Peripheral Neuropathy, Neuritis or Neuralgia (nerve damage and dysfunction)
Peripheral neuropathy (PN) means damage to the nerves of the peripheral nervous system. There are several types:
• Polyneuropathy where many nerves are involved
• Autonomic neuropathy
• Mononeuropathy where one nerve is involved
• Mononeurits multiplex
Neuritis & neuralgia are covered in Part 2
The treatable causes of all forms of nerve damage often overlap. You can find information about many of these on my website:
• Abnormal red cells, especially anemia
• Circulation problems, especially small vessel damage and arteriosclerosis and depleted nitric oxide
• ATP depletion
• Lung problems, where low oxygen leads to circulation problems
• Kidney disease, especially in the early phases
• Physical problems – obesity, lack of exercise, unhealthy food intake, uncontrolled stress
• Toxins – alcohol, some prescription drugs, especially psychiatric drugs, anti-bacterials (quinolones, metronidazole, nitrofurantoin), seizure drugs and chemotherapy, marijuana, street drug use, tobacco, toxic chemicals, radiation
• Infections: viral (especially herpes 1, 2, 3 (shingles) 4 (Epstein Barr), 5 (Cytomegalovirus), 6 & 7), coxsackie virus and others), fungal (candida, aspergillus, mucor and others), bacterial infections (especially mycoplasma, chlamydia pneumonia, Lyme’s, strep, others), HIV others
• Immune problems – abnormal CRP, glucose problems, others
• Genetic problems
• Nutritional problems – pre-diabetes, diabetes, obesity, high cholesterol, B 6 (too low or too high), vitamin A or E, B1, B12, magnesium, zinc, potassium, selenium deficiencies, amino acid deficiencies
• Neurotransmitter problems – ATP, nitric oxide, serotonin, dopamine, adrenaline, acetylcholine & others
• Auto immune problems – abnormal ANA test, lupus, rheumatoid arthritis, fibromyalgia, thyroid problems, Reynaud’s, multiple sclerosis, others
• Amyloidosis (found with beta microglobulin tests) and hyaline disease (found with urine tests)
• Porphyria – often secondary to infections
• Hypothyroidism and other metabolic disorders
• Cancers and rare genetic conditions
Treatments should focus on eliminating or controlling the causes, next at maintain muscle strength and functions with exercise and finally controlling the symptoms. All too often, the focus is controlling symptoms with drugs, such as opiate pain medicines, anti-depressants, Neurontin, Lyrica, Cymbalta, Duloxetene and others. These drugs can relieve symptoms (at least initially) but often lead to other problems or can slowly exacerbate symptoms because these drugs deplete neurotransmitters and can imbalance the autonomic nervous system.
General symptoms for any nerve problem include:
• Loss of function – numbness, tremors and gait (balance & walking) problems. Weakness, fatigue, heaviness are common symptoms.
• Abnormal functions – tingling, pain, itching, crawling sensations, pins & needles. Cramps, twitches and restlessness are common. Nerve hypersensitivity (excessive sensation) means discomfort or pain with things touching body parts, such as bed sheets, socks or shoes.
Peripheral polyneuropathy, where many nerves of both (symmetrical) arms, hands, legs or feet are affected, is the most common type. Neuropathy is often associated with fatigue, weakness, twitches, cramps, spasms, loss of muscle size, sensory changes (pain, pins, needles, electric shocks, decreased sensation or excessive sensation), problems with balance or coordination or autonomic problems (see below).
Polyneuropathy involves many nerves in different body parts. Pre-diabetes and diabetes, which are easily diagnosed and managed with blood tests or glucose tolerance testing, is the most common cause. Infections (especially viral) and auto-immune disorders are also common causes. Demyelinating neuropathy is where the myelin sheath around the nerve is damaged (as in multiple sclerosis) where nerve electrical impulses are inconsistent. Typical symptoms include weakness, clumsiness, abnormal sensations (tingling, burning), diminished sensation to touch or temperature. Commonly, this starts in the feet but can affect any body part.
Polyneuropathy commonly overlaps with autonomic neuropathy (see below). Most cases progress fairly slowly over months or years, confusing clinicians and patients. Glucose levels often spike after meals even though fasting and average glucose levels remain normal. That’s why I do glucose tolerance tests, hemoglobin A1C and fructosamine tests to detect abnormal glucose levels before diabetes develops or when diabetes is supposedly “controlled”. Typical symptoms include tingling, pain and decreased sensation in the feet and hands.
The nervous system has three interconnected compartments:
• The central nervous system or brain
• The peripheral nervous system connected to all organs and the extremities
• The autonomic nervous system connected to all organs and the extremities
Autonomic neuropathy is the next most common form and affects internal organs that run “automatically”, such as the bladder, digestive tract, cardiovascular (blood vessels & heart), lungs and genital organs. The autonomic system (also known as the parasympathetic system) nerves are not under conscious control and function automatically. You do not have to think about regulating respirations, heart rate, blood vessel opening or constriction or bladder control – these function automatically.
The autonomic nerves form junctions (ganglia) in the brain, chest, abdomen and pelvis separate from the spinal cord, but have connections to the spinal cord and brain. 80% of patients with pre-diabetes and diabetes will develop autonomic problems and these nerves can be damaged by the treatable conditions listed in Part 1. Neuropathy is only one type of autonomic system damage. One can also have autonomic dysfunction, dysautonomia or reflex sympathetic dysfunction.
Common symptoms of autonomic neuropathy or autonomic dysfunction include:
• Brain problems: anxiety, depression, attention or memory problems, temperature problems
• Cardiovascular and blood vessels: fast, slow or irregular heartbeats, low blood pressure, dizziness, minimal or no heart rate increase with exercise
• Pre-diabetes diabetes: low or high glucose with or without symptoms
• Gastrointestinal problems: swallowing problems, abdominal pain, nausea, vomiting, constipation, diarrhea, malabsorption, incontinence, gastroparesis (distress after meals)
• Urinary: bladder incontinence, urgency, irritability, urinary retention
• Genital: erection problems, hot flashes
With all forms of nerve damage one should focus on treatments to eliminate or control the causes, next at maintaining muscle strength and functions with exercise and finally controlling the symptoms. All too often, the focus is controlling symptoms with drugs, such as antidepressants, heart drugs, digestive or bladder control drugs – which can lead to other problems or can slowly exacerbate symptoms because these drugs can deplete neurotransmitters and further imbalance the autonomic nervous system.
A common type of mononeuropathy is carpal tunnel syndrome, where a single nerve in the wrist is compressed. However, this often overlaps with other types of nerve damage.
Mononeuritis multiplex involves individual nerves that are not connected t and is difficult to understand and diagnose. The symptoms are not symmetrical (not on both sides) initially but then becomes symmetrical (affecting left and right sides). In addition to the above symptoms, this may also cause deep, aching pain, often worse at night and frequently in the back, hip or leg. In pre-diabetic or diabetic patients, this can cause significant one sided thigh pain, with muscle weakness and loss of knee reflexes. EMG nerve tests often identify the nerve involved, but not the treatment.
Neuritis means inflammation of a nerve or inflammation in the peripheral nervous system. Neuralgia means nerve pain. Both of these have the same causes of damage and treatment approaches. Tight fitting shoes commonly cause neuritis. Neuritis symptoms can include pain, pins & needles, weakness, numbness, lack of feeling, wasting of affected muscles, absent reflexes and paralysis.
Part 3: Treatments
A discussion of the many treatments we offer (drugs, alternative medicines) are beyond the scope of this article. Electrical treatments are often very effective but depend upon the type and method used. There are also many different devices (machines) and what works for one person may not work for another. Electrical treatments involve running low level and painless electrical current through the area, extremity or organs affected by autonomic dysfunction neuropathy, neuritis or neuralgia. While drugs have many potential side effects, electrical treatments have none (when used correctly). You can find information about these on my website or in appointments:
• Neuromuscular stimulation
• Auriculotherapy and needle-less acupuncture
• TENS or transcutaneous nerve stimulation
Additional treatments are covered in appointments or consultations by phone or internet.
David Overton, PA-C owns Natural Medicines & Family Practice where he combines conventional and alternative treatments under the supervision of Dr. Richard Faiola, MD, ABFM.