Sunday, 1 March 2015

Small Fibre Neuropathy: What's That?

Today's post from (see link below) is a very sensible and probing discussion of small fibre neuropathy and its relationship to fibromyalgia. It's written by a fibromyalgia patient who's also been told that she has small fibre neuropathy and this is a source of confusion for many patients, whose diagnosis is often both vague and unsatisfactory. Doctors often avoid lengthy explanations because they feel that the patients just won't understand the theory, which is a little demeaning to say the least. Maybe the point is that it doesn't really matter in the end what sort of nerve damage you have - the symptoms are very recognisable to most neuropathy patients and the important thing is treating those symptoms and learning to live with the disease. Nevertheless, this is a very good article and well worth a read.

What is Small Fiber Neuropathy
February 27, 2015 By Julie 

In the last few years we’ve seen many articles about the overlap of small fiber neuropathy (or small fiber polyneuropathy – same thing) in Fibromyalgia and the hope that we may be able to use skin biopsies of these small fiber nerves to diagnose Fibromyalgia. I’ll be honest I thought for a while we were just seeing the same study popping back up in the news (and it frustrated me); however, I’ve realized I was wrong. There have actually been a couple of studies in as many years that have made this connection. That said all of the studies I’ve read have been very small (less than 30 participants), and they are not finding that all of the Fibromyalgia patients have this (only about 50% of those in the studies). However, these studies may be a stepping stone to uncovering one potential cause for the pain associated with Fibromyalgia.

But, what is Small Fiber Neuropathy?

Small Fiber Polyneuropathy (SFPN) is a disease (yes, an actual disease) that cause degeneration in the small fiber neurons. The small fiber nerves are the ones that transmit the information about pain and temperature. These small fibers are also involved in many areas of the autonomic nervous system (the part that controls the automatic features like breathing, digestion, blood flow), so it’s a little more than just burning and itching in the feet.

Small Fiber Neuropathy is more than just burning and itching hands and feet.

Unlike problems in the large nerves small fiber neuropathies don’t show up in EMG and nerve conduction studies. SFPN is most commonly associated with diabetes, but can be caused by a variety of other diseases and illnesses, and can even be genetic. A skin biopsy is the primary way of diagnosing SFPN. Unfortunately, diagnosis of SFPN doesn’t do much for those of us with Fibromyalgia except perhaps make us feel like we have a better diagnosis than just Fibromyalgia. The treatments for SFPN are basically the same ones that we already use for Fibromyalgia (anti-depressants, anti-convulsants, topical pain treatments, gabapentin, and tramadol to name a few.

What are the symptoms of Small Fiber Neuropathy?

Painful burning/ itching feeling in the hands and feet – this seemsto be the primary symptom
Often worse at night and/or made worse with heat or cold – often people can’t stand to have the sheets touching their feet.
Alcohol can also increase this symptom
Digestive symptoms including diarrhea, constipation, nausea, vomiting
Urinary incontinence
Periods of increased heartbeat
Dry eyes/ mouth
Abnormal sweating
orthostatic hypotension
erectile dysfunction
Skin changes in affected areas

Interestingly, I have pretty much all of the symptoms listed, and so many of these are symptoms we often attribute to “just Fibro”. My diagnosis journey began with burning and tingling in my hands, a variety of tests turned up nothing. I’ve often had a burning in my feet (and they get red and puffy) if I do much walking but I just wrote it off as the effects of walking too much in poorly fitted shoes. Then in December I noticed that I was waking up with this extreme burning in my feet. They would feel like they were burning but also as if they were extremely dry, even if I’d put lotion on them just before I went to sleep. To feel my feet the skin didn’t feel dry to the touch, but that’s the sensation that was being transmitted to my brain (along with the severe burning). I noticed that more and more often they were also very red and puffy looking. After doing some research I found that this is a (rare) side effect of the medication I was on for migraines (Verapamil) and when I told my neurologist about the symptoms he had me stop the med. The symptoms did decrease after about a month off of Verapamil but they haven’t completely disappeared. I think they were there all along I just hadn’t really connected them. I have noticed that the tingling in my hands and the burning in my feet are much worse on nights when I’ve been drinking. I would never have thought to connect the other issues like the urinary and digestive issues had I not read it for myself in the NIH documentation.

Do you also have painful tingling and burning in your hands and feet? How many of the other symptoms do you have?

Further reading:

Saturday, 28 February 2015

Using Sensors To Improve Neuropathy Balance

Today's post from (see link below) talks about using technology to monitor balance issues for people with neuropathic foot problems. It involves a sort of physiotherapy that involves interactive balance training, using information gleaned from sensors. Unfortunately, the article doesn't go into detail about the sensors themselves, which I'm sure most readers are interested in. However, there's no doubt that more emphasis on training to avoid loss of balance due to numbness and wrong signals would be very helpful to all people living with neuropathy - it's a somewhat neglected area of neuropathy treatment. Don't worry about the title reference to diabetes - it applies to all forms of neuropathy.

Can Sensors And Balance Exercises Improve Balance And Reduce Fall Risk In People With Diabetic Neuropathy?
Thursday, 02/26/15 David G. Armstrong DPM MD PhD
Diabetic peripheral neuropathy can be a risk factor for falls due to deficits in sensory and motor skills that can lead to proprioceptive difficulties. In a new study in Gerontology, my coauthors and I investigate the use of interactive balance training to increase postural stability.1

The randomized study performed at our unit focused on 39 patients with diabetic peripheral neuropathy (with an average age of 63.7 years) with one group performing sensor-based interactive exercise twice a week for four weeks and the other group being a control group.1 The exercises included shifting weight and crossing virtual obstacles. Participants wore sensors to acquire kinematic data and provide real-time joint visual feedback during the training.

Patients in the intervention group showed a significantly reduced center of motion sway, ankle sway and hip joint sway during the balance test with open eyes, according to the study.1 Ankle sway in our study was also significantly lower in the intervention group during measurements while the eyes were closed. These promising data certainly provide early evidence to potentially promote the use of wearable technology in exercise training but we need future studies to compare this technology with commercially available systems to evaluate the benefit of interactive visual joint movement feedback.

There are some really extraordinary technologies available to us in the sensor world. Trends are moving to smaller, cheaper and more flexible sensors. Some of the newest flexible sensors we have available are actually more like medical tattoos. These sensors would normally have taken up an entire backpack just a few years ago. The sensors are becoming so inexpensive and so ubiquitous that we are not only going to be able to measure aspects of instability but we are also going to be able to intervene right away by trying to measure and steadily improve people’s postural stability. By doing this, I believe we can reduce the completely unnecessary number of falls and unnecessary morbidity and death that occurs every day in homes and hospitals not only in the United States but around the world.

This problem of falls is getting more and more common not only in people with diabetes but also in the aging population overall. This fall risk is preventing people from being independent, productive members of society, keeping them at home and putting them forever on this cycle of dependence. We think these sort of sensors can really help us measure what we manage as doctors and patients.


1. Grewal GS, Schwenk M, Lee-Eng J, et al. Sensor-based interactive balance training with visual joint movement feedback for improving postural stability in diabetics with peripheral neuropathy: a randomized controlled trial. Gerontology. 2015; epub ahead of print.

Friday, 27 February 2015

Unexpected Side Effects Of Chemotherapy

Today's post from (see link below) reflects the increase in cancer treatent in the modern world. That's both good and bad news: there may be an increase in cancers thanks to our lifestyles and other factors but it also may mean that cancer is being detected and treated both better and faster these days. People living longer also contributes to the rise in cancer cases - they tend to appear more frequently in later years. Unfortunately one of the common side effects of chemotherapy is neuropathy and nerve problems but there are others and this article may help you avoid being surprised if something happens after chemo sessions. Unfortunately, doctors are not the best at preparing patients in advance for side effects; possibly because there's such a variation and not everybody will suffer from one or all of them.

6 Things You Didn't Know About Chemo
By Camille Noe Pagán WebMD Feature Reviewed by Melinda Ratini, DO, MS

Chemotherapy.” Just the word may make you remember images you’ve seen in movies or on TV. If you or someone you love needs chemo, is that what you’re headed for?

Maybe, but maybe not. Yes, it will probably be hard and have side effects. But you might be surprised by some of the things people who have been through chemo would want you to keep in mind.

1. “I don’t want to hear about your friend, sister, or dog walker’s chemo experience.”

“One of the biggest things patients complain about is how many people share cancer “horror stories” with them while they’re in the middle of treatment,” says Marisa C. Weiss, MD, author of Living Well Beyond Breast Cancer.

“The individual telling the story may mean well, but usually they’re not thinking before they speak,” says Weiss, president and founder of “The last thing someone going through chemo wants to hear is about how treatment went poorly for someone else.”

Her advice: The minute someone begins sharing, hold a hand up and say, “Thank you for caring, but I don’t want to hear stories about other people right now.” 

2. “The most helpful information didn’t come from my oncologist.”

“Yes, doctors are really important. But when I hear that a friend or family member is going through cancer treatment, I tell them to talk to the nurses,” says Dana Kuznetzkoff, a New York film and TV producer who was treated for lymphoma in 2010. “They’re the ones who will tell you exactly what you need to know, like your hair will fall out on the second day of treatment, or expect to be really tired the day afterchemo.”

She has a simple suggestion. “Listen to other people who’ve been there or who are involved in your care, too. I got good tips from my wigmaker and other women who’d been through cancer treatment.”

3. “It’s not just about nausea and hair loss.”

When Paulette Sherman was treated for breast cancer several years ago, “I was shocked when my toenails fell off,” says Sherman, a psychologist and author living in Brooklyn, NY. “I knew my hair would fall out, but didn’t remember [my doctor] telling me about the nails. It was a little upsetting at first, because it was one more way chemo was affecting my body.”

There are many types of chemotherapy. The side effects you have depend on what kind of chemo you get and how your body reacts to it. Hair loss and nausea are common, but they don’t happen to everyone. It’s also common to have other side effects that people don’t talk about as much, such as trouble with memory and concentration, feeling dizzy, or having pain and numbness during or after chemo.

4. “I don’t want to think about cancer all the time.”

You’re much more than a patient. You’re a person with a full life. Your daily routines -- even the little things -- can hold comfort as an anchor when cancer rocks your world.

Still, you’ll want to be realistic and flexible about it. Sherman often took a day off work the day following a chemo treatment because that was when she felt the most side effects. She worked during the rest of her treatment, though.

“Many people were surprised by that,” she says. “I love my work and get energy from it. It’s different for everyone. But for me, it was important to have part of my life be “normal.” I didn’t want cancer to take over my entire life.” 

5. “I can’t support you emotionally right now.”

Friends and family may be upset about what you’re going through. That’s understandable, but you can’t wear yourself out reassuring them.

“I told the people closest to me, “I’m happy to tell you how I’m doing when I can, but I need to take care of myself. If you need extra emotional support or more information than I’ve given you, please reach out to someone else,” Kuznetzkoff says. While it was hard to do this, “It was crucial for keeping my own stress levels down, which helped me get healthy,” she says.

“I tell patients to have a “point person,” like a spouse or good friend, who can update the people whom the patient wants to keep in the loop,” says S. Adam Ramin, MD, who treats men with prostate cancer. “That way, not every update becomes a difficult or emotional conversation.”

If someone seems to be having a really hard time, you may want to suggest that they speak with a counselor who can give them the support that you want them to have but are not in a position to offer.

6. “Chemo’s over and I feel depressed.”

Your friends and family may want to celebrate the end of your cancer treatment, not realizing that instead of feeling excited or triumphant, you may feel blue, anxious, let down, or even scared. These feelings are normal, especially in ­­­­­the year following treatment.

“During chemo and radiation, you’ve got everyone’s support. When you’re done, people often expect things to go right back to normal for you, when you’re still experiencing mental and physical side effects,” Weiss says.

No need to fake it. Instead, tell well-meaning loved ones you’re adjusting and doing the best you can.

Talk to your doctor about how you’re feeling, too. Counseling (plus medication such as antidepressants, if needed), support groups, exercise, and taking time for yourself can help you feel better and ease back into your post-treatment life.

Thursday, 26 February 2015

How Good Is The Scrambler Treatment For Neuropathy?

Today's post from (see link below) is a strong claim for the benefits of the so-called 'scrambler' treatment for neuropathy. The scrambler treatment is basically one of the several electro-stimulation devices on the market today. It is somewhat surprising that the Mayo clinic places so much faith in this apparatus but they do admit that it may not work for all patients and as such, it joins the ranks of other electrical stimulant devices like TENS. You have to make up your own mind in the end and discuss it carefully with your doctor or specialist and not just the clinic that offers it as part of their services. It may also be wise to be prepared for failure or disappointment but there's no doubt that some people are helped by these treatments. The reader's comment at the end of this article may well be worth reading - it does offer an alternative opinion.

Breaking Away From Pain With the Help of 'The Scrambler'
Posted by Hoyt Finnamore (@hoytfinnamore)

Karen Safranek didn't take a worry-free step for 10 years. Severe peripheral neuropathy — a side effect of breast cancer treatment she received in 2002 — left her with constant burning, tingling, numbness and pain in both her feet.

Over time, Karen tried dozens of treatments to rid herself of the discomfort. Nothing worked. So in 2012 when she found out about a clinical research trial available at Mayo Clinic for people who had peripheral neuropathy after chemotherapy, she was interested, but not optimistic.

"I tried so many things. Anything a doctor recommended or heard about, or anything I heard about, I'd give it a try if I could," Karen says. "But years past, and the pain didn't get any better. By 2011, life was not good. I was analyzing my house to figure out where we could put a wheelchair ramp. At that time, I thought it wouldn't be much longer before I couldn't walk anymore."

This new treatment was different. With MC-5A Calmare Therapy, often called "the scrambler" for short, Karen noticed improvement following the first session. After completing a series of treatments, she was pain-free for the first time in more than a decade. Through her participation in the clinical trial and occasional follow-up treatments at Mayo Clinic, Karen has been able to leave peripheral neuropathy behind and reclaim her life.

Battling pervasive pain

Karen began to notice symptoms of peripheral neuropathy shortly after she started receiving chemotherapy. By the end of her treatments, her breast cancer was gone, but she had constant shooting pain and numbness in her feet and legs that left her weak and unable to maintain her balance.

Peripheral neuropathy is a common side effect of some chemotherapy drugs. For many people, the condition fades away after treatment is over. But for some, like Karen, it can last long after other chemo side effects are gone and can have a significant impact on day-to-day life. The effect on Karen's life was overwhelming.

"It hurt if I was sitting, walking or standing," she says. "Blankets hurt my legs. I wasn't getting a good night's sleep. Going back to work wasn't an option. In time, it got so bad that whenever I went somewhere, I would analyze where I had to park my car and how far it was to get to the building. If there wasn't a spot close enough for me to walk the distance to and from my car, I would just go home."

Retraining the brain
Traditionally, chronic peripheral neuropathy has been challenging to successfully treat. Like many others who have this debilitating disorder, Karen tried everything she and her doctors could think of to relieve her pain. But still she suffered. Then in December 2013, Karen learned of the clinical trial at Mayo Clinic that would change everything for her.

Peripheral neuropathy happens as a result of nerve damage. The damaged nerves send aberrant signals to the brain, causing pain and the other symptoms of peripheral neuropathy. During her treatment sessions as a participant in the research study, the damaged nerves in Karen's feet were connected by electrodes to the scrambler. The device sent painless electrical signals to the damaged nerves, and the nerves relayed those signals to the brain. The new signals broke the pain cycle by retraining Karen's brain to understand that it was not really experiencing pain.

Reclaiming her life

Although the scrambler does not ease symptoms of peripheral neuropathy in all cases, Karen's response was dramatic.

"I was tremendously better after just one treatment," she says. "My feet and legs felt light and pain-free. Previously, I had felt as though they were very heavy to lift and walking was comparable to wearing cement shoes. After the treatment, I could walk really fast. I could take the stairs. I could even run."

After a total of 10 treatment sessions in January 2013, Karen no longer had any symptoms. The effects of the treatment were not permanent, however. She returned to Mayo Clinic for additional scrambler treatment nine months after her first sessions and again eight months after that.

Even though she knows she'll likely need follow-up care over the long-term to keep peripheral neuropathy at bay, Karen is enthusiastic about the difference the treatment has made for her.

"Before this, I wasn't able to do some of the smallest things. I couldn't go grocery shopping alone. If I reached up to take an item off the shelf, I'd lose my balance and tip over. I couldn't walk on uneven ground because I couldn't feel my feet. I'd just fall down," she says. "Being able to participate in this clinical trial at Mayo Clinic with the scrambler, it brought my life back to me. It's a miracle. It really is."

Oscar Lonzo (@oscarlonzo) · 9 hour(s) ago · I hope everyone appreciates how nonsensical the sentence, "The device sent painless electrical signals to the damaged nerves, and the nerves relayed those signals to the brain," is? I suggest anyone interested in this device contact a local neuroscientist and inquire as to the validity of that statement. I'm confident that they will agree with my own assessment that ALL that Ms. Safranek experienced was some benign TENS therapy and ALL she achieved was a placebo effect.

The device itself was "invented" by character named Giuseppe Marineo. In its original incarnation, it was designed to treat AIDS. Fortunately, Italian authorities arrested Mister Marineo for practicing medicine without a license before he injured too many people. Subsequently, it became a device to cure cirrhosis by "adjusting" hepatocellular "entropy." While that didn't get him in trouble with authorities, it also didn't attract much attention, and perhaps that led to its next "incarnation" as a device to treat pain. You can check out his "deltard" website and read all about the latest marvels it achieves in removing scars and reversing the effects of aging.

In promoting his "research," Mister Marineo has in various publications claimed to have a "MD,PhD," "MD,DSc," "PhD" degrees and has only this month claimed "DSc,ScD" degrees! Unfortunately, Mister Marineo has NONE of those. In fact, I seriously doubt he has ever attended college! Indeed, I'd be willing to bet hard currency that Dr. Loprinzi hasn't the faintest idea where Marineo got his degrees and wouldn't be willing to try and find out either!

The company that has been promoting this QUACK medical device for over EIGHT YEARS now is called "Calmare Technologies" -- a near bankrupt penny stock ("CTTC") trading in the "pink sheets." It's currently being sued by GEOMC -- the company that manufactured the device for them -- because CTTC hasn't paid them. According to GEOMC, ALL of the devices CTTC has distributed are outdated and in need of servicing. Does Dr. Loprinzi's patients know that? Indeed, does Dr. Loprinzi know how to determine whether the device is indeed putting out the appropriate "signals." If he does, then he must have his own personal oscilloscope because the device itself has NO mechanism for ascertaining whether it's producing the correct signals.

Congratulations to Mayo for the part its playing in promoting fraud and medical quackery in the US. I'm sure all the naive victims of chronic pain who read thie article and who, in consequence, find themselves looted of the 3-5 THOUSAND dollars charged for this "therapy" NOT covered by insurance will applaud you.

Wednesday, 25 February 2015

UK Appraisal Of Neuropathic Pain

Today's post from (see link below) is another very useful and accurate summary of the main aspects of neuropathic pain. Useful for current patients, people new to the disease and family and friends who may be wondering what all the fuss is about. Definitely worth checking out - there may be a few things you didn't know and having an overall picture of the problem helps us to understand it better and learn to live with it.

Neuropathic Pain  
Original Author:Dr Tim Kenny Current Version:Dr Colin Tidy Peer Reviewer:Dr Adrian Bonsall
Last Checked:13/01/2014 Next Review:12/01/2017

Neuropathic pain (neuralgia) is a pain that comes from problems with signals from the nerves. There are various causes. It is different to the common type of pain that is due to an injury, burn, pressure, etc. Traditional painkillers such as paracetamol, anti-inflammatories and codeine usually do not help very much. However, neuropathic pain is often eased by antidepressant or anti-epileptic medicines - by an action that is separate to their action on depression and epilepsy. Other pain-relieving medicines and techniques are also sometimes used.

What is neuropathic pain?

Pain is broadly divided into two types - nociceptive pain and neuropathic pain.

Nociceptive pain

This is the type of pain that all people have had at some point. It is caused by actual, or potential, damage to tissues. For example, a cut, a burn, an injury, pressure or force from outside the body, or pressure from inside the body (for example, from a tumour) can all cause nociceptive pain. The reason we feel pain in these situations is because tiny nerve endings become activated or damaged by the injury, and this sends pain messages to the brain via nerves.

Nociceptive pain tends to be sharp or aching. It also tends to be eased well by traditional painkillers such as paracetamol, anti-inflammatory painkillers, codeine and morphine.

Neuropathic pain

This type of pain is caused by a problem with one or more nerves themselves. The function of the nerve is affected in a way that it sends pain messages to the brain. Neuropathic pain is often described as burning, stabbing, shooting, aching, or like an electric shock.

Neuropathic pain is less likely than nociceptive pain to be helped by traditional painkillers. However, other types of medicines often work well to ease the pain (see below).

The rest of this leaflet is just about neuropathic pain.

What causes neuropathic pain?

Various conditions can affect nerves and may cause neuropathic pain as one of the features of the condition. These include the following:
Trigeminal neuralgia.
Pain following shingles (postherpetic neuralgia).
Diabetic neuropathy - a nerve disorder that develops in some people with diabetes.
Phantom limb pain following an amputation.
Multiple sclerosis.
Pain following chemotherapy.
HIV infection.
Atypical facial pain.
Various other uncommon nerve disorders.

Note: you can have nociceptive pain and neuropathic pain at the same time, sometimes caused by the same condition. For example, you may develop nociceptive pain and neuropathic pain from certain cancers.

More about the nature of neuropathic pain

Related to the pain there may also be:

Allodynia. This means that the pain comes on, or gets worse, with a touch or stimulus that would not normally cause pain. For example, a slight touch on the face may trigger pain if you have trigeminal neuralgia, or the pressure of the bedclothes may trigger pain if you have diabetic neuropathy.
Hyperalgesia. This means that you get severe pain from a stimulus or touch that would normally cause only slight discomfort. For example, a mild prod on the painful area may cause intense pain.
Paraesthesia. This means that you get unpleasant or painful feelings even when there is nothing touching you, and no stimulus. For example, you may have painful pins and needles, or electric shock-like sensations.

In addition to the pain itself, the impact that the pain has on your life may be just as important. For example, the pain may lead to disturbed sleep, anxiety and depression.

How common is neuropathic pain?

It is estimated that about 7 in every 100 people in the UK have persistent (chronic) neuropathic pain. It is much more common in older people who are more likely to develop the conditions listed above.

What is the treatment for neuropathic pain?

Treatments include:
Treating the underlying cause - if possible.
Physical treatments.
Psychological treatments.

Treating the underlying cause

If this is possible, it may help to ease the pain. For example, if you have diabetic neuropathy then good control of the diabetes may help to ease the condition. If you have cancer, if this can be treated then this may ease the pain. Note: the severity of the pain often does not correspond with the seriousness of the underlying condition. For example, pain after shingles (post-herpetic neuralgia) can cause a severe pain, even though there is no rash or sign of infection remaining.

Medicines used to treat neuropathic pain

Commonly used traditional painkillers

You may have already tried traditional painkillers such as paracetamol or anti-inflammatory painkillers such as ibuprofen that you can buy from pharmacies. However, these are unlikely to ease neuropathic pain very much in most cases.

Related articles

Meralgia Paraesthetica
Tricyclic Antidepressants
Peripheral Neuropathy
See more articles »

Tricyclic antidepressant medicines

An antidepressant medicine in the tricyclic group is a common treatment for neuropathic pain. It is not used here to treat depression. Tricyclic antidepressants ease neuropathic pain separate to their action on depression. It is thought that they work by interfering with the way nerve impulses are transmitted. There are several tricyclic antidepressants, but amitriptyline is the one most commonly used for neuralgic pain.

A tricyclic antidepressant may ease the pain within a few days, but it may take 2-3 weeks. It can take several weeks before you get maximum benefit. Some people give up on their treatment too early. It is best to persevere for at least 4-6 weeks to see how well the antidepressant is working.

Tricyclic antidepressants sometimes cause drowsiness as a side-effect. This often eases in time. To try to avoid drowsiness, a low dose is usually started at first, and then built up gradually if needed. Also, the full daily dose is often taken at night because of the drowsiness side-effect. A dry mouth is another common side-effect. Frequent sips of water may help with a dry mouth. See the leaflet that comes with the medicine packet for a full list of possible side-effects.

Other antidepressant medicines

An antidepressant called duloxetine has also been shown in research trials to be good at easing neuropathic pain. In particular, duloxetine has been found to be a good treatment for diabetic neuropathy and is now often used first-line for this condition. Duloxetine is not classed as a tricyclic antidepressant but as a serotonin and norepinephrine reuptake inhibitor (SNRI). It may be tried for other types of neuropathic pain if a tricyclic antidepressant has not worked so well, or has caused problematic side-effects. The range of possible side-effects caused by duloxetine is different to those caused by tricyclic antidepressants.

Anti-epileptic medicines (anticonvulsants)

An anti-epileptic medicine is an alternative to an antidepressant. For example, gabapentin or pregabalin. These medicines are commonly used to treat epilepsy but they have also been found to ease nerve pain. An anti-epileptic medicine can stop nerve impulses causing pains separate to its action on preventing epileptic seizures. As with antidepressants, a low dose is usually started at first and built up gradually, if needed. It may take several weeks for maximum effect as the dose is gradually increased.

Opiate painkillers

Opiate painkillers are the stronger traditional painkillers. For example, codeine, morphine and related drugs. As a general rule, they are not used first-line for neuropathic pain. This is partly because there is a risk of problems of drug dependence, impaired mental functioning and other side-effects with the long-term use of opiates.

Tramadol is a painkiller that is similar to opiates but has a distinct method of action that is different to other opiate painkillers. Tramadol can be used for short-term treatment of neuropathic pain. Tramadol should not be used for prolonged treatment.

Combinations of medicines

Sometimes both an antidepressant and an anti-epileptic medicine are taken if either alone does not work very well. Sometimes tramadol is combined with an antidepressant or an anti-epileptic medicine. As they work in different ways, they may complement each other and have an additive effect on easing pain better than either alone.

Capsaicin cream

This is sometimes used to ease pain if the above medicines do not help, or cannot be used because of problems or side-effects. Capsaicin is thought to work by blocking nerves from sending pain messages. Capsaicin cream is applied 3-4 times a day. It can take up to 10 days for a good pain-relieving effect to occur.

Capsaicin can cause an intense burning feeling when it is applied. In particular, if it is used less than 3-4 times a day, or if it is applied just after taking a hot bath or shower. However, this side-effect tends to ease off with regular use. Capsaicin cream should not be applied to broken or inflamed skin. Wash your hands immediately after applying capsaicin cream.

Other medicines

Some other medicines are sometimes used on the advice of a specialist in a pain clinic. These may be an option if the above medicines do not help. For example, ketamine injections. Ketamine is normally used as an anaesthetic, but at low doses it can have a pain-relieving effect.

Another example is lidocaine gel. This is applied to skin, with a special patch. It is sometimes used for pain following shingles (postherpetic neuralgia). But note, it needs to be put on to non-irritated or healed skin.

Side-effects and titrating dosages of medicines

For most of the medicines listed above it is common practice to start at a low dose at first. This may be sufficient to ease the pain but often the dose needs to be increased if the effect is not satisfactory. This is usually done gradually and is called titrating the dose. Any increase in dose may be started after a certain number of days or weeks - depending on the medicine. Your doctor will advise as to how and when to increase the dose if required; also, the maximum dose that can be taken for each particular medicine.

The aim is to find the lowest dose required to ease the pain. This is because the lower the dose, the less likely that side-effects will be troublesome. Possible side-effects vary for the different medicines used. A full list of possible side-effects can be found with information in the medicine packet. Some people don't get any side-effects, some people are only mildly troubled by side-effects that are OK to live with, but some people are troubled quite badly by side-effects. Tell your doctor if you develop any troublesome side-effects. A switch to a different medicine may be an option if this occurs.

Physical treatments

Depending on the site and cause of the pain, a specialist in a pain clinic may advise one or more physical treatments. These include: physiotherapy, acupuncture, nerve blocks with injected local anaesthetics, percutaneous electrical nerve stimulation (PENS) and transcutaneous electrical nerve stimulation (TENS) machines.

Psychological treatments

Pain can be made worse by stress, anxiety and depression. Also, the feeling (perception) of pain can vary depending on how we react to our pain and circumstances. Where relevant, treatment for anxiety or depression may help. Also, treatments such as stress management, counselling, cognitive behavioural therapy, and pain management programmes sometimes have a role in helping people with persistent (chronic) neuropathic pain.

Further help & information

Action on Pain

British Pain Society

Chronic Pain Policy Coalition

Pain Concern

Pain Relief Foundation

References & Disclaimer | Provide Feedback

Tuesday, 24 February 2015

Melatonin Receptor Analgesic May Reduce Neuropathic Pain

Today's post from (see link below) talks about a new analgesic, (imaginatively named UCM924!!!) which targets the melatonin receptors in the brain and may provide a much safer and just as effective alternative to opioids in the treatment of neuropathic pain. Over-the-counter melatonin products from health shops have been found to be largely ineffective but UCM924 can switch off the neurons that cause pain and stimulate the melatonin receptors into thinking they are being flooded with melatonin - resulting in much less pain. It's been successfully tested on animals already, so the next step is human trials and then manufacture. Can't come soon enough as far as this blog is concerned. Of course it has to pass all tests and get FDA approval but the result may be a much cheaper and infinitely less dangerous alternative to the hard drugs we presently need to control our symptoms. Keep the name UCM924 in mind (hopefully when it hits the shelves, it'll have something much catchier!)
New hope in the fight against pain: Analgesic drugs could be used to treat patients with neuropathic pain
Date: February 18, 2015 Source:McGill University


Drugs that selectively target the melatonin MT2 receptor represent a novel class of analgesic drugs that could be used to treat patients with neuropathic pain, an international study reports, for the first time.

An international study led by scientists at McGill University reports, for the first time, that drugs that selectively target the melatonin MT2 receptor represent a novel class of analgesic drugs that could be used to treat patients with neuropathic pain.

Neuropathic pain is a disorder characterized by severe pain that sometimes develops following nerve damage resulting from conditions such as shingles, injury, amputation, autoimmune inflammation and cancer. It is a permanent pain that persists for months or years.

An estimated 7% to 8% of adults worldwide suffer from neuropathic pain, with 5% of cases considered severe. The problem has significant economic implications, including reduced productivity and substantial health care costs.

Melatonin, a neurohormone present in mammals, acts on the brain by activating two receptors called "MT1" and "MT2" that are responsible for regulating several functions including sleep, depression, anxiety and circadian rhythms.

Now, a team led by Dr. Gabriella Gobbi, Associate Professor in the Department of Psychiatry of McGill's Faculty of Medicine, has demonstrated that UCM924, a melatonin MT2 receptor drug, relieves chronic pain in animal models; the team has also identified the drug's mechanism of action in the brain. UCM924, by activating the MT2 receptors in the periaqueductal grey (a brain area controlling pain), is able to switch off the neurons that trigger pain and switch on the ones that turn off pain The findings are reported in the February issue of the journal PAIN.

"There are very limited treatments available for neuropathic pain, and a lot of patients use opioids," says Dr. Gobbi, who is also a researcher at the Research Institute of the McGill University Health Centre (RI-MUHC). "In the long term, these can lead to addiction and severe side effects, including dependence and tolerance, opioid-induced hyperalgesia (the pain becomes even worse), and risk of death. For these reasons, identifying novel analgesics is of keen interest in the medical field today."

Previous studies have shown that over-the-counter melatonin has very limited effect. Dr. Gobbi and her team demonstrated that this is because exogenous melatonin activates both MT1 and MT2 receptors, which have conflicting and opposite effects.

In the course of their work to investigate the efficacy of MT2 receptor drugs for insomnia, the researchers discovered that UCM924 also soothes neuropathic pain at lower doses. This suggests that these drugs could offer relief both to people who suffer from pain during the day, using low doses, and from insomnia at night, using higher doses. At least 50-70% of patients with neuropathic pain conditions complain of significant sleep disturbance, and this new study unveils how the mechanisms of pain and sleep are closely related.

The research team is now looking for partners interested in pursuing clinical development and eventual commercialization of these novel drugs.

Story Source:

The above story is based on materials provided by McGill University. Note: Materials may be edited for content and length.

Journal Reference:

Martha Lopez-Canul, Enza Palazzo, Sergio Dominguez-Lopez, Livio Luongo, Baptiste Lacoste, Stefano Comai, Debora Angeloni, Franco Fraschini, Serena Boccella, Gilberto Spadoni, Annalida Bedini, Giorgio Tarzia, Sabatino Maione, Vinicio Granados-Soto, Gabriella Gobbi. Selective melatonin MT2 receptor ligands relieve neuropathic pain through modulation of brainstem descending antinociceptive pathways. PAIN, 2015; 156 (2): 305 DOI: 10.1097/01.j.pain.0000460311.71572.5f

Monday, 23 February 2015

Read How Professionals Learn How To Treat Neuropathic Pain

Today's post from (see link below) is a long but very informative summary of how health professionals in the UK approach neuropathic pain. Normally, patients don't get to see this sort of information but it's always useful to know how health professionals are taught to approach our problems. It also helps us anticipate what the next step in our treatment might be. This article also helps us to understand how diverse neuropathy can be. Doctors need to be able to slot our cases into the overall pattern and identify both cause and appropriate treatment and as you can see here, that's by no means an easy job. There are over 100 causes of neuropathy and more than 100 different 'types' to deal with so maybe we should be a little more tolerant of our health carers as they try to fit us into the puzzle. Having done that, they and we, are faced with a disease where everybody responds differently to different treatments. While we sit and grumble at how long it's taking to get relief from the symptoms and how many different sorts of drugs we have to take; this article may at least help us to be more patient. Neuropathy can be the most complex chess game!

Neuropathic Pain and its Management Original Author: Dr Laurence Knott Current Version: Dr Colin Tidy
Last Checked:13/01/2014  

PatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Neuropathic pain
is defined by the International Association for the Study of Pain (IASP) as pain arising as a direct consequence of a lesion or disease affecting the somatosensory system.[1]

Clinical features[2]
The discomfort is usually of a chronic nature and may be described by the patient as a burning sensation, a sharp, stabbing or shooting pain, or 'like an electric shock'.

Other features may include:
Allodynia - seemingly harmless stimuli, such as light touch, provoking pain.
Hyperpathia - a short episode of discomfort causing prolonged severe pain.
Hyperalgesia - discomfort, which would otherwise be mild, being felt as severe pain. The IASP states that hyperalgesia is a psychophysical term; it is has been suggested as the umbrella term for all conditions of increased pain sensitivity. Its definition parallels that of the physiological term 'sensitisation'.[2]


There are no accurate figures for the overall prevalence of neuropathic pain.
The prevalence of neuropathic pain has been estimated to be between 6% and 8%.
A large study of computerised records in primary care from the Netherlands estimated the annual incidence of neuropathic pain in the general population to be almost 1%.
Painful diabetic neuropathy is estimated to affect between 16% and 26% of people with diabetes.
Prevalence estimates for postherpetic neuralgia range from 8% to 19% of people with herpes zoster when defined as pain at one month after rash onset, and 8% when defined as pain at three months after rash onset.
The development of chronic pain after surgery is also fairly common, with estimates of prevalence ranging from 10% to 50% after many common operations. This pain is severe in between 2% and 10% of these patients, and many of the clinical features closely resemble those of neuropathic pain.


Peripheral causes

Central causes

Mononeuropathies and multiple mononeuropathies:

Diabetic mononeuropathy and amyotrophy.
Trauma: painful scars, compression, transection of a nerve, post-thoracotomy.
Neuralgic amyotrophy.
Damage to nerve plexi (plexopathy) from malignancy or radiation.
Connective tissue disease.
Rare causes - trench foot (damage due to cold exposure over several days), borreliosis.

Cuban neuropathy (usual cause B-group vitamin deficiency)
Burning feet syndrome.
Tanzanian neuropathy (may be Coxsackie infection).
Strachan's (Jamaican) neuropathy (orogenital ulceration, sensory neuropathy, ambylopia - cause unknown).

Vincristine, cisplatin, arsenic.

Acute inflammatory polyneuropathy (Guillain-Barré syndrome).
Chronic inflammatory demyelinating polyneuropathy (CIDP).

Anderson-Fabry disease.
Dominantly inherited sensory neuropathy/hereditary sensory and autonomic neuropathy (HSAN) - an inherited sensorimotor axonal neuropathy.[4]


Idiopathic small fibre neuropathy.

Spinal root/dorsal root ganglion:
Prolapsed disc.
Root avulsion.
Trigeminal neuralgia.
Postherpetic neuralgia (herpes simplex or varicella zoster).
Surgical rhizotomy.

Spinal cord:

Multiple sclerosis.
Vascular: infarction, haemorrhage, arteriovenous malformations.
HIV and syphilis.
Syringomyelia and intrinsic tumours.
Neural tube defect.
Vitamin B12 deficiency.
Anterolateral cordotomy.


Lateral medullary syndrome.[5]
Multiple sclerosis.


Surgical lesions.

Subcortical and cortical:

Arteriovenous malformation.


The treatment of the underlying causative condition is central to the management of neuropathic pain but is outside the scope of this article. Neuropathy caused by mechanical pressure, for example, may require surgical and other interventional procedures.

The main role of the GP in the management of neuropathic pain is in the control of symptoms where the underlying cause is medical, where the condition is of a chronic, recurring or acute self-limiting nature, or whilst awaiting specialist intervention.

Prescribing of therapy with little evidence of efficacy in neuropathic pain is still common in the UK and consequently treatment is often not in line with current guidance.[6

When selecting a particular medication, the National Institute for Health and Care Excellence (NICE) recommends considering comorbidities, safety considerations, contra-indications, patient preference, lifestyle factors, any history of mental health problems (eg, anxiety, depression) and existing medication history.

Clear advice should be given about dosage instructions, preferably in writing.
Consider overlapping old and new treatment to prevent deterioration in pain control.

Review the patient early after starting or changing treatment.

Review the patient regularly, covering such aspects as pain control, side-effects, effect on daily living (eg, driving, working), mood, sleep and overall improvement.


Consider referring the person to a specialist pain service and/or a condition-specific service at any stage, including at initial presentation and at the regular clinical reviews, if:[3]
They have severe pain; or
Their pain significantly limits their lifestyle, daily activities (including sleep disturbance) and participation; or
Their underlying health condition has deteriorated.

Non-pharmacological measures

Psychological techniques - cognitive behavioural therapy has shown some benefit in the treatment of chronic pain.[7]
Studies of chronic pain management suggest that a combination of psychological, pharmacological and physical therapies, tailored to the needs of the individual patient, may be the best approach.[8]
Electrical stimulation - interpretation of systematic trials is difficult due to differing methodologies.[9] However, transcutaneous electrical nerve stimulation (TENS) performs consistently well compared with placebo.[10]
Percutaneous electrical nerve stimulation (PENS) has shown evidence of short-term benefit for refractory neuropathic pain.[11]
NICE recommends the use of spinal cord stimulation in patients who have had chronic pain for six months (measuring at least 50 mm on a 0-100 mm visual analogue scale) despite conventional medical management (providing a prior trial of stimulation has proved to be effective).[12]
Acupuncture - systematic evidence to support its use in neuropathic pain is limited.[13]

Pharmacological measures[3][14]

All neuropathic pain (except trigeminal neuralgia):
Offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain (except trigeminal neuralgia).
If the initial treatment is not effective or is not tolerated, offer one of the remaining three drugs, and consider switching again if the second and third drugs tried are also not effective or not tolerated.
Consider short-term tramadol only if acute rescue therapy is needed.
Consider capsaicin cream for people with localised neuropathic pain who wish to avoid, or who cannot tolerate, oral treatments.

Do not start the following to treat neuropathic pain in non-specialist settings, unless advised by a specialist to do so: cannabis sativa extract, capsaicin patch, lacosamide, lamotrigine, levetiracetam, morphine, oxcarbazepine, topiramate, long-term tramadol, venlafaxine.

Trigeminal neuralgia:
Offer carbamazepine as initial treatment for trigeminal neuralgia.
If initial treatment with carbamazepine is not effective, is not tolerated or is contra-indicated, consider seeking expert advice from a specialist and consider early referral to a specialist pain service or a condition-specific service.

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Further reading and references
Management of chronic pain; Scottish Intercollegiate Guidelines Network - SIGN (Dec 2013)
Scadding J; Advances in Clinical Neuroscience and Rehabilitation 2003;3(2)
Pain Terminology; International Association for the Study of Pain (IASP), 2008
Neuropathic pain – pharmacological management: The pharmacological management of neuropathic pain in adults in non-specialist settings; NICE Clinical Guideline (Nov 2013)
Neuropathy, Hereditary Sensory And Autonomic, Type IA, HSAN1A; Online Mendelian Inheritance in Man (OMIM)
Wallenberg's Syndrome; National Institute of Neurological Diseases and Stroke
Hall GC, Morant SV, Carroll D, et al; An observational descriptive study of the epidemiology and treatment of neuropathic pain in a UK general population. BMC Fam Pract. 2013 Feb 26;14:28. doi: 10.1186/1471-2296-14-28.
Williams AC, Eccleston C, Morley S; Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2012 Nov 14;11:CD007407. doi: 10.1002/14651858.CD007407.pub3.
Turk DC, Audette J, Levy RM, et al; Assessment and treatment of psychosocial comorbidities in patients with Mayo Clin Proc. 2010 Mar;85(3 Suppl):S42-50.
Fargas-Babjak, Angelica M.D. Acupuncture, Transcutaneous Electrical Nerve Stimulation, and Laser Therapy in Chronic Pain. Clinical Journal of Pain. Etiology, Prevention, Treatment, and Disability Management of Chronic Pain. 17(4) Supplement:S105-S113, December 2001.
Cheing GL, Luk ML; Transcutaneous electrical nerve stimulation for neuropathic pain. J Hand Surg (Br). 2005 Feb;30(1):50-5.
Percutaneous electrical nerve stimulation for refractory neuropathic pain; NICE IPG (Mar 2013)
Pain (chronic neuropathic or ischaemic) - spinal cord stimulation; NICE Technology Appraisal Guideline, October 2008
Guidelines on the management of neuropathic pain; Clinical Resource Efficiency Support Team (February 2008)
British National Formulary

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

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