Management for Cleveland 
Neuropathy Pain Relief

What is Peripheral Neuropathy?

The peripheral nervous system serves an important function, which is to make the person aware that there is possible tissue damage or a dangerous element in their immediate environment. Normal function of the nervous system is such that pain is an indicator of imminent or actual harm to a body part, which results in protective reflexes that will either prevent or minimize the damage. The term for this type of pain is nociceptive pain. It’s generally described as sharp, aching, and throbbing. When pain occurs without any noxious stimuli or threat of imminent harm, this is termed neuropathic pain. It is maladaptive, or dysfunctional, and does not serve any purpose for the nervous system. Typically, the sensations are described as tingling, shooting, or stinging.

The nervous system is comprised of two parts: the central nervous system, which includes the brain and spinal cord, and the peripheral nervous system, which includes all the nerves apart from the brain and spinal cord. Peripheral neuropathy affects the peripheral nerves. The peripheral nervous system has two parts: the somatic nervous system and the autonomic nervous system. The somatic nervous system exerts control over the skeletal muscles and allows us to have voluntary control over our bodies. The autonomic nervous system controls automatic and involuntary functions of the body, which include our cardiovascular, respiratory, digestive, and urinary tract systems. These systems all work outside of our conscious control … for example, we don’t have to remind ourselves to breath or tell our heart to beat every second. In the peripheral nervous system there are two major types of nerves. There are the motor nerves and the sensory nerves. The motor nerves carry electrical impulses from the brain to the peripheral skeletal muscles. The sensory nerves carry messages from the periphery (the arms, legs, and organs) to the spinal cord and brain.

Structure of Peripheral Nervous System

The peripheral nerve cells have two types of nerve fibers, large and small. The large nerve fibers are responsible for motor function, vibration perception, positional sense, and perception of temperature. They are typically myelinated and long. Myelination, or insulation of the nerve fibers, allows them to carry nerve signals at a very rapid rate to the central nervous system. When the large fibers don’t work well, dysfunction is characterized by numbness, tingling, weakness, and loss of deep tendon reflexes.

Small nerve fibers can be either myelinated or unmyelinated. These small nerve fibers are typically very sensitive to pain and abnormal sensations such as tingling or burning. Small fiber neuropathy symptoms may include pain, altered sensation, pressure, or insensitivity to heat/cold. The pain may be described as burning or stabbing, and the altered sensations may be described as warmth, coldness, a warm fluid dripping down the leg, or bugs crawling on the skin. Autonomic dysfunction may also occur with small nerve dysfunction. Autonomic dysfunction is a change in controls of our normal homeostasis of the cardiovascular, respiratory, digestive, or urinary tract systems.

What happens in peripheral neuropathy?

In peripheral neuropathy there is a dysfunction or abnormal function of the nerves in the peripheral nervous system. The symptoms associated with peripheral neuropathy depend on which nerves are affected. Remember that there are three types of nerves in the peripheral nervous system: the sensory nerves, the motor nerves, and the peripheral nerves. The sensory nerves relate to the input from the periphery of the body to the central nervous system. If the sensory nerves are damaged this may lead to pain, numbness, tingling, burning, or a loss of sensation. Typically, the symptoms start in the legs or the hands and move centrally towards the trunk. The nerve damage can either be in the large or the small fibers and the symptoms may be either continuous or intermittent. If there is lack of sensation, multiple recurring injuries may occur because the limbs are numb and the injuries aren’t noticed.

Peripheral Neuropathy Classification

There are three classifications of neural neuropathy which include mononeuropathy, multiplex mononeuropathy and polyneuropathy. Simply, mononeuropathy means one nerve or the involvement of a single (peripheral) nerve. Carpal tunnel syndrome is the most common cause of mononeuropathy and it may be a result of nerve entrapment or trauma. Mononeuropathy multiplex is a term used when there are more than one peripheral nerves in separate areas of the body that are affected by peripheral neuropathy. There are a number of medical conditions that are associated with mononeuropathy multiplex including vasculitis, diabetic amyotrophy, sarcoidosis, Lyme’s disease, lymphoma carcinoma, HIV, amyloidosis and polyarteritis nordosa.

Polyneuropathy

Polyneuropathy affects multiple nerves and usually in more than one extremity and more than one side of the body. The symptoms are typically in the legs and the arms. Polyneuropathy is associated with the following conditions: diabetes, alcoholism, vitamin D deficiency and HIV. There’s a type of polyneuropathy that is termed distal symmetric polyneuropathy. There are two types of polyneuropathy. It may either be acute or chronic. Acute polyneuropathy comes on suddenly and becomes rapidly progressive. Typical conditions associated with acute polyneuropathy include: Guillain–Barré Syndrome, diphtheria, vasculitis, tumor, porphyria and medication therapy. Polyneuropathy evolves over a much longer time period. This is associated with diabetes, which is the most common cause, nutritional deficiencies, cancer, renal failure, medication toxicity and alcohol abuse.

Risk factors for Neuropathy

Risk factors for development of polyneuropathy include diabetes. Sixty percent of patients with diabetes, type I or II, develop peripheral neuropathy. There seems to be a correlation between the control of elevated blood sugars. Poor control of blood sugar leads to a marked increase in the risk of onsite of peripheral neuropathy autoimmune diseases include: Systemic lupus erythematosus (SLE), rheumatoid arthritis and Guillain–Barré Syndrome. There are also risk factors with metabolic diseases such as amyloidosis and hypothyroidism, hereditary disorders, Charcot-Marie-Tooth’s disease. Infectious disease such as HIV, hepatitis B, leprosy, Lyme’s disease, ischemic disorders, chronic kidney or liver failure, trauma or compression of a nerve, repetitive motion disorder, vitamin deficiencies including B12, alcohol abuse, paraneoplastic disorders, toxic substance exposure, chemotherapy including vinca alkaloids, platinum-based drugs and taxanes; all of the above are risk factors and are associated with the increased incidence of peripheral neuropathy development. Incidents of peripheral neuropathy estimates as high as 20 million Americans suffer from some type of peripheral neuropathy. This is a approximately 8% of our adults over the age of 55. Worldwide, the incidents of peripheral neuropathy are estimated to range from 2-10% of the population. Approximately 25-60% of diabetics are thought to have some type of diabetic peripheral neuropathy with estimates varying widely. Worldwide, the most common cause of neuropathy is leprosy with HIV infection gaining rapidly.

Diabetic Neuropathy

In the western countries the most common cause of peripheral neuropathy is diabetes mellitus; both type I and type II. The peripheral neuropathy occurs in approximately 30-50% of diabetic patients as estimated by the American Academy of Family Physicians. The characteristic symptoms of diabetic peripheral neuropathy include loss of sensation, typically in a stocking glove pattern. This typically starts in the feet and spreads towards the trunk. Symptoms include burning, tingling and aching that worsens at night. Other symptoms may include allodynia, which is pain from light touch that is typically not painful in normal patients, and hyperalgesia, which is termed as an increased sensitivity to painful stimuli. Diabetic neuropathy is related to hypoglycemia and insulin deficiencies, but the mechanism of nerve damage is not known

Risk factors for diabetic peripheral neuropathy include a long duration of the disease, poor control of blood sugars and obesity. Other risk factors include hypertension, smoking, dyslipidemia with elevations of cholesterol and triglycerides. The common characteristics of diabetic neuropathy include numbness, reduced sensation, pain, burning, pins and needles, shooting pain, hyperesthesia, pain worsening at night, poor posture control, hyperextension of the big toe and clawing of the toes, reduced thickness of the plantar tissue and foot ulcers.

Foot Ulcerations and Diabetes

Foot ulcerations are a serious complication of diabetic peripheral neuropathy. The causes are reduced sensation in the feet, reducing the reflexes and mechanisms or reduction in circulation, changes in gait and abnormalities of movements causing abnormal pressure points. Diabetic neuropathy also affects nearly 50% of diabetics. The autonomic neuropathy is typically associated with cardiac disease. Diabetic focal neuropathy may include the following symptoms: inability to focus the eye, double vision, aching behind one eye, Bell’s Palsy, severe pain in the low back or pelvis, pain in the front of the thigh, pain on the outside of the shin or the foot and chest or abdominal pain. Remission or resolution of pain from diabetic peripheral neuropathy is related to change of the metabolic status that is better control of blood sugars, weight loss and sensory loss that is not severe.

Pre-diabetes and Peripheral neuropathy

There has been a renewed focus on elevated blood sugars and pre-diabetes as it relates to the development of peripheral neuropathy. Mounting research evidence shows that elevated blood sugars may be related to damage of peripheral nerves. The neuropathy associated with pre-diabetes or poor glucose control is the same type that diabetics suffer from. The following symptoms occur in both pre-diabetics and diabetics, which include tingling, paraesthesia, pain, numbness and autonomic dysfunction. The symptoms with pre-diabetes are typically lessened as compared to those with diabetes. Metabolic syndrome is common in pre-diabetes. Metabolic syndrome is characterized by excess weight around the waist, high triglycerides, dyslipidemia, high blood pressure and high fasting blood glucose levels.