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Neuropathy Pain and Nerve Pain
Have you ever had the feeling that your feet were on fire, that you have pebbles in your shoes, it feels like your socks are wadded up or you have loss of feeling and numbness in your feet, but yet they are very sensitive to something as light as the bed sheets laying on them. However your feet are not on fire, there’s no pebbles in your shoes and you have no problems with your socks. All of these symptoms can be due to a condition we call peripheral neuropathy. peripheral neuropathy is not an uncommon condition and is one of the most common disorders of the peripheral nervous system in adults. And as we age the incidence of peripheral neuropathy increases. And it is reported 2 to 7% of the worldwide population may be affected by peripheral neuropathy. Symptoms can occur intermittently or be constant. Typically the pain is worse at night when the patient is relaxed and trying to go to sleep. In patients who suffer from neuropathy they frequently will try multiple types of shoes in order to relieve the pain or make walking more tolerable. It is not uncommon for those patients that have the complaints of severe burning in their feet not to wear socks and sometimes even go barefoot or wear sandals in the freezing months of winter.
Symptoms and signs open are peripheral neuropathy very from patient to patient. However, typically nerve pain is what brings patients to the doctor. This pain can vary in its intensity from mild discomfort to disabling pain. Other people frequently describe that their feet feel like stones or logs. It is sometimes difficult for the patient who is suffering from painful neuropathy to describe their pain accurately. Frequently family members of those affected cannot understand the discomfort and pain that the patient is experiencing because on the outside the patient looks perfectly normal.
Peripheral neuropathy can get bad enough to affect balance and stability causing the patient to be at increased risk of falling an injury. This is crucial especially as patients get older. Several studies have linked peripheral neuropathy as a significant risk factor for falls in the elderly. This is primarily due to the loss of sensation in the feet. Subtle progression of the loss of sensation puts the patient at risk without them knowing it. Frequently patients will state that they have increased problems with her balance and walking if the room is dark or if they close their eyes.
As previously discussed there are many causes of neuropathy. However, diabetes is the number one cause world wide. Other causes include toxic exposure, cancer, genetics and idiopathic, meaning we don’t know the reason. The peripheral nervous system is divided into 2 parts we call these large fiber and small fiber. Certain diseases will affect either one of these in a different manner. Typically small fiber is the most painful. As previously mentioned diabetic neuropathy is the most common. However it is not unusual to have patients present with numbness tingling or burning in their feet years prior to being officially diagnosed as a diabetic. The prediabetic state which affects an estimated 88 million adults are at risk of developing diabetic neuropathy. Sugar is toxic to the nerve and the nervous system. Innocuous levels of sugar overtime frequently damages the small nerve fibers in the feet that results in a numbness tingling and burning that many people with pre diabetic or diabetic neuropathy experience.
With the American diet high in carbohydrates this is one of the leading causes to the development of metabolic syndrome leading to eventual diabetes.
When you present to the neurologist for evaluation of your numbness, tingling and burning of the feet he will try to obtain an accurate history but when it begins what makes it worse or better and if you have any other associated conditions or problems that may be associated with peripheral neuropathy. His neurological examination will include reflexes and testing the sensation of your feet for light touch, temperature, pinprick and vibration. Loss of any of these or all of them would suggest peripheral neuropathy. However it is not unusual for the patient that has complaints of small fiber neuropathy such as burning numbness and tingling to have complete normal sensation of the feet. This is a factor that is confusing to the patient who suffers from neuropathy thinking how can their feet be in so much pain when they have normal sensation. Reflexes are also important because absent reflexes could suggest something coming from the low back. skin condition and color can also give us clues to neuropathy. These cutaneous manifestations are very common especially in diabetic neuropathy.
Your neurologist will obtain different blood tests and urine tests to look for any underlying causes causing your neuro pathic pain in your feet. Frequently deficiencies in vitamins can cause neuropathy such as vitamin B12. This vitamin also can cause pernicious anemia. Typically those patients who suffer from B12 deficiencies we’ll need to supplement this either with intramuscular injections or sublingual vitamin B12 supplement. Vitamin B12 tablets are typically not as effective since most people get enough vitamin B12 in their diet. It is not uncommon to help to collect 24 hours of urine in the diagnosis of neuropathy. Certain abnormal proteins can result in neuropathy. These abnormal proteins are commonly associated with certain types of bone marrow cancers.
In addition to lab test your neurologist will obtain electrodiagnostic studies such as EMG/NCV. The EMG, Electromyography and the nerve conduction study, NCV will help clarify between the differences of small fiber and large fiber. Small fiber neuropathy have a normal electrodiagnostic test. he may also use skin biopsies in order to assess in fact if the small fibers have been injured.
So once the work up is complete and all the lab tests and electrodiagnostic studies finished he will be able to give you an idea of what type of neuropathy you are suffering from. If all the lab work and diagnostic test are normal. It does not mean that you do not have a problem. What it does mean is that you have idiopathic peripheral neuropathy. In reality this is the second most common neuropathy after diabetes. Despite it being called idiopathic these can be quite disabling due to the severe pain that you experience.
There are many treatments of neuropathy. However, treating pain associated with the nerve is not an easy task. Multiple trials of medications may be needed as well as dosages. It should be the goal of your neurologist to control your painful complaints with the minimum amount of medication needed. The typical pain medication such as narcotics are usually not effective in treating this type of pain. We frequently use anti-epileptic medications and antidepressants. It needs to be clarified that if you are treated with an antidepressant medicine you are not being treated for depression; these medications are sometimes quite effective in treating pain. In addition to these medications which are taken orally frequently, medicated lotions can be prescribed and given over the area of pain. One crucial aspect is frequently overlooked by medical physicians in the treatment of neuropathy and that is the use of diet and exercise. Good nutrition, low carbohydrate, high fiber exercise is crucial for general health as well as health of the nervous system.
Migraine Headaches
Around the world migraine headaches are one of the leading causes of disability. Migraine headaches frequently affect women more so than men. They can occur at any age but most frequently in the younger populations.
The definition of migraine is a headache of severe pain that is paradoxical, associated with light, sound sensitivities nausea and vomiting. These headaches can last several hours to several days. Frequently migraine headache sufferers will have their daily activity interrupted resulting in disability from their jobs or normal life.
There are many types of migraine headaches even some headaches that are considered migraine have no associated head pain. Frequently migraine headaches will begin one or two days before the actual headache. A stage called the prodrome stage, during this period of time prior to the migraine headache the patient may experience difficulties with their vision, speech or thinking. In some people the migraine prodrome is frequent yawning or tiredness. A migraine aura which can occur after the prodrome stage and before the head pain can affect vision, tis visual aura is frequently described as shimmering lights in the visual field.
Migraine headaches can also be triggered by a multitude of causes, these include changes in the weather, certain smells, increase or decrease stress, some people under a lot of stress at work and then when the weekend comes, the stress is gone and wham they get a headache or vise versa. Someone without stress is put in a stressful situation and wham, a migraine headache. Certain foods, probably the most well-known for this is MSG, this additive is frequently found in Chinese foods. an hormones fluctuation can also trigger migraines.
After an evaluation from a neurologist who is a headache specialist, a detailed history will be obtained regarding the characteristic and nature of your migraine headaches. Frequently migraine headaches run in families. An in depth and thorough neurological examination may suggest the need for neural imaging such as an MRI of the brain or cat scan. Blood test may also be beneficial to help uncover if there is any underlying metabolic or hormonal deficiencies.
Depending on the frequency and the number of headaches that one suffers from through the month will determine the type of treatments that are recommended. Typically, more than two disabling migraines per month would warrant prophylactic (prevention) migraine treatment. If the migraine headaches only occur once or twice a month acute treatment maybe the only thing needed. When the patient suffers with more than four headaches per month prophylactic treatment is usually recommended. These treatments include the uses of anti-epileptic medications, certain blood pressure medicines, and antidepressant medicines. With disabling headaches numbering 50% of the month, proper lactic treatments for these would include Botox injections and some of the newer once a month injectable migraine medications.
Patient suffering from migraines may also benefit from a dietary evaluation and possible dietary changes. Frequently subtle food allergies can place the patient at risk of headaches. Sometimes an elimination diet is helpful to discover which types of food or ingredients may provoke the migraine headache. There are specialty lab tests also that can help distinguish certain types of food allergies. Many of these food allergies the patient is unaware of. Sleep disorders such as sleep apnea can provoke migraine headaches. A sleep study may be beneficial in determining sleep apnea as a cause of migraine. Rarely despite many patient’s concerns are headaches or migraines caused from brain tumors or aneurysms.
One of the major concerns by physicians about their patients who have migraine headaches that the patient avoids proper evaluation and treatment and exchange of this treat themselves with over-the-counter medications. Frequent use of over-the-counter medications can lead to a condition known as overuse or analgesic rebound headache. This is caused by the frequent daily use of over-the-counter medications. These headaches are frequently some of the most difficult to treat since the patient will usually require abstinence from all medications for a period of time. Once a period of time has pasted without any medications, treatment can then be re-established utilizing prescribed medications for acute treatment and prevention. Other alternative therapies can be found with chiropractic, acupuncture an neutraceuticals in the form of certain vitamins and supplements.
Treatments not recommended for migraine headaches include narcotics and pain medications. These are not effective and typically increase the risk of patients developing addiction and rebound headaches.
Forms of migraines which do not cause pain are optical/ophthalmic migraines. These headaches symptoms are frequently flashes of lights, blind spots or loss of vision. When these occur the evaluation and work up must rule out other causes. Another form of headache is vestibular migraine. These migraine headaches have symptoms typically affecting balance, dizziness or Vertigo. These can affect patients of all ages.
It is important when you see your neurologist or headache specialist that you keep accurate records regarding the frequencies of migraine attacks, the characteristic and nature of the headache and events that lead up or are associated with their onset. This will help him better develop a treatment plan avoiding unnecessary medical procedures and medications.
In addition to migraine headaches many people suffer from different types of headaches examples include, cervical genic headache which is caused from abnormalities and pain in the neck. This could result from previous neck injuries or the way that one holds their neck during their normal daily activities such as working at a computer. Eye strain is frequently a cause of muscle tension headaches. Cluster headaches are also extremely severe. These headaches typically affect one side around the eye occur in clusters and the patient may do well for several months and then have a week of several headaches throughout the day for several days. Typically, these headaches are associated with bloodshot eye runny nose and runny eyes. The pain associated with cluster headaches according to the patient is excruciating.
Many of the medications used for the treatment of headaches are frequently the same medications to used to prevent migraines. Typically, your doctor will look at other conditions that you may be suffering from and pick a medication which may cover two conditions. Examples would be if you have difficulty sleeping at night in addition to having headaches, he may use a medication such as amitriptyline, which is excellent for the treatment of headaches but as a side effect can cause you to sleep better. However amitriptyline itself is not considered a sleep medication and it does not affect the architecture of sleep. Therefore, you get benefits from its side effect in addition to controlling your headaches.
The treatment of headaches is always challenging. Many times, patients what a quick fix. However, this is frequently not possible especially if the headaches can be triggered by certain environmental triggers such as certain ingredients in food, weather or hormonal fluctuations. Treatment will usually begin with a slow course to optimize the right medications, diet nutrition. This also avoids any side effects that may be experienced if medications are prescribed too rapidly.
Epilepsy
The description of epilepsy dates to biblical times and one of the first miracles that performed by Jesus when He cured someone of epilepsy. So what is the seizure. Our brain function is based on electrical activity. This activity changes through the day and changes when we sleep. A seizure is caused by abnormalities in this electrical activity. In one area of the brain electrical activity begins to become abnormal, its electrical impulses increase in size until it spreads to the next brain cell and on and on. This irritation of the neighboring brain cells causes that brain cell to be irritated. This process continues over and over again until the area becomes so electrically agitated that an almost electrical explosion occurs causing abnormal electrical activity to spread across the entire brain. When this occurs the patient will have a convulsion.
There are many causes of seizures, causes frequently are based on a patients age. Frequently, we never find a cause of a seizure. Genetics can also result in seizures as well as trauma, stroke and brain tumors.
Seizures are not uncommon with more than 200,000 new cases every year in the United states. Epilepsy itself is defined as a condition with recurring seizures. There are about 39 million people who have epilepsy. However, most new cases are most frequently seen in babies and the elderly. Five to ten percent of the population will have a seizure by the time they are 80 years old. However, this does not mean they become epileptic. The presentation for seizures very from patient to patient depending on the type of seizure they have. Seizures are all caused by abnormal electrical activity in the brain. Depending on the location where this abnormal activity begins will manifest itself in different physical characteristics. If a seizure occurs in a small area of the brain that controls the movement of the limbs the patient may only experience jerking or shaking without any confusion if the seizure doesn’t spread. If the same type of seizure occurs in the area that only controls sensation, the patient may only experience numbness and tingling. If seizure spreads across the entire brain, the patient typically will have a violent convulsion with jerking of all limbs and frequent tongue biting and loss of bowel and bladder, this is called a generalized tonic clonic seizure. These seizures are frequently followed by a period of time which the patient is extremely fatigued and will frequently sleep. The two previous seizures that occur as with jerking or sensation abnormalities can also expand to affect the entire brain and then become a generalized convulsion. these seizures which are generalized affecting the whole body are frequently accompanied by tongue biting and loss of bowel or bladder control.
Seizures can occur at anytime of the day or night. Some seizures will give the patient a warning. we call this an aura. An aura can be anything from flashing lights, a bad smell or taste or confusion. other seizures may give no warning at all. These seizures occur suddenly without warning frequently causing the patient to fall to the ground if standing or sitting. Convulsions that affect the entire body are called generalized tonic clonic seizures. These are extremely violent but last only a few minutes. Convulsions lasting longer are considered a medical emergency and 911 should be called.
When a person has a seizure they will most likely be referred to a neurologist who will evaluate them and look for an underlining cause. A detailed history of how the seizure occurred is important in developing a treatment plan. Your neurologist will do an extensive physical and neurological examination to make sure there is no signs of a brain abnormality. He will then precede with an MRI of the brain which will take detailed pictures of the brain to look for any structural abnormality of the brain such as a stroke, brain tumor or developmental defect. He will also obtain an EEG, an EEG is a electroencephalogram, like an ECG for the heart, this looks at electrical activity of the brain. This test is usually done in his office. Many wires will be attached to the head and will measure electrical activity. He will be looking for abnormal electrical activity that could be the source of the seizure. Abnormal electrical activity however does not always equate with abnormalities of the brain seen on MRI and frequently the EEG will be normal.
A person that has a single seizure will have approximately a 40% chance of having a second. Treatment is not typically given to a person that has a single seizure unless there’s abnormalities on the MRI or EEG. Treatment typically occurs after the second seizure or if there is an abnormality found on the MRI or EEG.
There are many choices for medications in the treatment of seizures or epilepsy. Given the advances in the pharmaceutical industry many of these medications cause very few or no side effects. Many of the seizure medications are also used for treatment of other conditions such as migraine headaches and nerve pain due to diabetes. They are also even used in the treatment of some psychiatric diseases such as bipolar. Many times, patients will respond to one medication in the control of their seizures. However, there are a few patients that require treatment from more than one medicine. In addition to medication, nutrition is extremely important. Avoiding processed foods may help with seizure control as well as avoiding certain drinks such as the high caffeinated sports drinks. In the past prior to the development of seizure medications the choice of treatment was the ketogenic diet which is a diet of very high fat and low carbohydrates. This diet was quite effective but difficult to maintain. The diet was used extensively in the 1920s which was many years prior to the food industry having available to us poor quality and processed foods. Other advances in the treatment of seizures or epilepsy include a vagal nerve stimulator. The vagal nerve stimulator is a small electrical device very similar to a pacemaker that has a wire that is attached to the Vagus nerve which is located in the neck. This generator gives little electrical impulses constantly to the vagus nerves that helps eliminate seizures. This electrical stimulation is usually noted by the patient in the beginning but after a few days they do not realize it. Also depending on the severity of seizures actual brain surgery to remove the area of abnormality can be made. All of theses treatments are based on the type of seizure or epilepsy that the patient is experiencing.
Memory Loss
Do you ever worry when you cannot find your keys or you forget your friend’s name? Frequently these slips will cause a sense of panic knowing that possibly this memory loss can be the beginning of dementia. The main concern of adults 50 years and older is that they possibly could become demented. This is most likely due to the fact that adults at the age of 50 may be the primary caregivers of their parents who are 75 years of age and older Anne suffer from dementia.
Memory loss is something that we’re seeing more and more frequently at a younger and younger age. Currently 10% of 65 year olds suffer from dementia of Alzheimer’s type. At 85 years of age this percentage increases to 50%. Memory loss in the beginning can be subtle but as the disease processes expand this has become one of the most costly diseases affecting our society.
When we look at dementia essentially this is a general term for loss of memory, language and problem solving and other thinking abilities. Alzheimer’s is the most common form of dementia or memory loss. However, there are many forms of dementia currently.
Many times memory loss will not be the presenting factor to a patient that brings themselves to a neurologist for evaluation. They may be making mistakes in their checkbook and getting lost when driving. Frequently family members and caregivers we’ll be the first ones to notice these problems. The patient may have difficulty following instructions Anne may make mistakes and cooking and following a recipe.
Due to this fear of this disease many times memory loss is downplayed infrequently patience in caregivers are in denial of the deficit.
There are many risk factors that place a patient at risk for developing memory loss leading to dementia. There are frequent genetic components. History of traumatic brain injury or insult especially with concussion now that we are recognizing professional sports athletes. Diabetes also puts a patient in significant risk of developing memory loss associated with Alzheimer’s dementia. In 2008 the Alzheimer’s journal classified Alzheimer’s as type 3 diabetes. Obesity is also a crucial risk factor for developing the memory loss of Alzheimer’s.
When being evaluated by the neurologist for memory loss it is important that he take a past medical history learning about any types of injuries you could’ve had to the brain, your family history and also levels of education. He will give you a memory test that he will help to determine what type of memory loss you are suffering. Depending on these findings he may further have you evaluated with a neuropsychologist that will do an in depth memory test which frequently is done over 2 days due to its extensiveness. He will also proceed with a cat scan or MRI of the brain to detect any previous strokes or brain abnormalities such as shrinkage or cerebral atrophy. Electrodiagnostic testing such as an EEG can be helpful to rule out other causes of memory loss such as seizures. He will do extensive blood work to look at thyroid, nutritional status such as certain vitamin deficiencies. Sleep study to rule out sleep apnea or sleep disorders that can affect memory loss. He will also ask you about your activities of daily living if you exercise your social interactions with people.
Memory loss is a frequent symptom of dementia of all types. However dimensions are frequently divided into several specific types depending on their underlying abnormalities found in the brain. Memory loss associated with Alzheimer’s disease frequently will find abnormal protein accumulation within the brain resulting in dysfunction. Other types of memory loss dementia such as lewy body may present with difficulty in walking sometimes mimicking Parkinson’s. Each year with the advances in diagnostic imaging earlier diagnosis of memory loss can be made. These advances however treatment advances have been slow Anne few tile.
Early diagnosis is crucial in memory loss, not all memory loss specifically means dementia. However if a patient is diagnosed with dementia intervention can be made. In the beginning stages of dementia we call the initial stage or subjective cognitive impairment at this stage of memory loss frequently the patient may complain all problems with their memory. However they go to the neurologist and are evaluated and no obvious underlining cause of memory loss can be detected. Frequently at this point the patient will be followed for the next several years to make sure there is no progression this stage typically lasts three to four years which is then followed by a stage called mild cognitive impairment. At this stage of memory loss mild cognitive impairment the patient now will start showing signs that can be recognized by the health care professional. Frequently treatment will be started at this stage to prevent or slow progression of the disease. The final stage is dementia at this stage frequently we will see difficulties in the patient doing their normal activities of daily living such as maintaining their household balancing their checkbook and managing their medications. As the disease progresses dementia can sometimes be accompanied by behavioral disorders such as agitation or irritation. Frequently the behavioral issues noted in memory loss typically occur at night which we call sundowning.
The treatments of memory loss caused by dementia or limited there has been no new medications for memory loss of dementia for over 15 years. The current medications available R limited in slowing the progression and do nothing for reversal or prevention. In addition to the treatment of memory loss with medications it is crucial that your neurologist address issues of brain health such as nutrition, exercise, sleep an well being. Dietze in high carbohydrate content can put one at risk, poor sleep is a significant risk factor for developing memory loss of Alzheimer’s exercise also is a contributing factor for brain health and atrophy.
As memory loss progresses patients usually require long term care in the form of nursing homes or memory care units. There is no cure for this devastating condition and as it progressive it becomes more difficult to treat requiring more and more from the caregiver.