Capsaicin: Neuropathic Pain Topical Treatment

This article brings to mind a long forgotten medication for nerve pain. I will probably start experimenting again with it. Looks like it comes as a patch also. Sweet!!

http://www.podiatrytoday.com/blogged/can-topical-capsaicin-be-treatment-alternative-neuropathic-pain

Nerve Innervation Foot: Great Review of Local Nerves and Low Back Innervation

Nerve pain, also called neuropathic, is one of three common causes of pain in the foot. This is a wonderful review of this innervation. Any pain can have one, two, or three causes: mechanical, inflammatory, and neuropathic. Each aspect can be simple or complex to treat or even recognize. So many of my patients start with mechanical pain (for example, the sesamoid hits the ground too hard in a work out), develop chronic inflammatory pain as the body unsuccessfully tries to heal it, and then nerve pain sets in making the pain intolerable as the body tries to protect itself. It does not take long for an injury to have all 3 types of pain going on, each needing its own treatment. For example, the same sore sesamoid bone may need mechanical off loading, a daily dose of ice and contrasts, and neural flossing, Neuro-Eze, gentle but deep massage to get at the nerve pain. 

https://youtu.be/cpOTXT_Zd0g

Neuropathic Pain Article on Recent Studies

https://arstechnica.com/science/2017/06/scientists-come-up-with-neural-mechanism-and-possible-fix-for-chronic-pain/

600 mg of Alpha Lipoic Acid for Neuropathy

http://www.podiatrytoday.com/emerging-role-alpha-lipoic-acid-diabetic-neuropathy

Calmare Therapy: A Rising Star for Nerve Pain (even CRPS)!?

Hi Dr. Blake, I have some very exciting news to share. I have been on the East Coast having some experimental treatments for the last three weeks. A new generation of electronic device that delivers healthy nervous system signals to the brain, somehow erasing old pain pathways.
I was very skeptical initially, seemed like one more silly Tens kind of gizmo, but I have been completely astounded at the results.

The technology does not rely on the Gate theory  of pain, but rather on a different kind of signal theory.

Almost all of the pain and allodynia has been eliminated from my foot.
It is like a miracle.

I don't know how long this improvement will endure. Most patients experience some regression over time, and need additional treatments. and I also will have a lot of rehab to do to get a normal sock and shoe on that foot, and very gradually rebuild strength and endurance in walking.

But for right now it has given me so much hope to have relief from that horrible neuropathy that was like the worst kind of torture.

The name of the machine is called Calmar. There have been some small scale studies demonstrating efficacy, and larger scale trials, including at the Mayo Clinic, are now underway. It is effective with CRPS, post herpetic neuralgia, diabetic neuropathy, and post chemo therapy neuropathy. Goodness knows these are all patients who need help and hope.

I know you care so much about your patients and have been trying very hard to find solutions for me and others. I will send you more information when I get home.

Unfortunately my L5 – S1 disc issue, which was a sleeping tiger, has been set off by the travels, so I am having very painful sciatica now And  will have to get that calmed down. But even that is nothing compared to the CRPS.

I'll be in touch with more information about Calmar, when I'm home and doing a little better.

I hope you are doing well and thank you again for all your care and concern.

Best to you, 


http://youtu.be/GzbbkS-Imm0

http://youtu.be/KFkTEr-uz78

http://youtu.be/NElvi0ZYhYY

http://www.calmarett.com/pain/index.html

Sublingual Ketamine for Severe Neuropathic Pain

I keep hearing about sublingual Ketamine for severe nerve pain flareups. All MDs that I discuss this with are reluctant to prescribe. Here at least is blog post from one pain specialist supporting it. 

http://painsandiego.com/2012/08/22/ketamine-iv-vs-nasal-spray-or-sublingual/

Nerve Symptoms: Start with Neuro-Eze but Evaluate the Cause

After several months trying to heal my sesamoiditis I started getting sporadic tingling sensations all over my foot, and a numb feeling around the sesamoid and along the inside of my big toe. After reading this post I subsequently bought neuro-eze with the hope that it would alleviate these symptoms. However, I have been hesitant to use it because the description on the bottle says that it helps with neuropathic pain, and I do not have any nerve pain and I'm not entirely sure if what I have would be defined as neuropathy. Would you still recommend to using it for my symptoms of tingling and numbness?


Dr Blake' s comment: 

   Yes, it is a good starting point for the neuropathy (abnormal nerve sensations). Patients with neuropathy get just numbness/tingling, just pain, or a combination of the 2, but it is still neuropathy. Neuro-Eze in my experience works on 50% of those cases. That being said, please have a neurologist or physiatrist look into the cause of this problem. Is it coming from your back because you limped for a while? Did the swelling around the sesamoid trigger some excitable nervous activity that now needs to calm down? Is it a totally separate problem called peripheral neuropathy related to pre-Diabetes, Vit B12 deficiency, osteopenia, etc? I hope this helps you. Rich

Lyrica: A Program to Gradually Get Used To This Neuropathic Drug

Lyrica (pregabalin) is one of the main drugs used in neuropathic pain. Neuropathic pain is pain from nerves, it is probably/is the worst of all pain, and the patients truly suffer with this type of pain. The pain, when originating in the nerves, have a direct path to the brain heightening the pain syndrome. Lyrica, like Neurontin (gabapentin) works to stop the flow of the nerve stimulus to the brain quite differently than opioids, and without the addictive qualities. Lyrica is normally twice daily, but can be used 3 times daily, and has a maximal dose of 300 mg per day. Below is a typical gradual process of getting use to the drug, although many go much faster. The side-effect of drowsiness is more prevalent as you get use to the drug in the lower doses than at the higher doses. Typically, if I can ease the transition onto the drug gradually, my patients can avoid much of the side effects. The AM dose should be done around 7 am and the PM dose as soon as you get home in the evening for good (latest 7 pm if you arise between 6-7 am). It is a 12 hour drug and you want the PM dose to be out of your system when you have to function in the morning. 

Week I (weeks can be changed into 4 day periods):       No AM dose                 25 mg PM

Week II:                                                                        No AM dose                 50 mg PM

Week III:                                                                       No AM dose                 75 mg PM

Week IV:                                                                         25 mg AM                   50 mg PM

Week V:                                                                          25 mg AM                   75 mg PM

Week VI:                                                                         25 mg AM                 100 mg PM

Week VII:                                                                        50 mg AM                   75 mg PM

Week VIII:                                                                       50 mg AM                 100 mg PM

Week IX:                                                                         50 mg AM                  125 mg PM

Week X:                                                                          75 mg AM                  125 mg PM

Week XI:                                                                         75 mg AM                  150 mg PM

Week XII:                                                                      100 mg AM                  150 mg PM

Week XIII:                                                                     125 mg AM                  150 mg PM

Week XIV:                                                                     150 mg AM                  150 mg PM

Of course there are many versions of this. At times, based on symptoms and symptom relief you stay at a certain level. Each new level requires time to see how it is helping the overall neuropathic pain. Since most of your healing of this problem, like so many other problems, occurs at night during REM sleep, the medication dosing until the last level is always more during the evening. Dosing like this one requires an initial RX of 25 mg to see if you can coexist with the drug, then soon after, two more prescriptions of 25 mg and 50 mg that you can mix and match to get the right dose. 

The goal of all this is to find a level of drug that reduces the neuropathic pain to a level 0-2 consistently. Whatever level that is, you stay at that level for typically 3 months, and then you gradually, every 4 days, go backwards down the slide. If you get to a level and the symptoms flare, go back up 2 levels and stay there for several weeks, and try to go down again. There are many versions of all this. 

You can see quite easily that making a decision to use this drug is quite a committment. If you get to the highest level, or the highest level you can tolerate without adequate pain relief, it is common to add other drugs to the mix. For those patients who can not tolerate Lyrica, Neurontin can be tried. Some patients respond more to one than the other. 

I hope this has been helpful. Lyrica has been a wonderful drug for so many of my patients, but getting on and off can be such a challenge that many patients stop taking it. It is common for patients to be started at 75 mg twice daily, and have such a bad experience, that the drug is stopped unnecessarily. This is an option to an easier way to get used to the drug.               

Neuropathy: What to Do?

Dear dr. Blake

my friend  saw you a few years ago with a broken ankle, recommended I write to you about what happened to me recently that resulted in neuropathy in the soles of my feet and toes.  She says you are wonderful.

Well, cheap footwear from a drugstore apparently had some toxic substance in or on the shoes.  These were a pair of flipflops, boy's size 4/5, with fabric covering the foot-bed.  Being chemically sensitive, I chose this model over all the plain plastic ones (which often reek of plastic fumes), thinking fabric would make them safer -- plus the fact that none of the other models they had available fit me anyway.

 I wore the shoes for about one hour total, and about 2-3 hours later began to notice the sensation of numbness in my feet.  This happened on Sunday April 21st, and there has been zero improvement.

That evening (soon after I noticed the problem) I soaked my feet in epsom salts dissolved in warm water, for about an hour.  Still had the problem, so next two nights I packed clay on my soles and toes (a friend suggested this detox method, and I was glad I had some clay ready to use).  I felt after these two nights that the toxins had been removed but that I was left with lasting nerve damage.  My right foot is worse, the first 4 toes and the sole of ball of my foot feel numb, sometimes there is a burning feeling, and if I stub a toe just a little there can be a sharp pain.  There is nothing visibly wrong, but the sensation I have when walking around is as if I am walking on wadded up kleenex.  I also noticed the skin of my toes felt clingy, as if the toes were sticking together, and my feet seemed to cling to my old plastic flipflops with a very unpleasant sensation.  I have found some relief from this by  putting cornstarch between my toes and wearing loose socks (no flipflops of course). Fortunately I have a pair of Aerosoles w cushiony insoles, which I discovered make it possible for me to go for walks -- and get some exercise.

But now I am scared to buy shoes of any kind.  I wonder if you can recommend some footwear known to be safe (even for the especially chemically sensitive).  I feel kind of ridiculous even asking such a question, but there it is.   Actually I think those shoes from the drugstore would be toxic to anybody but maybe the non-sensitive might not have an acute reaction.  The fact that these were a child's size gives me real concern for the intended wearers.

Dr Blake's comment: Here is a blog posting on this topic.

http://tipsforcs.blogspot.com/2013/04/shoes-for-chemically-sensitive.html

And if you have further suggestions what to do for neuropathy beyond:  I see that you recommend a lot of vitamin D, which I already have been taking for a long time now, so that should be covered.  I started taking B12 and other Bs, plus lecithin and various herbs that I saw recommended online.  I have the impression that massage is NOT a good idea.  Deep probing of the affected areas seems to hurt and not be helpful.

Any ideas appreciated.  Thank you.

Dr Blake's comment: 

     Thank you for the email, and I am sorry for your suffering. One of my medical assistants getting allergic reactions to the dyes in leather shoes and now uses only vegetable based shoes. She went to an allergist who tested everything, and it really helped her begin to control her symptoms and live more normal. Below is my nerve pain outline and so much can be used in your situation. I have highlighted in red the most common things you can do. Also see the video emphasizing exercise, healthy diet, sugar restricted diets, and no smoking or alcohol. 

3.      Topical Medications/Applications (should be gels for ease of application)

§         Warm Compresses

§         Non Painful Massage

§         Parafin Wax

§         Chinese Herbs

§         Lidoderm Patches

§         Neuro-Eze

§         Multiple Compounding Medications which include (usually not all of these):

ü      Ketamine 10%

ü      Clonidine 0.2%

ü      Gabapentin 6%

ü      Baclofen 2%

ü      Nifedipine 2%

ü      Lidocaine 2%

4.     Alternative

§         Biofeedback (Thermal to increase circulation)

§         Hypnosis

§         Meditation

§         Accupuncture (can be to opposite limb or ear)

·       Nutritional (next 3-12 months)

1.      Lipoic Acid 300mg 2x/day

2.      Acety-L-Carnitine 2000 mg/day

3.      Inositol 500-1000mg/day

4.      Vit B6 50mg/day

5.      Vit B12 1000mg/day

6.      Vit E (up to 1,600units/day)

7.      Thyroid Natural Supplements

This Mayo Clinic article gives a good overview. I hope this points you in the right direction. 

http://www.mayoclinic.com/health/peripheral-neuropathy/DS00131/DSECTION=treatments-and-drugs

Neuropathy or Referred Pain from the Low Back: Email Advice

Hi Dr. Blake,

I have a few symptoms that I will be telling my doctor about at my annual physical in two months. In the meantime, I thought I would ask you about them.

For about a year or so, I have a hard time with walking around the house barefoot. It is especially difficult first thing out of bed. Recently I have been having numbness in the corner of my right big toe. I thought this was just and old ingrown toenail thing acting up again, but it seems to be more than that. I have pain in my arches-just below the ball of my foot. I bought some arch inserts from Germany, and now have to put them into almost any shoe I wear, except my dansko clogs.

Dr Blake's comment: I have linked this with my video on foot nerve pain and it's relationship to the back. You can see how the corner of the big toe is related the L4 Disc as well as the pain in the ball of the foot into the arches.

Sometimes I imagine I get relief after stretching my hamstrings. I have one of those green stretch nylon ropes with loop holes I got after rehabbing from my knee surgery(right knee)  I got a little freaked out tonight after standing in a rite aid store. There I was getting dental floss and the auto message over the loud speaker was warning customers of their possible undiagnosed diabetic neuropathy. They listed off some sensations that sounded like a few of my symptoms.  Of course, walking home, I kept thinking.."what if this is something I have?" I don't have diabetes, that I am aware of anyway?

My questions are:

Why would the upper left corner of my big toe feel numb and burning on and off? Not just at the toenail, but under it on a callous pad and at side of toe bone.

Why is it so painful to walk barefoot? As if I need the support of a shoe or else it feels like my bones crunch with each step. As though not enough muscle in my arche to hold myself up?
Dr Blake's comment: The video above should explain what nerve root in your back is probably effected. Pressure on a nerve can cause both abnormal sensations and abnormal muscle function (ie your muscles are not supported the bones and they complain mightily.) 

Should I be concerned about diabetic neuropathy?
Dr Blake's comment: This does not sound like neuropathy, but, in the early stages of development, the symptoms can be atypical. If you were in my office, I would send you to our back doc to check if this was coming off your back. 

How can you tell the diference between foot weakness symptoms  - foot neuropathy -- Morton's neuroma - plantar fascia pain ?

Also what type of doctor would I want to be seen by. Is this for a podiatrist or a neurologist?
Dr Blake's comment: Both a podiatrist to treat the local symptoms and a neurologist or physiatrist to evaluate and possibly treat the back. The MDs would definitely help in pinpointing the diagnosis better, but the lion's share of the treatment can be left with the podiatrist. Sure hope this helps. Rich

Thanks for your time.

Spinal Cord Stimulation: Summary of Recent Lecture by Dr Tory McJunkin

Treating Neuropathic Pain, pain that feeds itself, pain that needs little to no stimulus to turn on, and can be difficult to turn off, can be very difficult to treat. I found in talking to my patients that I really had little knowledge of a wonderful new edition to this arena of pain management called spinal cord stimulators. I hope those who are suffering from severe pain, with no end in sight, will get themselves to a pain specialist skilled in this treatment to see if they are a candidate. I have listed under this lecture other links to my blog posts around complex regional pain syndrome, one of the types of neuropathic pain I see in practice. If you want to know if you have neuropathic pain, just answer this simple question: I am suffering with this pain? Neuropathic pain patients truly suffer. I have had severe back pain that I could manage and endure, but did not suffer. I have had back pain so bad that I have suffered, could not go to work, and was able to get relief with a sympathetic block (lucky me!!). This is one view, not complete by any means since it is through the eyes of one profession. But, it is an important understanding for patients suffering with neuropathic pain. I sure hope this helps. Dr Rich Blake

Algorithm for Treating Neuropathic Pain

                           by Dr Tory McJunkin

     Step 1: ID pain as neuropathic or mixed

                 Treat mixed if can

     Step 2: Initiate Tx Regimen for Neuropathic Pain

                     8 week Trial of one medication

                     If not completely responsive, add 4 week trial of 2nd medication

     Step 3: Week 12 Refer to Interventional Pain Specialist

                     Nerve Blocks (Sympathetic)

                     If not completely responsive, 3-5 day trial of Spinal Cord Stimulator

                                                        (Pacemakers for Pain)

                     If 50% pain relief or greater, Spinal Cord Stimulator 

                                  Level T12-L1 if foot pain

     Step 4: Referral back to Podiatrist for long term maintenance and mechanical/local treatments

     Step 5: When pain level and function still not optimal, consider the following:

                 Chronic Opiods (little effect overall)

                 Neurolytic or destructive procedures (chemical or surgical sympathetomies)

                 Intrathecal Pump Therapy (Ketamine)---very serious side-effects 

  

Other key points of lecture

• Patient Care enhanced by Team Approach
• Sympathetic Blocks (L2 to L4, sometimes L5, for foot problems) Overall 5-10% helpful
• Peripheral Blocks (0-1% helpful)
• Spinal Cord Stimulation 80% successful if done in first 2 years, earlier the better
• 4 Tiers of Treatment

1. Diagnosis
2. First Tier Pain Therapies (cognitive and behavioral modulations, TENS, physical rehabilitation, exercise, and OTC pain meds)
3. 2nd Tier Pain Therapies (thermal procedures, neurolysis, systemic opiods, nerve blocks)
4. Advanced Pain Therapies (neuro ablation surgeries, spinal cord stimulators, implantable drug pumps)

http://www.drblakeshealingsole.com/2012/09/complex-regional-pain-syndrome.html

http://www.drblakeshealingsole.com/2013/02/crps-followup-email-with-checklist.html

http://www.drblakeshealingsole.com/2012/12/crps-initiation-of-flashcards-for.html

http://www.drblakeshealingsole.com/2013/01/lecture-on-surgical-treatments-for-crps.html

http://www.drblakeshealingsole.com/2012/12/followup-on-treatment-for-crps-all.html

http://www.drblakeshealingsole.com/2012/11/graded-motor-imagery-chronic-pain-tool.html