Small nerves of the feet neuropathy

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

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Information from the National Institutes of Health

Peripheral neuropathy is a term used to describe disorders of the peripheral nervous system or smaller nerves. This includes nerves in the arms, and legs.

When damaged, these nerves cause symptoms such as pain or numbness.

Peripheral neuropathy often affects people with diabetes and autoimmune diseases such as rheumatoid arthritis and lupus. Certain vitamin deficiencies, some medications, and alcoholism can also damage peripheral nerves.

The network of peripheral nerves helps muscles contract (motor nerves) and gives the ability to feel sensations (sensory nerves). In addition, the peripheral nerves help control some of the involuntary functions of the autonomic nervous system, which regulates internal organs, sweat glands and blood pressure.

Peripheral nerves are fragile and easily damaged. If a sensory nerve is damaged, symptoms that occur are:

• Pain
• Numbness
• Tingling
• Burning
• Loss of feeling

These symptoms often begin gradually. Tingling or numbness starts in the toes and spreads upward. Tingling might also begin in the hands and extend up into the arms. In some cases the skin may become so sensitive that slight touch is agonizing. Numbness, or even a complete lack of feeling, may develop in the hands or feet.

Symptoms start slowly and become more frequent or become constant. At night they may be almost unbearable. Signs and symptoms also include:

• A sensation of an invisible glove or sock
• Burning pain
• Sharp, jabbing or electric-shock like pain
• Extreme sensitivity to touch, even light touch
• Lack of coordination

If motor nerves are affected, weakness or paralysis of the muscles can occur. Damage to nerves that control functions of the autonomic nervous system can lead to bowel or bladder problems, reduced sweating or impotence. Sharp falls in blood pressure with standing may cause fainting or lightheadedness.

Many factors can cause neuropathies. If a single nerve is affected, the most likely cause is trauma or repetitive use leading to pressure on the nerve. Nerve pressure can result from using a cast or crutches, spending a long time in one position — such as typing at a computer keyboard — or having a tumor.

When damage occurs to many nerves, the cause is often diabetes. About half of all people with diabetes develop some type of neuropathy. Other common causes include alcoholism, HIV/AIDS, inherited disorders and a deficiency of certain vitamins, especially B vitamins. Syphilis was one common cause many years ago.

Autoimmune diseases, including lupus and rheumatoid arthritis, kidney disease, liver disease and an under active thyroid (hypothyroidism) also can damage peripheral nerves. Other causes are exposure to poisons, toxic substances and certain medications — especially those used in cancer chemotherapy. Genetics plays a role in some forms of peripheral neuropathy.

Occasionally, bacterial or viral infections may cause neuropathy. A condition called Guillain-Barre syndrome frequently causes severe damage to the peripheral nerves by destroying the myelin sheath that covers nerve fibers. The myelin sheath acts as an insulator for nerves and helps conduct nerve impulses. Although the exact cause of Guillain-Barre syndrome isn't known, approximately two-thirds of cases occur after an infection, surgery or immunization.

Unfortunately, it's not always easy to pinpoint the cause of peripheral neuropathy.

Fifty per cent of diabetics have some form of neuropathy. The risk increases the longer the disease exists. It is highest for those who've had the disease for more than 25 years. The risk also increases with poorly controlled disease.

Other risk factors:

• Alcohol abuse.

• Vitamin deficiency. A lack of certain vitamins, especially B-1 (thiamin) and B-12. Pernicious anemia, which occurs when the body can't absorb B-12 properly, often leads to peripheral neuropathy.

• Autoimmune diseases such as lupus or rheumatoid arthritis or AIDS also can cause peripheral neuropathy.

• Other health problems. Medical conditions including certain types of cancer, kidney and liver disease, also can increase risk of nerve damage.

• Repetitive stress. A job or hobby that puts stress on one nerve for long periods of time increases the chances of developing peripheral neuropathy.

• Toxic substances. Exposure to some toxic substances can increase susceptibility to peripheral nerve damage. These substances include heavy metals, such as lead, mercury and arsenic; organic solvents; carbon monoxide and certain medications, such as those used to treat cancer or AIDS.

Peripheral neuropathy isn't a single disease, but rather a syndrome with many causes.

Diagnosis will include examination as well as blood tests, a urinalysis, thyroid function tests and, often, electromyography (EMG) — a test that measures the electrical charges produced in the muscles. A nerve conduction study, which measures how quickly the nerves transmits electrical signals also will be done. A nerve conduction study is often used to diagnose carpal tunnel syndrome and other peripheral nerve disorders.

A nerve biopsymay be ordered. But even a nerve biopsy may not always reveal what's damaging the nerves.

Diabetic neuropathy may cause a number of complications. Damage to the nerves in the feet, along with poor circulation, can lead to ulcers and even gangrene.

The goal of treatment is to manage the underlying condition causing the neuropathy and to repair damage, as well as provide symptom relief.

Controlling a chronic condition may not eliminate the neuropathy, but it can play a key role in managing it. Here's what may be recommended for treating various underlying conditions:

Diabetes. Maintaining normal blood sugar levels helps protect the nerves.

Vitamin deficiency. If neuropathy is the result of a vitamin deficiency, it's likely the symptoms will improve once the deficiency is corrected. Injections of vitamin B-12 and possibly additional vitamin supplements might be recommended.

Autoimmune disorder. If neuropathy is caused by an inflammatory or autoimmune process, treatment should be directed at modulating the immune response.

Nerve pressure. In cases where neuropathy is the result of pressure on a nerve, treatment will likely focus first on eliminating the source of the pressure.

Toxic substances or medications. If toxins or medications are responsible for the neuropathy, it's critical that the medication or further exposure to the toxin be stopped.

Medications can ease pain symptoms, but most have side effects, especially if taken chronically. Medications that may help provide pain relief for neuropathy include:

Pain relievers. OTC pain relievers, such as acetaminophen (Tylenol, others), and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen (Advil, Motrin, others), usually help mild symptoms.

Anti-seizure medications. Drugs such as gabapentin (Neurontin), carbamazepine (Tegretol) and phenytoin (Dilantin) were originally developed to treat seizure disorders (epilepsy). However, doctors often also prescribe them for pain. Side effects may include drowsiness and confusion.

Lidocaine patch. This patch contains the topical anesthetic lidocaine. Apply it to the area where the pain is most severe. Up to three patches a day may be used to relieve pain. One side effect is rash at the site of the patch.

Tricyclic antidepressants may provide relief for mild to moderate. Common side effects include balance problems, dry mouth, nausea, tiredness or weakness, constipation, and weight gain.

Other medications. Opioid analgesics, such as codeine or oxycodone (OxyContin) may be used to relieve pain. However, this class of medications produces numerous side effects.

Mexiletine (Mexitil), a drug ordinarily used to treat irregular heart rhythms, sometimes helps relieve burning pain.

The topical ointment capsaicin (Capzasin, Zostrix) may help ease the pain of diabetic neuropathy.

Several other techniques may also help with pain relief. Doctors frequently use them in conjunction with medications, but some may be effective on their own. They include:

Transcutaneous electrical nerve stimulation (TENS). TENS delivers tiny electrical impulses to specific nerve pathways through small electrodes placed on the skin. Although safe and painless, TENS doesn't work for everyone or for all types of pain. It's generally more effective for acute pain than for chronic pain and is often used in conjunction with other therapies.

Biofeedback. This therapy uses a special machine to control certain body responses that reduce pain.

Acupuncture. The National Institutes of Health has found that acupuncture can be an effective treatment for chronic pain, possibly including the pain of neuropathy.

Hypnosis. Many adults can be hypnotized by a trained professional

Relaxation techniques. Designed to help reduce the muscle tension that makes pain worse, relaxation techniques range from deep-breathing exercises to visualization, yoga, and meditation.

Whether or not you have a medical condition, eat a healthy diet that's rich in fruits, vegetables, whole grains and lean protein. The best food sources of vitamin B-12 are meats, fish, eggs and low-fat dairy foods. If you're a strict vegetarian, make sure you get enough B-12 by choosing soy products such as tofu, sea vegetables (dulse, kelp, kombu or nori — the wrapping for sushi) or brewer's yeast. Consider B-12 supplements.

As much as possible, avoid repetitive motions, cramped positions and toxic chemicals, all of which may cause nerve damage.

The following suggestions can manage peripheral neuropathy:

Take care of the feet, especially with diabetes. Check the feet daily for signs of blisters, cuts or calluses. Tight shoes and socks can worsen pain and tingling and may lead to sores that won't heal. Wear soft, loose cotton socks and padded shoes. Use a semicircular hoop, which is available in medical supply stores, to keep bedcovers off sensitive feet.

Exercise. Ask the doctor about an exercise routine that's right. Regular exercise may reduce neuropathy pain and can help control blood sugar levels.

Limit caffeine. Try to avoid foods or drinks high in caffeine, including coffee, chocolate and sodas. Caffeine can make pain worse.

Eat healthy meals. Healthy eating is especially important. Emphasize low-fat meats and dairy products and include lots of fruits, vegetables and whole grains in the diet.

Massage the hands and feet. Massage helps improve circulation, stimulates nerves and may temporarily relieve pain.

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