodegenerative-diseases/neuropathy/

Sometimes No News About Nerve Pain Treatment Is Just As Bad As Fake News!

I have to say that today's post from sciencedaily.com (see link below), which is widely repeated across the internet at the moment, is problematic for me. When you see the words: 'moderate evidence' and 'probably' and 'Unfortunately, more research is still needed', littering an article, you know that what you're reading is more of the same and nothing new. So, we have a report from the esteemed, Agency for Healthcare Research and Quality (AHRQ) which broadly supports the continued use of the anti-depressants and anti-seizure drugs to treat nerve pain we all know and are generally disappointed by but offers no new evidence, or new alternatives, just more vague estimations that these drugs are probably better than nothing. Frankly it's not good enough. People are going to read this in the way that people do and come to the conclusion that pregabalin, duloxetine, gabapentin, amongst others; with botox and capsaicin thrown in for good measure, are all okay for nerve pain. Now, forty years of stagnation in pain control for nerve pain, suggests the opposite. The side effects are so often worse than the symptoms themselves that yet more suffering is heaped upon innocent patients who believe what they read here. Of course, these days, no article of this sort is ever complete without the statutory warning about the evils of opioids (as if sensible opioid users don't already feel guilty enough about taking the only thing that really reduces their pain!). If you look carefully at this story and maybe read some of the other versions that are currently sweeping the neuropathy net, you'll see that while this is not a 'fake news' story, it is a non-news story - we've heard these conclusions for decades - why are they getting so much publicity?

Which drugs effectively treat diabetic nerve pain?
American Academy of Neurology (AAN) Date: March 24, 2017

A federal health agency has found certain antidepressants and anti-seizure drugs are among medications that effectively treat diabetic nerve pain. The research is being published simultaneously in the March 24, 2017, online issue of Neurology®, the medical journal of the American Academy of Neurology (AAN) and in a more comprehensive report by the Agency for Healthcare Research and Quality (AHRQ).


AHRQ is the lead federal agency charged with improving patient safety and the quality of America's health care system.

The Centers for Disease Control and Prevention (CDC) says more than 9 percent of the U.S. population has diabetes and an estimated 50 percent of people with diabetes have some form of diabetic peripheral neuropathy, nerve damage caused by high levels of blood sugar, although not all have symptoms. Symptoms can include nerve pain, numbness and tingling in the legs and feet. The longer someone has diabetes, the greater the risk of developing neuropathy, especially for those who have problems controlling blood sugar. Severe neuropathy may eventually lead to the need to consider amputation.

"Providing pain relief for neuropathy is crucial to managing this complicated disease," said Julie Waldfogel, PharmD, of The Johns Hopkins Hospital in Baltimore, Md., and author of the systematic review. "Unfortunately, more research is still needed, as the current treatments have substantial risk of side effects, and few studies have been done on the long-term effects of these drugs."

A systematic review is an analysis of the results of multiple, carefully designed studies available on a topic.

For this systematic review, researchers looked for studies and other systematic reviews conducted after the American Academy of Neurology's 2011 guideline "Treatment of Painful Diabetic Neuropathy." A total of 106 studies were included in the review.

Researchers found moderate evidence that the antidepressants duloxetine and venlaxine, which act as serotonin-norepinephrine reuptake inhibitors, were effective in reducing neuropathy-related pain.

They also found weak evidence that botulinum toxin, the anti-seizure drugs pregabalin and oxcarbazepine, as well as drugs classified as tricyclic antidepressants and atypical opioids were probably effective in reducing pain.

Waldfogel noted that the long-term use of opioids is not recommended for chronic pain due to lack of evidence of long-term benefit and the risk of abuse, misuse and overdose.

Researchers noted that while pregabalin works in the same way as gabapentin -- both are often used interchangeably in clinical care -- this review found gabapentin was not more effective than placebo. This is contrary to the 2011 AAN guideline, which found gabapentin to be probably effective.

The seizure drug valproate and capsaicin cream, which were considered probably effective in the 2011 AAN guideline, were ineffective in this meta-analysis.

"We hope our findings are helpful to doctors and people with diabetes who are searching for the most effective way to control pain from neuropathy," said Waldfogel. "Unfortunately, there was not enough evidence available to determine if these treatments had an impact on quality of life. Future studies are needed to assess this."

There were other limitations. One was that all studies were short-term, less than six months, and all studies on effective drugs had more than 9 percent of participants drop out due to adverse effects. Longer-term outcomes should be evaluated in future studies so that side effects and continued effectiveness of the drugs can be assessed.

Story Source:

Materials provided by American Academy of Neurology (AAN). Note: Content may be edited for style and length.

Journal Reference:
Julie M. Waldfogel, Suzanne Amato Nesbit, Sydney M. Dy, Ritu Sharma, Allen Zhang, Lisa M. Wilson, Wendy L. Bennett, Hsin-Chieh Yeh, Yohalakshmi Chelladurai, Dorianne Feldman, Karen A. Robinson. Pharmacotherapy for diabetic peripheral neuropathy pain and quality of life. Neurology, 2017; 10.1212/WNL.0000000000003882 DOI: 10.1212/WNL.0000000000003882
 
https://www.sciencedaily.com/releases/2017/03/170324192328.htm

Questions About Neuropathy A Doctors Answers

Today's very useful post from neuropathy.org (see link below) is a series of commonly asked questions posed to Dr Hunter, followed by his answers. It may be that your own doctor will give slightly different responses to these questions, depending on either the sort of, or cause of your neuropathic problems but in general, most doctors would agree with Dr. Hunter's answers and in that respect this article can be seen as being helpful to the vast majority of neuropathy patients. Definitely worth reading, even for experienced neuropathy patients.

Questions Are The Answers: What You Need To Know To Beat Neuropathic Pain!
By Corey W. Hunter, M.D.

Addressing questions—even when there may be no clear cut answers—is a big part of what I do every day to help people living with chronic pain. Many patients I work with also battle neuropathic pain: some newly diagnosed, and others barely living through their pain. I realized recently that there is a theme to the questions I hear most often from my patients, and I hope that in sharing my responses to them, I can help you better understand your neuropathic pain and work with your health care provider to improve your life with neuropathic pain:

1. Why does it feel like my skin is burning? Numb? Pins and needles? What is causing me to have these symptoms?
 
Typically, a healthy nerve will only send a signal when it is stimulated, e.g., a nerve in the hand that senses temperature will stay quiet until the hand gets near the flame on the stove. However, an injured nerve is like a broken telephone that rings when no one is calling (burning) and is unable to get a dial tone when you need to make a call (numbness). Even when it has nothing of importance to say to the brain, the nerves will send a message and a confused message at that. The “confused” message can be interpreted by the brain as pain or strange sensations like “pins and needles.”

Over time, the spinal cord can become accustomed to getting bombarded by a nerve that never seems to turn off and makes adjustments to account for it. So, even once the nerve manages to stop firing, the spinal cord has become so used to sending that signal that it will take over and keep doing it on its own.

2. Why are my usual pain relievers--acetaminophen (or Tylenol), ibubrofen (or Motrin), or even the acetaminophen and oxycodone combination (or Percocet)--not working?
 
In very simple terms, there are two basic types of pain: nocioceptive (pain that can usually be pinpointed to an actual event, e.g., pain resulting from a broken arm) and neuropathic (pain that is vague and nondescript in nature, e.g., burning pain in the feet resulting from uncontrolled/too high blood sugars for too long causing injury to the nerves in the feet). The former is from an injury to a part of the body and the nerves in your arms or legs tell the brain that something was hurt and we feel pain. The latter is an injury to the nerve itself. Medications such as acetaminophen (or Tylenol), ibubrofen (or Motrin), and the acetaminophen and oxycodone combination (or Percocet) are effective in treating nocioceptive pain. They can decrease the inflammation at the injury which may mean the nerve now has less to tell the brain about the injury. They can also dull the pain message being sent altogether. However, when the pain itself is coming from an injury to the actual nerve, the effect will be limited. That is where neuropathic pain medications become important because they act on the nervous system directly.

3. What kind of tests can you order to see what is happening?
 
Neuropathic pain can be the result of an injury to a nerve or the nervous system which interferes with its function. MRIs are a good test to evaluate the body for structural abnormalities, but it tells you nothing about function. It is a still picture taken in a virtually motionless individual.

It is estimated that nearly ¾ of Americans have abnormalities which could be seen on an MRI but have no pain. On the flip side, there are many patients I have treated with no findings on the MRI which are consistent with their symptoms. This perhaps suggests it does not tell the whole story. The importance of an MRI should not be overlooked in diagnosing things like a bulging disc or soft tissue injury, but one should view it as more of a “guide” when it comes to neuropathy rather than a map.

A good test to evaluate the function and integrity of the nervous system is a nerve conduction study (NCV)/ electromyography (EMG). The NCV tests how fast a nerve can send a signal and how much of that signal is getting through. The EMG tests the interaction of those nerves with the muscles which gives the doctor an idea of whether the nerves are healthy.

4. Are there any medications I can take for this? How much relief can I expect?
 
Most patients who suffer from neuropathic pain will tell that traditional pain relievers tend to be ineffective. Medications such as acetaminophen and oxycodone combination (or Percocet) and acetaminophen and hydrocodone combination (or Vicodin) only “take the edge off,” but the burning and/or painful numbness seems to always be present, no matter how much they take. It is for this reason that opioids should not be considered as a first-line treatment option. Medications such as anti-depressants (e.g., duloxetine) and anticonvulsants (e.g., gabapentin and pregabalin) have been the mainstay for the treatment of neuropathic pain for some time now.

Tizanidine (or Zanaflex) is another medication which has been used fairly frequently for neuropathy. It is a muscle relaxer which has been used to treat spasticity in patients with cerebral palsy and is effective in treating neuropathy with small doses taken once daily. Methadone is also a particularly good medication as it not only acts as a powerful pain reliever but has been shown to be quite effective for neuropathic pain. An older medication called ketamine has come back into relevance as physicians have found it to be extremely effective for neuropathy. It can be used topically when added as the active ingredient in a cream or infused intravenously in a hospital setting under the supervision of your doctor.

The amount of relief varies from one patient to the next and it is nearly impossible to predict the degree of success one should expect. Many of the medications mentioned will need to be titrated to an effective dose which means your doctor will need to start with a smaller amount and slowly increase it over time. Others simply need time to build up in your body. Hence it is important to ask your doctor to help you understand what to expect with the medication(s) being prescribed: dosing, side effects, degree of relief, improvement in quality life and physical function…

5. My last doctor requested drug tests every time I saw him and he also asked me to bring my medications along so we could track how much I have left. Neuropathic pain is challenging enough, and then I have to deal with the stigma of being treated like an addict. Do you have any suggestions?

Presently, opioids are a very controversial topic and with that comes increased scrutiny and procedure. No one sets out to become addicted to prescription pain relievers, but the potential for dependency is always a concern. Because of this, strict monitoring should be in place for any patient on opioids to make sure they are being used appropriately and as directed – this includes the doctor or his/her staff counting the pills and even asking for a urine sample.

While they should not be considered a “first-line” therapy for neuropathic pain, opioids are commonly used by many physicians first simply because he or she may not know the most effective way to treat it. Therefore, you would not be incorrect in asking for an alternative therapy, even if the request is simply due to the perceived stigma and hassle that can accompany opioid use.

6. What types of treatments are there if the medications do not work? How much relief can I expect? Are there treatments that don’t involve medications or surgeries that I could try?
 
Physical therapy (PT) typically is prescribed at the very beginning or along with neuropathic pain medication. In cases where patients present as having failed medication and PT has not yet been provided, PT can still be tried. The prescription should include therapies that aim to decrease the intensity of the pain (i.e. contrast baths) and increase the function of the extremity (i.e. range of motion and strengthening).

If conservative measures fail, a skilled interventional pain physician may offer a plan that includes injections like a sympathetic or stellate ganglion block. In basic language, the doctor will attempt to deliver medication to the relay centers for the patient’s pain to slow down or even turn off the pathway. Other injections may be directed at the nerves themselves that are believed to be responsible for transmitting the pain. There are a variety of procedures which can offer relief which are all minimally invasive in nature.

Finally, there are implantable devices like spinal cord stimulators (SCS) and intrathecal pumps (ITP). Many physicians describe an SCS as “a pacemaker for the spinal cord.” There is a battery that is implanted just under the skin with a small, flexible lead that goes into the spine and essentially interferes with the cord’s ability to transmit pain. An ITP involves a reservoir placed right under the skin instead of a battery and a tube rather than a lead. In the reservoir, the doctor can place any pain medications or cocktail of medications he or she thinks will be effective. The advantage of the ITP is because the tube is placed right on the cord, less is needed.

7. Will this ever get better? Will the pain go away?
 
The chances of improvement depend on the extent of the injury to the nerve. If the injury is mild and the cells that support the nerve are left intact – the neuropathy should improve as the nerve heals. Many times the nerve is injured by a something that can be treated or reversed, i.e. a compressed or pinched nerve, chemotherapy or exposure to a toxic chemical. In these cases, whatever is the culprit can simply be removed from the equation and allow the nerve to heal. However, if the injuring agent is still present, it is harder for the nerve to heal. In fact, if the nerve stays injured for too long, the damage can be irreversible. The most important thing to keep in mind is the sooner a neuropathy is treated, the better the chances to have a good recovery.

8. Will this get worse? What should I expect five or ten years from now?
 
Neuropathic pain left untreated will undoubtedly get worse. The longer it is left untreated, the harder it is to get it to a manageable level even once the appropriate plan has been implemented. Unfortunately, even some patients who are under the care of a skill pain physician from the start will get worse. There is no way to predict who these patients will be or why so many others were successfully managed with the same therapies while others fail. As with any field in medicine, there are always exceptions to the rule. Compared to other specialties, pain medicine is relatively new and there is much we are still learning. With that, there are always new treatments being discovered.

9. Do a lot of your patients use multiple therapies for relief for their neuropathic pain? E.g., prescription medications, acupuncture, and physical therapy?
 
Treating pain should be thought of like climbing stairs. The first step should include the most basic therapy, like PT, and an over-the-counter pain reliever. As more care is needed, we climb to the next step. With each successive step, the more we add. By the third step, a patient may need to be on two different neuropathic pain medications, PT, and be scheduled for an injection. Treatments like acupuncture are not unusual to incorporate early on, as well. We call this a “multidisciplinary approach.” The idea is to not assume there is simply one main contributor to the pain and subsequently place all the focus on that. By spreading out the focus, the patient benefits from the idea of “casting a large net” and seeing which treatment works best, not to mention saving time early on.

Corey W. Hunter is a pain management specialist working at the New York Pain Management Group and is a member of The Neuropathy Association’s Neuropathic Pain Management Medical Advisory Council.

http://www.neuropathy.org/site/News2?page=NewsArticle&id=8259