Peripheral Neuropathy A Doctors Analysis

Ever wondered how the doctors or neurologists assess you and come to their conclusions? Today's post from medical-illness.blogspot.com (see link below) is a doctor's summary of a patient's condition after examination. His conclusion is neuropathy, probably caused by diabetes. It's interesting to look at this particular case study and see the bigger picture and maybe see similarities with our own general health. There may be a few warning pointers to look out for!
 

Diabetic Peripheral Neuropathy Personal history

Tuesday, November 4, 2014

 A known diabetic patient male patient, 46 years old, from ……….…., ………..……, married and has 3 off spring, the youngest is 16 years old, heavy smoker with no other special habits of medical importance, he is Rt. handed.

4 c/o
Loss of sensation in both hands and feet of 15 years duration.

4 HPI
The condition started 15 years ago by nocturnal burning painassociated with tingling, numbness started in both feet then progressed, one year later , to involve both hands then the patient developed gradual loss of sensation in both hands and feet, and he felt as if he walkedon cotton.
4 years later, the patient experienced weakness associated with flaccidity, falling of hair, brittle nails with no wasting or twitches. This weakness started in L.Ls then progressed, one year later, to involve both ULs. It's more in distal than proximal muscles, in extensor more than flexor muscles, in adductor more than abductor muscles. The patient also suffers from unsteadiness during eye closure with no involuntary movements.

The condition was associated with diminutionof vision, visual field defects, disturbance of color vision, ptosis in both eyes for which the patient was investigated and treated by laser photocoagulation more than once. The patient can't close his eyes firmly, with accumulation of the food behind both cheeks, no symptoms of other cranial nerve affection.
The patient has organic impotence with lost morning erection with no history of drugs known to cause erectile dysfunction.

The patient developed unsteadiness during standing with palpitation, nocturnal diarrhea, gustatory sweating and dyspepsia.

No symptoms of increased I.C.T.
No speech disturbance.
No symptoms suggesting other system affection.

4 Past history
- There is past history of D.M started 20 years ago manifested by polyuria, polydypsia, polyphagia. The patient is on insulin treatment and his blood sugar is out of control.

- There is past history of HPN started 15 years ago manifested by headache, blurred vision. The patient is on capoten and his hypertension is not controlled.
- Appendectomy operation was done at the age of 20 years.
- No history of other drug intake.
4 Family history
- No similar condition in family.
- No consanguinity.
- No common disease in family.

4 General exam
- Temperature: 37.2o c.
- Bl. Pressure: 140/80 (Recumbent position), 100/60 (standing position).
- Pulse: regular, 110 beat/minute, average volume, no special character, vessel wall not felt, equal in both sides with absent dorsalis pedis, anterior and posterior tibial and popliteal pulsation with intact femoral, radial, brachial and axillary pulsation.
- Mentality: The patient is fully conscious, well oriented for time, place and person. Average mood and memory. The patient is co-operative with average intelligence.
- Head: Examine for Retinopathy, teeth (Artificial teeth).
- L.L: Trophic ulcer, diabetic dermopathy.

4 Sensory:
- Superficial sensations: above knee and elbow level stock and glove anesthesia. Circumferential comparison must be done to exclude diabetic radiculopathy.
- Deep sensation:
§ Joint sense lost on both sides.
§ Vibration sense lost at level of peripheral nerve (medial malleolus, radial styloid process) with intact vibration sense at the level of posterior column (ASIS, clavicle).
§ Muscle sense lost (Calf muscles).
§ Lost nerve sense (Ulnar and lateral popliteal nerves).
§ +Ve Romberg's test.
- Cortical sensation : can't be examined due to loss of superficial sensation.

4 Examination of Speech: Normal.


4 Examination of Cranial Nerves:
- Optic Nerve is affected in the form of: diminution of visual acuity (Rt. eye : can count fingers at one meter, Lt. eye :blind), Tubular visual field defect .
- Ocular nerves
§ Inspection: bilateral ptosis (thumb test >> can't elevate his eye lids),pupils are dilated and irreactive to light or accommodation with no squint.
§ Power: loss of eyeball movements in all direction denoting paralysis of recti and oblique muscles of the eye.
N.B: nystagmus and conjugate eye movements can't be examined b because of loss of eye movements on examining each eye separately .
§ Reflexes: absent light and accommodation reflexes.
- Facial nerve
§ Inspection: symmetrical forehead, obliterated nasolabial folds on both sides with no tearing, no drippling of salive, no mouth deviation
§ Power: patient can't close his eyes firmly, can't elevate his eye brows , can't whistle, can't show his teeth, can't blow his cheeks
§ Reflexes: absent glabellar reflex à (bilateral LMNL).

4 Examination of Motor System :
4Inspection__
- There is wrist and ankle drop, trophic ulcer in L.L, loss of hair and brittle nail in U.L,L.L.
- No muscle wasting, no skeletal deformities, no involuntary movement.

4 Examination of Tone__
- Bilateral symmetrical hypotonia in both upper and lower limbs.

4 Percussion__
No fasciculation or myotonia.

4 Examination of Muscle Power
- Bilateral symmetrical Weakness in both upper and lower limbs. It is distal more than proximal, abductors more than abductors, extensors more than flexors.
- Abdominal muscles: weakness may be attributed to trunkal neuropathy or related to myopathy as the patient gives history of thyrotoxicosis.

4 Coordination
Coordination cannot be examined on both upper and lower limbs because of weakness.

4 Reflexes

- Deep reflexes: Areflexia in both upper and lower limbs.
- Superficial reflexes: lost plantar reflex in both L.L., lost abdominal reflex (trunkal neuropathy).
N.B: lost planter reflex may be due to loss on sensation on the sole of the foot, LMNL at S1, weakness in muscles of the big toe or skeletal deformities in big toe).

4 Back: No deformity, no swelling, no scars .
4 Gait: stamping (may be high steppage).
4 other system examination (search for autonomic neuropathy):

1- Cardiovascular system:
- Absent respiratory sinus arrhythmias.
- Persistent sinus tachycardia (already examined with pulse, and ask for palpitation).
- Painless myocardial infarction.
- Postural hypotension (already examined with pulse).

2- Genitourinary:
- Bladder disturbances (incontinence à ask for it)
- Impotence (psychic and organic à ask for it)

3- Marked sweating specially with meals (gustatory sweating à ask for it )


4- Gastrointestinal:
- Gastroparesis diabeticorum (ask for dyspepsia).
- Diabetic enteropathy (ask for nocturnal watery diarrhea and constipation).

4 pathogenesis
Sorbitol pathway.

4Investigation
- For diabetes: Bl. Sugar level with HBA1C, ECG, RFTs, blood lipid profile (cholesterol, HDL, LDL, TG)
- For P.N: Nerve Conduction velocity.

4 Treatment
- For diabetes: tight control.
- For the P.N.: Tegretol, gabapentin, vitamins, aldose reductase inhibitor
(disappointing results).


4 Diagnosis :
Diabetic Peripheral Neuropathy

4 N.B.

Lost abdominal reflex in this case may be due to trunkal neuropathy.
Abdominal muscles power can't be examined by resistance because of proximal myopathy à the patient has history of Thyrotoxicosis.
Lost knee reflex à not related to high stock level as lost superficial sensation has nothing to do with deep reflexes but is related to lost deep sensation at the level of the knee (evidenced by lost vibration sense at the knee and may be due to amyotrophy due to femoral neuropathy).
No muscle wasting à mainly sensory.

http://medical-illness.blogspot.com/2014/11/diabetic-peripheral-neuropathy.html

Why Arent Neuropathy Symptoms Recognised By Doctors

Today's post from cidpusa.org (see link below) refers to a report published by the Neuropathy Trust in which the lack of good diagnosis by home doctors and others, leads to many neuropathy patients having to wait far too long before seeing a specialist. It's a report on a U.K. situation but is almost certainly reflected worldwide. You have to ask yourself why this still happens with such alarming regularity. Doctors claim the disease is difficult to diagnose, yet the symptoms of most neuropathies are so unique, it's hard to imagine that doctors can't recognise them and move on to further investigation via a specialist. Is it because patients own accounts aren't being listened to? Or if they are, they're not taken seriously? Unfortunately the latter is all too often the case. A patient's own story of neuropathic symptoms should be enough to at least set doctors on the right track and begin the long process of testing and diagnosis but far too often it's not and in this day and age that's unacceptable.

Pain condition 'ignored' by GPs
November 2015

Doctors misunderstand or ignore a severe pain condition thought to affect more than a million people in the UK, sufferers believe.

Peripheral neuropathy (PN), a condition in which nerve disturbances cause chronic pain, often goes undiagnosed.

The survey for the Neuropathy Trust revealed a quarter of patients wait at least a year for referral to a specialist.

Doctors said the condition was often difficult to detect.

Two-thirds of patients felt their condition was not satisfactorily kept under review, leading to the feeling that they were being forgotten by doctors.

The only way I can describe the pain is like a ring of cheesewire tightening around my toes Shirley Hughes 
 
More than six in ten had never been given a definitive diagnosis, according to the survey of 662 members of the trust.

The condition often gives rise to severe neuropathic pain (NeP) which causes parts to the body to become super-sensitive.

NeP mainly affects the arms, hands legs and feet. It can be triggered by light pressure from clothing, air movement or temperature changes.

The pain is often described as stabbing, burning, tickling, prickling or tingling.

Impact

The survey showed almost three-quarters of people with the condition are unable to work due tostabbing, burning, tickling, prickling or tingling type pain. The trust estimates there are 1.4 million sufferers in the UK.

One of them, 70-year-old Shirley Hughes, from Runcorn, Cheshire, said the condition had a massive impact on her life.

She said: "Sometimes the pain in my feet is too much to bear. The only way I can describe the pain is like a ring of cheesewire tightening around my toes.

"I had so many plans for my retirement and these are no longer possible. I had to cancel a planned trip to Australia this summer for a family wedding."

Dr Steve Allen, a consultant in chronic pain management based at the Royal Berkshire Hospital in Reading, backed the findings of the survey.

He said: "Many patients seen in my pain clinic have waited for many months from the time that they first visited their GP to the time that they receive a definitive diagnosis and commence treatment.

Worsened

"During this time their condition has often worsened, and their quality of life significantly reduced."

Co-author of a report for the Neuropathy Trust Andrew Keen, himself a sufferer of the condition, said: "Peripheral Neuropathy and Neuropathy are not new conditions. What is new is the research that is exposing them as real physical illnesses which deserve more attention than they are at present given."

He said there was an urgent need to educate GPs about peripheral neuropathy and improve fast-track patient and investigation practices. The report called for specific action by the government.

More than 100 potential causes are thought to underlie the condition, including CIDP, diabetes, cancer, and HIV.

Dr Paul Watson at the Pain Society said: "It is a difficult condition to diagnose. Often people are missed."

The solution lay in educating GPs and other frontline staff about peripheral neuropathy, he said.

He said the condition was "not very common" but that there was not enough time to see patients who need a considerable length of consultation to allow a diagnosis to be made.

Dr Watson added: "We need more resources in pain clinics."

http://www.cidpusa.org/Pain%20polyneuropathy.html#.VlH6AUgrxYw.twitter

A Doctors View On Neuropathy Treatment

Today's post from neuropathytreatments.com (see link below) gives some sound advice from the point of view of a doctor with neuropathy patients. Not everything is covered here but there is some useful information for everybody living with the many forms of neuropathy. Worth a read.

The Advice Of A Medical Professional

Posted on February 24, 2014

Neuropathy is a complex condition that can have an effect on the body’s nervous system.  Peripheral nervous system occurs. The peripheral nervous system refers to the part of the nervous system outside of the brain and spinal cord; when damage occurs to the nerve cells or nerve axons, it is called peripheral neuropathy. Neuropathy is a painful condition that can have an effect on an individual’s life and their ability to maintain a normal active life.
Peripheral Neuropathy is a condition that will have an effect on an individual’s life and if not treated could have a severely negative effect. The pain and symptoms that are common place with neuropathy limit one’s mobility and ability to function in normal life situations. For instance, numbness is a symptom of neuropathy and can limit the patient’s ability to sense or feel terrain changes – risking further injury. Neuropathy symptoms have an implication on one’s social, vocational and functional life possibly causing the neuropathy patient to suffer with feelings of anxiety and depression.
Most doctors have to admit that when it comes to neuropathy treatment they have few options to offer their patients other than a prescription medication to help numb the pain. Numbing the pain does not fix the problem it only creates more problems; the medication used to numb neuropathy pain can leave the neuropathic patient juggling now both neuropathy pain and side effects from the medication.

What To Expect For Your Doctor
There are several different classes of medications for treating neuropathy. Since there is no cure for neuropathy, the only form of treatment is to discover a way to ease the painful neuropathy symptoms that create a stumbling block in one’s daily existence and most medical professionals believe that prescription medications are an excellent way to ease the pain of neuropathy. Below you will find more information on the most popular medications prescribed to those who suffer from neuropathy.

Antidepressants
Endorphins are the way the body naturally relieves pain and antidepressants are said to help treat neuropathy pain by blocking pain signals on their way to the brain and release endorphins. Antidepressants are further categorized that are available to help treat neuropathy.

Tricyclic anti-depressants calm levels of neurotransmitters in the brain. Tricyclic can reduce pain and improve mood and even help one sleep better. For help with reliving nerve pain, doctors will often prescribe the following tricyclic anti-depressants:

• Amitriptyline
• Desipramine
• Imipramine

Side Effects: dizziness, drowsiness, dries mouth and eyes as well as constipation.

Serotonin-norepinephrine reuptake inhibitors (SNRIs) increase serotonin and norepinephrine one has in their system. SNRIs block serotonin and norepinephrine from being reabsorbed by brain cells.

Side Effects: dizziness, drowsiness and insomnia

Selective Serotonin Reuptake Inhibitors (SSRIs) are like SNRIs in that they help increase serotonin levels in the body, yet they differ in that they focus on serotonin levels to help decrease one’s pain perception.

Side Effects: insomnia, headaches and nausea

Anti-Seizures
Anti-seizures are medications that were originally designed to treat seizures. Anti-seizure medication is often prescribed to treat diabetic neuropathy due to its ability to slow down nerve signals so that the pain levels are not communicated to the brain. Examples of anti-seizures anti-convulsants would be:

• Pregabalin
• Gabapentin
• Gabarone
• Neurontin

Side Effects: drowsiness, weight gain, dizziness and nausea

Opioids
Also called narcotics, opioids are painkillers and serious stuff that should not be tampered with unless prescribed. Opioids are prescribed to relieve severe pain quickly but can become addictive.

Side Effects: drowsiness, nausea and constipation

Heed The Warning
Though the use of prescription medication can be effective in treating neuropathy pain and symptoms, there are several downsides to selecting medications as the primary form of neuropathy treatment. Medication can become addictive and have severe adverse side effects that could affect ones emotional, physical and mental stability. Never use narcotics out from under the care of a doctor.
Neuropathy can be emotionally, physically and mentally taxing without adding further complications such as depression, suicidal thoughts, anxiety and irritability. To prevent side effects that could cause severe damage to one’s health treating neuropathy naturally is a great alternative to prescription medication.

http://neuropathytreatments.com/2014/02/

A Better Understanding Of Both Doctors And Patients Situations

Today's post from health.com (see link below) is pretty much a plea to give doctors a break. As neuropathic patients often in chronic pain and discomfort, we can get frustrated at our doctors' apparent lack of answers; especially if their bedside manner is also somewhat lacking. This article points out a few of the reasons why doctors need to be let off the hook now and then because of the stresses they're under from time management and a results culture. That's not to say that we shouldn't stand our ground now and then and refuse to accept shoddy medical attention but understanding a doctor's predicament will gain their appreciation and lead to better treatment anyway.

How to Get Your Doctor to Take Your Pain Seriously. How to get the treatment you need 

Last Updated: February 29, 2016

 

Good chronic pain treatment can be hard to find. A chronic pain patient has every right to believe that his or her doctor will listen sympathetically and prescribe the appropriate treatment, but that is not always the reality. Truth is, many doctors have not been trained to deal with the complex, changing area of chronic pain treatment. One 2001 survey of primary care physicians' attitudes toward prescribing certain medications found that only 15% said they enjoyed working with patients who have chronic pain.
This can lead to frustrating encounters at the primary-care level, especially if your doctor is rushed.

Pressures on doctors

"Doctors don't want patients to suffer, they want people to get better," says Bill McCarberg, MD, founder of the Chronic Pain Management Program at Kaiser Permanente in San Diego. "But they feel stress, they feel time constraints, they have to deal with pre-authorizations, it's not the kind of practice they wanted. They're stressed, and that leads to moving patients along."

"As a doctor in today's medical system, it's difficult to deal with chronic pain conditions," agrees S. Sam Lim, MD, a rheumatologist at Emory University School of Medicine in Atlanta. "Most practices are forced to see a certain number of patients in a limited amount of time. [With chronic pain] it's not so simple as five minutes, a few questions, and handing out a pill. It takes some time. And our system isn't set up for that."

"The patient needs to realize that the doctor may not be able to discern what's going on in the first visit. Often it takes a few visits," says Dr. Lim.

Doctors are frustrated by what they can't "fix"

In 25 years of caring for her chronically sick husband, who was injured in an industrial accident, Ann Jacobs, 62, of Laramie, Wyo., has watched physicians struggle with the trial-and-error progress of his treatment. "Doctors are programmed for success stories," she says.

Meanwhile, because of its complexity, pain treatment has emerged as a separate, multidisciplinary specialty. That's good, but pain patients often need to get to a pain specialist through their primary care physicians.

Emotions can cloud the diagnosis

The emotional effects of chronic pain may also make diagnosis more difficult. Maggie Buckley, 46, from Walnut Creek, Calif., learned this the hard way. She suffers from Ehlers-Danlos syndrome, a rare genetic tissue disorder that leaves her with chronically painful joints.

"If you say 'it's really depressing and upsetting me, I'm in so much pain,'" Buckley says, "doctors will see it in terms of emotion and treat it as an emotional problem, referring you to psychiatric care or antidepressants." That is sometimes the appropriate treatment route, because antidepressants can treat chronic pain and there is a link between pain and depression, but you need to stand your ground and make sure any treatment is addressing your specific problems.

Be gentle about your pain, but be firm

It's important to be clear about your pain and explain the way it impacts your life when you're talking to your doctor. Don't be intimidated. Stand your ground, calmly.

"Patients really need to be persistent about their complaints in a way that is constructive to get across to the physician that this is something real," says Dr. Lim. "There are some physicians who are more open to listening than others. It may take a few doctors to find a marriage."

"You have to go very gently to start with," advises Ann Jacobs. "Listen to what the doctor has to say first." Then, if you're not satisfied, press harder. But remember that the most important thing is to create a relationship with your doctor in which you're a team, both looking for the best way to alleviate your pain. After he or she has assessed your needs, you can consider seeing a pain specialist.

http://www.health.com/health/condition-article/0,,20188093,00.html

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

A Doctors Letter To Chronic Neuropathy Patients Recommended

Today's post from more-distractible.org (see link below) should be required reading for every neuropathy patient and every neuropathy patient's doctor. It's an exercise in humility we could all learn from and will help everybody with chronic pain understand where their doctors are coming from. If you like it, pass on the link to your friends or other people you know with chronic pain. This doctor deserves all our thanks for being honest and giving a side of the discussion we rarely get to see. (See another post on the same subject tomorrow on the blog)

A Letter to Patients With Chronic Disease

by Dr. Rob Lamberts on July 14, 2010 in BEING A DOCTOR, BEST OF, JUST STUFF KIND OF THINGIES, PERSONAL MUSINGS

Dear Patients:

You have it very hard, much harder than most people understand. Having sat for 16 years listening to the stories, seeing the tiredness in your eyes, hearing you try to describe the indescribable, I have come to understand that I too can’t understand what your lives are like. How do you answer the question, “how do you feel?” when you’ve forgotten what “normal” feels like? How do you deal with all of the people who think you are exaggerating your pain, your emotions, your fatigue? How do you decide when to believe them or when to trust your own body? How do you cope with living a life that won’t let you forget about your frailty, your limits, your mortality?

I can’t imagine.

But I do bring something to the table that you may not know. I do have information that you can’t really understand because of your unique perspective, your battered world. There is something that you need to understand that, while it won’t undo your pain, make your fatigue go away, or lift your emotions, it will help you. It’s information without which you bring yourself more pain than you need suffer; it’s a truth that is a key to getting the help you need much easier than you have in the past. It may not seem important, but trust me, it is.

You scare doctors.

No, I am not talking about the fear of disease, pain, or death. I am not talking about doctors being afraid of the limits of their knowledge. I am talking about your understanding of a fact that everyone else seems to miss, a fact that many doctors hide from: we are normal, fallible people who happen to doctor for a job. We are not special. In fact, many of us are very insecure, wanting to feel the affirmation of people who get better, hearing the praise of those we help. We want to cure disease, to save lives, to be the helping hand, the right person in the right place at the right time.

But chronic unsolvable disease stands square in our way. You don’t get better, and it makes many of us frustrated, and it makes some of us mad at you. We don’t want to face things we can’t fix because it shows our limits. We want the miraculous, and you deny us that chance.

And since this is the perspective you have when you see doctors, your view of them is quite different. You see us getting frustrated. You see us when we feel like giving up. When we take care of you, we have to leave behind the illusion of control, of power over disease. We get angry, feel insecure, and want to move on to a patient who we can fix, save, or impress. You are the rock that proves how easily the ship can be sunk. So your view of doctors is quite different.

Then there is the fact that you also possess something that is usually our domain: knowledge. You know more about your disease than many of us do – most of us do. Your MS, rheumatoid arthritis, end-stage kidney disease, Cushing’s disease, bipolar disorder, chronic pain disorder, brittle diabetes, or disabling psychiatric disorder – your defining pain - is something most of us don’t regularly encounter. It’s something most of us try to avoid. So you possess deep understanding of something that many doctors don’t possess. Even doctors who specialize in your disorder don’t share the kind of knowledge you can only get through living with a disease. It’s like a parent’s knowledge of their child versus that of a pediatrician. They may have breadth of knowledge, but you have depth of knowledge that no doctor can possess.

So when you approach a doctor – especially one you’ve never met before – you come with a knowledge of your disease that they don’t have, and a knowledge of the doctor’s limitations that few other patients have. You see why you scare doctors? It’s not your fault that you do, but ignoring this fact will limit the help you can only get from them. I know this because, just like you know your disease better than any doctor, I know what being a doctor feels like more than any patient could ever understand. You encounter doctors intermittently (more than you wish, perhaps); I live as a doctor continuously.

So let me be so bold as to give you advice on dealing with doctors. There are some things you can do to make things easier, and others that can sabotage any hope of a good relationship:

Don’t come on too strong – yes, you have to advocate for yourself, but remember that doctors are used to being in control. All of the other patients come into the room with immediate respect, but your understanding has torn down the doctor-god illusion. That’s a good thing in the long-run, but few doctors want to be greeted with that reality from the start. Your goal with any doctor is to build a partnership of trust that goes both ways, and coming on too strong at the start can hurt your chances of ever having that.

Show respect – I say this one carefully, because there are certainly some doctors who don’t treat patients with respect – especially ones like you with chronic disease. These doctors should be avoided. But most of us are not like that; we really want to help people and try to treat them well. But we have worked very hard to earn our position; it was not bestowed by fiat or family tree. Just as you want to be listened to, so do we.

Keep your eggs in only a few baskets – find a good primary care doctor and a couple of specialists you trust. Don’t expect a new doctor to figure things out quickly. It takes me years of repeated visits to really understand many of my chronic disease patients. The best care happens when a doctor understands the patient and the patient understands the doctor. This can only happen over time. Heck, I struggle even seeing the chronically sick patients for other doctors in my practice. There is something very powerful in having understanding built over time.

Use the ER only when absolutely needed – Emergency room physicians will always struggle with you. Just expect that. Their job is to decide if you need to be hospitalized, if you need emergency treatment, or if you can go home. They might not fix your pain, and certainly won’t try to fully understand you. That’s not their job. They went into their specialty to fix problems quickly and move on, not manage chronic disease. The same goes for any doctor you see for a short time: they will try to get done with you as quickly as possible.

Don’t avoid doctors – one of the most frustrating things for me is when a complicated patient comes in after a long absence with a huge list of problems they want me to address. I can’t work that way, and I don’t think many doctors can. Each visit should address only a few problems at a time, otherwise things get confused and more mistakes are made. It’s OK to keep a list of your own problems so things don’t get left out – I actually like getting those lists, as long as people don’t expect me to handle all of the problems. It helps me to prioritize with them.

Don’t put up with the jerks – unless you have no choice (in the ER, for example), you should keep looking until you find the right doctor(s) for you. Some docs are not cut out for chronic disease, while some of us like the long-term relationship. Don’t feel you have to put up with docs who don’t listen or minimize your problems. At the minimum, you should be able to find a doctor who doesn’t totally suck.

Forgive us – Sometimes I forget about important things in my patients’ lives. Sometimes I don’t know you’ve had surgery or that your sister comes to see me as well. Sometimes I avoid people because I don’t want to admit my limitations. Be patient with me – I usually know when I’ve messed up, and if you know me well I don’t mind being reminded. Well, maybe I mind it a little.

You know better than anyone that we docs are just people – with all the stupidity, inconsistency, and fallibility that goes with that – who happen to doctor for a living. I hope this helps, and I really hope you get the help you need. It does suck that you have your problem; I just hope this perhaps decreases that suckishness a little bit.

Sincerely,

Dr. Rob

http://more-distractible.org/2010/07/14/a-letter-to-patients-with-chronic-disease