Monthly Archives: June 2015

Making a Mirror Box

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donut-5

Using a mirror to ‘fool’ the brain into seeing a missing limb can certainly aid with reducing phantom pain. Sometimes, electrodes are placed on the ‘good’ leg as well so the brain senses ‘electrical sensation.’ In some cases, another electrode is placed on the ‘stump’ of the other leg. In very basic, non-technical terms, this is to ‘help train’ the brain and the nerves to accept ‘where’ the pain sensors are now located.

In the case of a stroke patient, however, there is no missing limb.  Again, the brain needs to be ‘rewired,’ so to speak, to allow both feeling and function to return into the non-functional limb.

Of course, this works just as well with the upper body limbs; missing or non-functional, as seen above. With or without electrodes placed on either or both arms/hands, the mirror reflects the functional limb; and the brain ‘thinks’ it sees the affected arm in the mirror. This works quite well when exercise is added. Often, the good hand will go through exercise, while the non functional limb is hidden from view inside a box. To the brain, apparently, the mirror shows both limbs undergoing exercise; and, surprisingly, sometime times the non-functioning hand will start to ‘mimic’ what is seen in the mirror. Not full function, mind you, to begin with; but often the fingers will move and the tendons and muscles in the hand, wrist and arm will begin to flex. Again, in layman’s terms, this is an example of the brain repairing (or more likely, ‘rewiring’) itself to make the arm and hand functional once more.

The beauty of using mirrors or Mirror Boxes is, one doesn’t have to just have therapy in the doctor’s office or clinic. The motivated patient, can do exercise every day at home; perhaps, not with neuromuscular stimulation, but with exercise.

Mirror boxes can be made any side to accommodate feet, legs or arm/hands. And, depending upon the nature of the disability, one may be able to simply place a mirror between limbs. Or, if making a box, one can sit in a chair, put their foot in and do exercise. But remember, one does not have to be sitting to do this. Refer back to the photo on the last blog… one can simply lay on a bed or sofa with a full or half length mirror between the legs as well.

For hands, it is much easier. Here are the directions for making your own Mirror Box for hand use. However, just a plain cardboard box will work just as well and is fast to make. Not fancy… but it works!

This first, is more of a pyramid, so to speak. Three pieces of 12″ x 12″ wood, cardboard or cork-board is required, as is a ‘sticky’ duct tape and a 12″x 12″ mirror.

donut (2)Make a box or three sided triangle as shown in the photo. Attach sides. (Mirror is reflecting material from wall) Make sure to use extra sticky tape, if using just cardboard or Cork Board.

donut-2donut-3

Place the mirror on one side and use double stick tape or ‘glue’ to hold it in place, as the photo at the top of this page shows. The box is ready to use. It’s that quick and easy.  Of course, one can purchase ready made boxes to use, or can make as ‘fancy’ or expensive a box as one wants. This box, cost only $15 to make.

But, it can be done even more quickly and easily, as show in the following pictures:

hershey-3box mirrorA plate easel can be used, to hold a mirror, as can the bottom of a cardboard box or even just ‘taping’ a mirror to a box or container. Anything which can, safely, uphold a mirror, can be used. In our office, if our mirror boxes are in use, and we need another, we will quickly tape a 12″ x 12″ mirror to a handled equipment box to be easily carried from one room to another.

The key to using a Mirror Box is ‘blocking’ the view of the affected limb from the eyes/brain; while ‘fooling’ the brain into seeing a ‘healthy, working’ limb. 

Mirror Box Therapy

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Many people seen surprised to find, that someone with a missing limb might have peripheral neuropathy; I don’t know why… they are like anyone else and can suffer from the same maladies, such as neuropathy, diabetes or other issues. In fact, diabetes may even be the reason they are missing the limb in the first place! In the same sense, if one, previously, has peripheral neuropathy, ‘losing a limb’ doesn’t necessarily mean that one ‘loses’ the neuropathy in that leg too! Many times, the patient suffers from, what the layperson probably HAS heard of…, “phantom pain.”

Diabetics are especially susceptible to phantom pain when they lose a limb; as the brain ‘remembers’ the pain it once had, but doesn’t really realize that the limb might be missing. So some people may feel discomfort in the leg even though it is not there. Even simple things like ‘itching’ can be felt in the missing area; surprisingly, often, if someone ‘itches’ in the air near the where the itch would have been, the itching sensation can often be relieved. “ Psychosomatic?” Perhaps!

But, when one has peripheral neuropathy, it is a somewhat different matter. Most neuropathies occur in both feet; so when a foot or leg is missing, the ‘neuropathy,’ often, is still there. Sometimes, we can just put an electrode on the ‘stump’ and that takes care of the problem with some neuromuscular stimulation. But other times, we need to go to extreme measures and ‘fool’ the brain, so to speak.

I keep a full length mirror on my office hallway wall for a reason; it’s not that I want to check my or my patients hair or clothing, I am, merely, storing the mirror on the wall, out of the way. Why, you might ask? When an amputee patient with neuropathy comes in, I take the mirror off the wall and place it between the patients full leg, and what is left of the missing leg. (If the leg is missing from the hip, then I’ll have someone hold the mirror in place.) The patient ‘leans’ a bit toward the full leg and looks in the mirror. Of course, what they see is a ‘reverse’ image of their leg… (in other words, two legs!) the same, as if they were looking down at both legs, if one wasn’t missing.

mirror

For whatever reason, the brain sees this reflection and associates it with the missing leg; so, again, if one had a ‘pain’ on the missing leg, the brain could be ‘fooled’ into relieving that pain! Confusing? How, exactly does this work? First, as previously mentioned, the brain is fooled by the reflection; but then, we fool it even more by attempting to remove the other symptoms in the phantom leg the way we do with a normal leg. We can use massage therapy on the opposite foot, acupuncture or even neuromuscular stimulation. In other words, if we were to put an electrode on the full leg, chances are, the patient would ‘feel it’ in the missing leg as well; and the symptoms are relieved. In extreme cases, we will place an electrode on the ‘stump’ of the missing leg as well… in an effort to ‘retrain’ the muscles and nerves to feel actual sensations and to ‘forget’ the phantom pain.

This can be done just as easily with missing hands/arms, as it can with the feet; and, best of all, one doesn’t have to be a physical therapist or neuropathist to do it at home. Yes, therapy is best left to the professionals… but, if one can’t receive the therapy they need, ‘home therapy’ is the next best thing; and, one really doesn’t have to be an expert to achieve some impressive results. Full length mirrors can be purchased cheaply in many stores or thrift stores for $20 or less! And/or one can make a ‘Mirror Box’ at home to use for themselves or with a family member almost as easily. Of course, there are many different models available on the internet for purchase too! Placing the affected limb into the box, simple stimulation/sensation is added in the form of massage, or heat and cold, or pin prick. Anything, to make the brain feel like there is ‘sensation’ when it sees it in the mirror.

The next question I, generally, get asked it: “Well, if this works with missing limbs, what about non-functional limbs… like from stroke or accident?” The same treatment holds true. Mirror Boxes can be purchased or made for foot/leg use as well or simply go back to a wall mirror. Reflection and stimulation of the functional hand or foot, will fool the brain and help to ‘reroute’ the nerves which may have been damaged through stroke or accident. Even exercise, such as squeezing a ball with the functional hand, will cause nerves and muscles in the affected limb to respond.

Does this work for everyone? Certainly not; but it works for many more than expected!

 

My next Blog, will go into more detail as to “Making a Mirror Box” and the treatment for non-functional limbs.

Treatment

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Treatment for peripheral, or other neuropathies can vary; depending upon the type of neuropathy (long or short nerves involved), the kind of neuropathy (autonomic, diabetic, proximal, focal, sensorimotor, etc.), if the patient has an implanted device (pacemaker, defibrillator, insulin pump, or etc.) and/or if the patient can personally handle any particular type of modality (artificial knees, not allowing whole body vibration, or the patient simply does not like a particular ‘feeling.’) This last is, probably, the most important as it directly affects patient compliance; as if someone doesn’t like something, they, probably, won’t continue with it!

After examination and testing is all finished, it’s time to start with whatever treatment which is best associated with the type of neuropathy the patient has. If they suffer from long nerve damage, we will, probably, treat with 7.83 Hz as a neuromuscular stimulation frequency. Treatment begins with placing electrodes in the particular part of the foot which is most affected; for example, if the ball of the foot hurts the most (has the most serious symptoms) an electrode of particular size is placed on it. An electrode is place bilaterally on the other foot; this way, the 7.83 Hz can ‘travel’ through the foot, up the leg, across the hips and lower back and down the other leg before reversing polarity and going back the other way. This both stimulates the foot itself (offering some pain relief, via, and underlined TENS signal.  PLEASE NOTE: NMES is not TENS therapy; but might have an underlined signal included as well!)

If other symptoms are present, such as edema in the foot and ankle, or ‘spotty’ numbness in the legs, another electrode may be placed in other areas of the leg or even opposite leg; again, should other issues be present, like polyneuropathy. In the case of drop foot, for example, multiple electrodes may be placed on the calf muscles as well as the ankles and foot. (Again, this is why a good Intake, Exam and Testing is so important!)

There is yet another way to treat with this frequency and sine wave; that is, to treat ‘wet.’ We will take tanks filled with warm electrolyte and water, appropriate for the size hands or feet, and place carbon/rubber electrodes in them. The DC current is then applied; which is amplified by the water. This helps to Vasodilate the tissue as well; meaning, bringing more blood/oxygen to the tissues, while electronic pulsations cause the muscles to contract and relax. At the same time, the small vascular valve in the back of the calf is forced open so that ‘pooled’ blood in the feet and lower legs can be sent back up to the heart, where is it ‘re-oxygenated,’ and sent back down to the feet again; thus, ‘feeding’ the myelin sheathing of each individual nerve. The synoptic junctions of the long nerves are, also, ‘fed,’ so to speak, by bringing more blood/oxygen to them… causing them to grow back closer together and naturally reduce symptoms.

With short nerves, we generally use a different frequency, 44 Hz, to help stimulate the Schwann cells to generate new myelin growth. This is an AC treatment, so it is never used ‘wet!’ If other symptoms are present, such as edema, muscle atrophy or again, drop foot, we may use multiple electrodes to treat each individual muscle group. Circulation is greatly improved and excess edema (fluid) is moved out.

One advantage electronic treatment has over, say massage, which too, can increase circulation, is that it also stimulates the brain to release endorphin’s; natural opiates/pain killers; which is ‘why’ people tend to feel better during or after treatment. In fact, patients often tell us during treatment, “I don’t know what you are doing to my feet… but my tennis elbow feels great!”  There is nothing in Endorphin’s which says, “Only go to the feet!” They go all over the body… so, it is only natural that ones ‘sore elbow’ or other issue would ‘feel better’ as well!

What else can be done?  Many things –  to much, in fact to go into detail in this single Blog; such as far wave (FIR) infrared light, acupuncture, acupressure, Acukoryo hand therapy, pressure point therapy, trigger point therapy, certified massage, lymphatic massage, localized vibration, whole body vibration, CES therapy, hypnotherapy, sensorimotor stimulation, nutrition, diet, vitamins, minerals and more! Each of these issues will be taken up on these pages, on a more individualized basis. Prescription drugs, however, is the one modality we don’t recommend. In fact, we attempt to work with the patient to get them off the prescription drugs… as many can actually cause the very neuropathy it is seeking to treat!

Many times, several of these modalities are combined for treatment; such as, the neuromuscular stimulation and far wave (FIR) infrared light. Both, will add comfort, while treating the muscles and nerves; however, the light helps the tissue create nitric oxide as well; which will help with oxygen and circulation.

When other issues, such as depression, PTSD, anxiety, stress, insomnia or added pain are an issue, we might add CES therapy as well; as it is FDA approved to treat such disorder. And frankly, I don’t know anyone who wouldn’t have at least some of these other disorders when having peripheral or some other neuropathy. With neuropathy of any sort, there is nothing to be happy about!

 

Next Blog: Cranial Electro Therapy Stimulation for Pain Control and Other Issues

 

 

Cranial Electrotherapy Stimulation (CES) for Pain Control and Other Issues

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Used around the world for over 50 years, Cranial Electrical Stimulation (CES) is used for neurotransmitter balancing, mood control, IQ gains, sleep, exploration of altered states, peak performance, pain, anxiety, stress, depression and much more.

First, lets have some technical information: 

Most CES units (of which there are many) are considered: Class IIa. Type BF medical device generating microcurrent pulses which are thought to reach the brain via the auditory meatus. 

By placing either ‘electrical clip/electrodes’ on the earlobes, or small, sticky electrodes behind each ear, cranial stimulation sends a micro-current which helps to ‘balance’ the chemicals and reestablish optimal neurotransmitter levels in the brain.  CES differs from TENS stimulation; which is low-frequency and tends to just block nerve pain. Also known as ‘The Sleep Machine,’ cranial electrotherapy stimulation has been proven to help reduce stress and anxiety in patients, while allowing them to become drowsy. In addition, it has been proven useful (although, not yet FDA approved) in treating ADD, ADHD, PTSD, stage 1 hypertension, headache, tics from Tourette syndrome, Alzheimer symptoms and dementia, autism, and painful conditions of traumatic brain injury, cancer, dental pain or surgery, Parkinson’s disease and MS. CES is not electro-convulsive therapy, and has few side effects –  such as causing more lucid dreaming. Some contraindications, however, are:

  • Do not use this device if you are pregnant or lactating without first seeking advice from your doctor.
  • Do not use if you have a pacemaker (particularly demand type pacemakers) or other implanted bio-electric equipment without, again, first consulting your doctor.
  • There have been isolated reports of CES treatment lowering blood pressure so care should be taken while using CES in conjunction with high blood pressure medication. The same is true with other medications; who’s effectiveness may be ‘sped up.’ This has the advantage of being able to ‘reduce’ the dosage of some medications.

How often should one use a CES device? That is something that the patient should ask their doctor or neuropathist. If having dental work, we recommend taking the device into the dentist office with you to use during treatment. If treating at home for depression, it depends upon your symptoms; some patients use CES on an ‘as needed’ basis, where others may use it once, twice or three times per day. In our office, we will have patients use it while having other treatments; which can help them to relax or sleep through treatment. Or, for insomnia, most patients use CES an hour before going to bed. While treatment keeps most patients asleep, some people may wake up in the middle of the night and use the device again.

Depending upon the CES device, some MS or Parkinson’s patients may use it on a continuous basis to reduce tremors, drooling or to help bring back the power of speech. With the proper frequency, even facial atrophy and tongue numbness can be helped.

A ‘prescription only,’ device, CES can be purchased through an authorized distributor. Chico Holistic Healthcare can, either, use a device on you during treatment, monitor your use through our office, or help you obtain a prescription to own and use your device at home.

Patient Compliance

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What is patient compliance; and why is it so important? Patient compliance is directly responsible for our office success rate of 90%; as it is the ‘negative people,’ who don’t follow through or continue treatment, whose results do not get counted in the first place. When it comes to ‘success’ in the field of neuropathy, it is only the patients who are truly motivated to succeed who will do so. If someone is not willing to ‘help themselves,’ we tend to ask them to leave our office. Isn’t this rather harsh? Not really. Patients whom are unwilling to help themselves, cannot be helped by us either; and treating them when we know treatment isn’t going to help, is not only a waste of time and the patients money, but can only give us a bad reputation! Simply put, patient compliance is the ‘patient complying with treatment plans;’ such as keeping appointment schedules, and following directives such as taking vitamins, nutrients, changing their diets, exercise, home sensorimotor stimulation and etc. which has been prescribed for their particular type and symptoms of neuropathy.

In actuality, only 50% of those who walk in our doors complete or even start treatment; as, unfortunately, they are simply not willing to make changes in their lives which will help… such as exercise, better diet or stop smoking. Sure, it can be for a number of reasons as well… financial, time, distance and etc., but the BIG issue is compliance – they simply, do not wish to make any changes or participate in their own recovery!

I will give my patients several items or directives to use or follow at home. When they come into my office for treatment, however, we end up with a conversation something like this:

            “So, did you do your Sensorimotor Exercises this week?”

            “No.”

            “How about taking your B Vitamins and Omega 3’s?”

            “No.”

            “Did you do your Stretching Exercises?”

            “No.”

            “How about record your results?”

            “No.”

            “You know, you are not going to get any better if you don’t follow my recommendations at home!”

I generally hear back:

            “Well, you just said it… they are ‘recommendations.’ I shouldn’t have to follow them if I don’t want to. Besides, I’m                            paying YOU to fix my neuropathy…, not to do it myself!”

If the patient doesn’t at least attempt to meet the neuropathist ‘half way’ in their own treatment, then they are wasting not only their money and time, but the neuropathists time as well! Unfortunately, I can’t help anyone who is unwilling to help them self.

Think of it this way, if a doctor prescribes a medication for a condition like blood pressure, but the patient is not willing to take that medication, the blood pressure is not going to improve no matter how much both the doctor and the patient might like it to. The patient has to comply and actually INGEST the blood pressure medication before it will work! Unfortunately, I have seen way too many patients unwilling to do this! I don’t know how they expect to ‘get better,’ if they are not willing to follow the direction/recommendations of the doctor and/or the neuropathist.

So, if we have a “90%” success rate, who are the 10% treatment doesn’t work on? The highest number of people, unfortunately, are the aged. The longer one might have neuropathy, the harder it is to reverse nerve damage.  We have seen, however, patients as old as 92, whom have had peripheral neuropathy for as long as 57 years achieve substantial reductions of symptoms. Others, tend to be the truly ‘idiopathic’ patients; who we don’t have any reason for their neuropathies… and they simply don’t get better.  Others, it can be from injury or trauma to the back, for example. If the back cannot be repaired, the neuropathy cannot either.

Unfortunately, the next largest number of people, are the ones whom are ‘self medicating;’ meaning, they are drug addicts or alcoholics.  One man, for example, has been a faithful, loyal patient of mine for years; we have substantially repaired his feet – but, his hands are another matter.  Once ‘balanced,’ he can easily go one or two months between treatments. His hands, however, see very little change. One reason, is that he has arthritis in his hands which complicates the neuropathy.  Treatments actually help his arthritis substantially; but when it comes to his peripheral neuropathy, he cannot make any headway at all.  His problem?  He is an alcoholic and does ‘recreational’ drugs.  By ‘self-medicating’ with alcohol and drugs, he counteracts any efforts we make with Neuromuscular Stimulation.

Of course, we have made the recommendation to him that he ‘quit’ his drinking and drug use; but, even with all the edema, pain, numbness and burning he experiences in his hands and fingers, nor, the fact that he has had several DUI’s while driving, he is simply not motivated enough to work on his addiction. Drug and alcohol addiction is very difficult to reverse; but it is possible… but one must WANT to quit before actually doing it.

I have told this man, what I have told others like him; “I’m not your Mama, so I am not going to lecture you! But, when you are ready to quit drinking – which you know is what is, mainly, causing your neuropathy – then I am willing to help you at that time.” What can we do for drug or alcohol addiction? Generally, I like to refer to a specialized program to help with such issues. But, if nothing else, we use a CES device (Cranial Electrotherapy Stimulation). Placed on a specific area of the ear, it works like acupuncture to cut down on the ‘cravings’ by the alcoholic or drug addict.

This treatment works so well, that in our town, one judge in particular, has told some of my patients; “either purchase and use the device and seek treatment as well, or go to jail!” Most, of course, will see us for treatment and purchase a CES device as well. Again, this is considered, ‘patient compliance;’ as the patient is motivated enough to continue treatment or purchase equipment. And, “Yes,” in this case, the motivation is ‘legal’ rather than medical… but, “whatever works,” in my opinion!

More on Cranial Electrotherapy Stimulation in another post.

 

 

Next Blog, Treatment.

What is Peripheral Neuropathy?

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(Taken from a previous blog on a different site)

 

Peripheral Neuropathy: Simply put… ‘Peripheral:’ meaning the ‘outer most parts of the body; i.e., hands and feet. ‘Neuropathy: meaning, nerve dysfunction.’

Being the only ‘Holistic Neuropathist’ in Northern California (at the time of this writing), I get invited to lecture around our community a lot; as well as, invitations to speak all around the state. I’m James Skaug; not only a neuropathy patient myself, but a practitioner whom treats most forms of neuropathy and other nerve and muscle pain/numbness issues through non-drug, and generally ‘holistic/natural’ means and modalities. In future Posts, I’ll often refer to myself as a patient for example.

What is a neuropathist one might ask? If you look it up in the dictionary, like neuropathy was just a few years ago, it’s not listed. Looking it up on Google, one either finds my name or merely listings for neuropaths, naturalpaths or neurologists. But, unlike a neuropath, naturalpath or neurologist, a holistic neuropathist deals with not only treating the existing pain/nerve/muscle issues, but REBUILDING the nerves and atrophying muscles. We do this by treating with several different modalities; everything from nutrition, to massage, to neuromuscular stimulation, to whole body vibration, to anodyne or far wave infrared therapy, and more!

But, there is more to treating neuropathy than just ‘applying a therapy’ to it or taking a vitamin or pain pill! It is a very difficult process learned by the neuropathist to identify their symptoms; not only as a ‘neuropathy’ but the ‘kind’ of neuropathy in the first place.

There are over 100 different kinds of neuropathy identified by doctors and researchers; and new ones being found every day. Even carpal tunnel syndrome is now considered a neuropathy. What are the most common types? Of course, as previously mentioned, peripheral neuropathy – being the most commonly identified forms of dysfunction. But, there is, also, idiopathic neuropathy, focal neuropathy, proximal neuropathy, autonomic neuropathy, sensorimotor neuropathy, age related neuropathies, mononeuropathies, polyneuropathies or even just ‘diabetic’ neuropathy…, which, also, takes in many of the afore mentioned neuropathy types.

Technically speaking, peripheral neuropathy is caused by a lack of oxygen (hypoxia) to the nerves and tissues. But, this lack of oxygen can be caused by many, many things. Many disorders can cause neuropathy, such as drug addiction, alcoholism, chemotherapy related issues, statin drugs and blood pressure meds, physical and emotional traumas, and etc.; even smoking or the onset of age can be responsible for a neuropathy. Fortunately or unfortunately, with so many different neuropathies and causes, most neuropathies are distilled down by the doctor, and even the neurologist, as being just ‘idiopathic’ neuropathy – meaning ‘of unknown origin.’ Unfortunately, most doctors are either unwilling or are too untrained to not only be able to ‘identify’ the neuropathy, as stemming from a disease such as diabetes, but even just to identify the ‘TYPE’ of neuropathy in the first place; i.e., is the neuropathy ‘short/small’ nerve related or is it ‘long’ nerve related? Does it make a difference? Of course it does; just like it makes a difference if one has type 1 or type 2 diabetes! How about hypoglycemia or either type of diabetes? All three disorders deal with the glucose or ‘sugar’ levels of the blood… high and low… again, of course it makes a difference! One would not ‘treat’ one disorder exactly as another; or else, why would we even distinguish between disorders?

Unfortunately, not all neurologists keep up with current innovations regarding the nerves and neuropathy. Like the term ‘neuropathist,’ neuropathy didn’t even appear in common dictionaries just 7 years ago. It’s a ‘keyword’now; and unfortunately, still, has become something of a ‘catch phrase’ for a lot of disorders when one is unsure of the disorder; with countless chiropractors purchasing ‘franchises’ to ‘treat’ peripheral neuropathy.  But, what they don’t realize is, just as type 1 and type 2 diabetes are different, each of the different neuropathy responds differently to treatment as well – not to mention every patient being different or reacting to treatment in different ways.

In the same sense, many doctors don’t properly identify neuropathy because it falls outside their range of training; choosing to blame the disorder on other issues. Sometimes, however, the “other issues” ARE the reason for the neuropathy. This is especially true with trauma issues to the lower back. Stepping back a bit to bring in more information and to use myself as an example, I have had peripheral neuropathy twice in my life. One was cured, one was not! Whereas, I often today tell people that “most likely, you did not develop this disorder overnight”… that is exactly what I did. I had my back broken and neck injured; and developed instant peripheral neuropathy. One year and 10 days later, I had surgery to correct the damage to the back and achieved an ‘INSTANT CURE’ for that neuropathy. Remember, I have said previously, that out of the over 100 different type of neuropathies out there, only a select few are curable. Mine was… trauma to the lower back, instant neuropathy; surgery to the lower back, Instant cure!

Some twenty years later in life, I developed peripheral neuropathy once again… pain, burning, numbness (something doctors said I couldn’t experience at the same time)… I could hardly walk. The ‘expert’ doctors looked at my back surgery history and proclaimed, “Oh, you’re just having more back issues again. What do you expect… you don’t have all the pieces back there anymore?” Being a neuropathist by this time myself, and running my own tests, I felt the answer lay elsewhere… in the form of diabetes. Seven different doctors all told me “nonsense” and wouldn’t even prescribe an HA1C test to look at my blood sugar levels. Instead, I was told I had, allergies, asthma, COPD, pneumonia, bronchitis, sensitivity to smoke (we had forest fires in our area that time), and even sudden aortic death syndrome…, all, before the last doctor I saw for the sudden aortic death syndrome (one smart cardiologist) asked: “Did you ever stop to think you might have diabetes?” “Yes,” I shouted, as I treated diabetics every day in my office and could see my patients’ very same symptoms in myself!

To make a long story short, he prescribed an HA1C test for me and my results came back that I was not only diabetic, I was VERY diabetic. The cardiologist felt that the pain and numbness I had in my feet was probably from the diabetes.  I concurred.  I, myself, had turned out to be just as I have told many of my diabetic patients for years; “most peripheral neuropathies appear 5 years BEFORE a diagnosis for diabetes is achieved.” So, like most of my own patients , I was a very common, ‘textbook’ case.

Unfortunately, none of the doctors I had seen, had ‘read’ that textbook like myself and the cardiologist had! Just as most doctors have had very little training or ‘book learning’ while in school about issues such as nutrition, most neurologists haven’t had very ‘up to date’ training in school in regard to new research on nerves; and don’t continue their education AFTER graduation to keep up with new procedures or modalities. Because of which, it is my recommendation, when a patient is seeking a neurologist, don’t look for the one who has been around the longest and has the best reputation, necessary; look for the NEW or YOUNG neurologist who has just finished school! Most likely, he/she is much more up to date on current nerve procedures. If nothing else, seek out the biggest and best and most experienced; but go to the new guy for a ‘second opinion!’

But, before ANY surgery is done or anything drastic such as toxic drugs be prescribed and taken, check out a neuropathist to see if the neuropathy can be reversed with something other than radical surgery or toxic drugs. Sometimes, the answer might be as simple as nutrition!

 

Next Blog: The New neuropathy Patient

 

 

Berg Balance Testing

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Part of every exam for neuropathy, is asking the question, “so… how are your balance issues? How is your walking gait?” Most patients will indicate that they have, at least some, balance issues. Even more, indicate that they cannot get up out of a chair without arms, at least, without some assistance. (This, is one reason, we don’t have arms on the chairs in our waiting room… they become part of the test!) But, if the patient indicates they “fall over or down a lot, stagger or have difficulty getting up and down,” we will give them what is known as a Berg Balance Test.

Developed by Katherine Berg (of whom it is named) and others, the test tests the static and dynamic balance abilities, of the patient. Scoring will indicate how ‘likely’ the patient is to end up in a wheelchair, or if they need to walk with assistance or can walk without much risk of falling. (Research shows, that if a patient – especially, an elderly one – falls and can get back up on their own within 15 minutes or less, they are more likely to be able to continue to live on their own. The longer it takes for the patient to get up, or if they need assistance, the more likely they will end up in assisted living or convalescent care).

The patient, depending upon their age, is scored on their ability to:

  1. Sitting to standing
  2. Standing unsupported
  3. Sitting unsupported
  4. Standing to sitting (without using arms on a chair or pushing up with hands on knees)
  5. Transfers
  6. Standing with eyes closed
  7. Standing with feet together
  8. Reaching forward with outstretched arm
  9. Retrieving object from floor
  10. Turning to look behind
  11. Turning 360 degrees
  12. Placing alternate foot on stool
  13. Standing with one foot in front
  14. Standing on one foot

Each task must be completed within a certain amount of time; and, is scored accordingly. These scores helps the neuropathist judge, not only what the ‘risk of falling’ is for the patient, but the extent of their neuropathy as well; in other words, the lower the score, the more likely to fall; and, most likely, the more severe the neuropathy.

Taking these scores and combining them with Toronto Clinical Scoring results, as well as examination of other parts of the body and information from Intake, all help determine the type of neuropathy the patient has; and ‘WHAT‘ issues need to be addressed first and foremost! For example, if a patient scores really well on the Berg test, we are not as concerned with treating muscle atrophy as we would someone with a low score. In the same sense, if Intake and examination indicate possible diabetic neuropathy, but the patient has stated he “trips over his own feet and falls a lot,” we might wish to look at drop foot or even send the patient to be checked for MS; if the muscles have not noticeably atrophied.

In other words, if we see a neuropathy with certain symptoms which are not common, we may refer out to neurologists to ‘look’ for other reasons besides, simple neuropathy for the symptoms.

 

Next Blog:  Patient Compliance.

Examination and Testing

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The first thing I do when I look at most new patients feet is observe the condition of the skin.  Is the skin firm?  Is it filled with fluid (edema), is it discolored, is it covered with fungus… etc., do the toenails have fungus, etc.?

However, if it is a man’s foot and legs which I am looking at, the first thing I might look for is ‘hair;’ hair on the foot, hair on the ankles, hair on the knuckles of the toes and lower legs. As 70% of the people whom enter my office are diabetic, it makes sense right from the beginning to look for signs of type II diabetes.  Of course, their Intake should tell me that; however, often we find that many patients are ‘pre-diabetic.’ Many, including myself, are diagnosed with peripheral neuropathy 5 years BEFORE the diagnosis of diabetes, in fact! Next, we, usually, examine and measure the calf muscles; noting, if they are equal in size. This is compared to other testing factors to tell ‘which’ leg might be more adversely affected. Actually, it IS possible to have a better score on one leg/foot than the other; but, have that ‘better’ leg, be more adversely affected with muscle atrophy or other issues. And, through treatment, or the patients diet, ‘good or bad sides,’ may even switch, from time to time.

Next, observation is made as to if the skin on the legs or feet are cracked and dry or not.  Diabetic ulcers or sores are looked for, measured and recorded/photographed as well; even on those patients who are not diabetic (as, this could be in indication that they are pre-diabetic or fully diabetic and not know it). By photographing the sores, we can accurately gauge how well or fast the sore might be healing.

We can learn a lot just from looking at the feet.  If the tissue is blue or purple, it will lead to the next question: “Do you smoke?”  Or, as stated in previous Blogs, “were you ever a skier or a pilot, etc.”  We need to attempt to find the cause of the lack of circulation to the feet.  If the feet are purple, that is certainly an indication that the blood is just ‘pooling’ down in the feet and there is little circulation.

At this point, we turn to what is known as Toronto Clinical Scoring.  If the patient is diabetic, we use a standard test; however, if the person is not, we use a modified version of it. So, what exactly is a Toronto Clinical Scoring Test; and even more important, what is a MODIFIED Toronto Clinical Scoring Test?

Toronto Clinical Scoring Tests were originally devised to check on the ability to sense ‘sensation’ in the foot or leg; mostly, to determine if someone was suffering from Sensorimotor Neuropathy.  The physician or clinician tests for cold, cool, heat, pin prick and other issues and records their findings.  A totally healthy foot/leg scores 74 points; and points are judged by sensation on a scale of 0 to 10; with minus 5 given for any ‘hyper’ sensitivity.  This test is very effective.  However, during our years of service performing this test, we have found it to be just as accurate and effective for ‘non-diabetics’ as well; we have just ‘modified’ this test to include hands and fingers, arms, toes. Even the face is checked to see if sensitivity is just as keen on one side as the other; as often it has been found that a stroke or small TIA could affect the results of the test. If one has had a stroke or TIA, then sensitivity is going to be lower on the side with the stroke; i.e; testing scores will be lower on the side with the stroke.

Generally speaking, if one scores the same up and down a leg and foot, but still has symptoms of pain or numbness (not to mention burning or tingling) or even restless leg syndrome, the results tend to dictate symptoms of  ‘long nerve’ neuropathy – meaning, the ‘long or longest’ nerve in the body. But, when the nerves test differently from one spot to the other on the leg and/or foot/toes (or with the hands/fingers and arms), one is more likely to have short nerve neuropathy. Some of the same symptoms, such as hypersensitivity may be present in either form; as can a few other symptoms.

Is it possible to have BOTH long and short nerve issues?  Most certainly.  In testing, we start looking for issues like hypersensitivity.  In a regular diabetic test, we might take off 5 points if the foot is a bit ‘overly sensitive’ to cold or merely running the tip of a pen or Wartenberg Wheel up the bottom of the foot.  However, we might take of an additional 5 points, for a total of 10, if the foot is also unusually sensitive to cold or other touch. Pain can come from both issues as well; this is one reason, we tend to ‘double check’ ourselves and treat at least once for each short and long nerves. Whichever treatment seems to work better, tends to indicate which neuropathy tends to be the most prominent.

Through the use of this test, we can generally determine what course of action is required for treatment; to RESTORE, MANAGE and MAINTAIN ones reduced symptoms.

Of course, there is much more to determining what is needed besides just a single test; balance issues and testing may be required as well… such as Berg Balance Testing or even examination of the back. We might even check sensitivity to pressure and trigger points; or muscles which have not only ‘shortened’ and are pulling on the spine, but are adding ‘unnoticed edema’ to the back as well. 

But, the ‘Modified Toronto Clinical Scoring Test’ is instrumental in determining the ‘type’ of nerve neuropathy.  The ’cause’ of the neuropathy is quite a different matter; and, depending upon our findings, ‘assorted modalities’ might be in order in addition to a change of diet or lifestyle.

 

Next Blog: Berg Balance Testing.

Intake

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Before we start an examination, we require some information just as with any doctor’s office. The neuropathist will, generally, either send by mail or email, a questioner to a new patient (or have them fill it out upon their first visit) in which they will ‘detail’ their medical history.

Often we hear:

“Why do you need to know this information, isn’t it rather ‘personal’ to ask about my medical history and medications; or if I have had any kind of injuries or diseases?” 

Frankly, no… it’s not too personal, when we are attempting to find out “why” the patient hurts!  It is not out of line to ask for a patient’s medical history, or even ask other so-called ‘personal’ questions, if one is trying to determine the type of neuropathy a patient might have… or, even to determine if the patient even HAS a true neuropathy (remember from past blogs, some issues like IBS may actually be autonomic neuropathy, or carpal tunnel, may or may not)!  Patients, most likely, wouldn’t go into a doctor’s office and tell the doctor “guess what is wrong with me,” they are going to give the doctor, hopefully, as much information as possible so he/she can make a good, educated determination as to the problem or disorder. The same is with the neuropathist!

Of course, most patients don’t mind or expect the obvious questions: “Do you have High Blood Pressure, are you a Diabetic, have you had any operations or injuries, and etc.”  But many times, questions don’t seem appropriate to the patient.  What kind of questions do people find ‘objectionable?’  “Have you ever been in the military?” 

“What would that have to do with anything,” we are often asked.  Well, if someone happens to be in their 60’s or so, it can help to determine ‘the reason’ for ones neuropathy.  Was the patient in Viet Nam? “Yes?”  Now, the possibility of exposure to Agent Orange comes into play!  Was the patient a pilot or airplane crew member during the war?  It gets rather cold high up in the sky… frostbite is not unheard of by pilots.

Other questions; “Are you or were you a skier?”  Same thing… possible frostbite at one time.  “Are you or were you a smoker?” Lots of objections on this question. Again, we hear, “what does that have to do with anything?  My lungs are not the issue here… it’s my feet that hurt!”  The issue is, that most peripheral neuropathy is caused by hypoxia, a lack of oxygen to the nerves and tissue via the blood. The hypoxia can have many root causes; but if one is a smoker, oxygen is being depleted to the tissue with every ‘puff’ the patient takes.  This can be easily seen in some smoker’s legs and feet. The tissue takes on a ‘blue’ or ‘purple’ coloration.  This is poor circulation, pure and simple; and poor circulation means less oxygen to the tissue. To reiterate, hypoxia may be the ‘root of the problem’ for the neuropathy; but ‘smoking’ may be the ‘root of the problem’ for the hypoxia!

Questions about legal and illegal drugs, now, need to come into play.  Again, we are not being nosey, nor are we looking to ‘turn in’ anyone one for illegal drug use.  But, we NEED to know about any self-medicating issues, as so many drugs can cause neuropathy; and/or treatment for drug addiction can also be responsible (not surprisingly, with ‘Baby Boomers, doctors and surgeons are finding that some patients still have drug addictions stemming from back in the 1960’s; and those addictions must be taken care of before surgery or treatment can take place. We neuropathists see the same issues… and, the addiction can be the ‘root issue,’ once again.) for many symptoms. 

As an added feature to treatment, however, if we know the patient has a drug addiction, we can possibly help with that as well – or, help the patient find the help they need.  In the same sense, if one is taking legal or prescription drugs, we need to look at the side effects of those compounds to see if they contribute to ones neuropathy.  Statin drugs for high cholesterol are very common culprits of this; but luckily, there are plenty of ‘natural statin’s’ one can take to reduce ones cholesterol.  In addition, depending upon some modalities, they might help to reduce not only cholesterol, but blood sugar or blood pressure as well.  If we know exactly what the patient is taking, again, we can make a more informed determination as to the best modality to use or what issue to address; as well as how to best address nutrition.

One more question that people seem to have an objection to sharing, especially if a younger patient, is:  if one has a pacemaker or defibrillator or not. Older patients don’t seem to mind answering this one, but younger ones do, as they seem to feel there is something of a ‘stigma’ of some kind associated with it.  Of course, there is not; but we do need to know, as there are certain contraindications (meaning it could be unwise to do) that accompany the patients’ device.

Next, is probably the most embarrassing: ‘bathroom habits!’  No, we really don’t want to know… but we may HAVE TO know to make certain determinations. For example, many patients present with, not only, a idiopathic neuropathy diagnosis, but with irritable bowel syndrome as well.  “How long have you had the Neuropathy or diagnosis of Neuropathy” we ask? Then, “how long have you had the Irritable Bowel syndrome?” If their answer is “20 or more years,” then we look at that irritable bowel just a bit differently. We consider the possibility of, the afore mentioned, autonomic neuropathy – in other words, neuropathy of the internal organs; which brings about even more questions for the Intake! “Do you get diarrhea when you go out to eat?  Do things like Thousand Island Salad Dressing bother you?  Does Gluten bother you?”  If the answer is “yes” to those questions, the person is more likely – not definitive, but more likely – to actually have irritable bowel syndrome.  If not, and the diarrhea appears at any time, or after eating just about anything… and/or incontinence is involved, we then start looking towards meds to make sure “loose bowels” are not a side effect from certain medication.

It is only through a complete Intake, and medical history, that we can make proper determinations as to the patients neuropathy and treatment.  It’s not being “nosey”… we have a genuine “need to know!”  And, because of that need to know, we are more likely to find the correct ‘modality of treatment’ for your neuropathy!

 

Next Blog: Examination and Testing

Ask the Neuropathist!

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Welcome to Ask the Neuropathist.

Neuropathists treat pain, burning, numbness, tingling and other issues; generally, associated with Peripheral, Autonomic, Proximal, Focal or Sensorimotor neuropathy; however, there are many more forms of neuropathy with other symptoms as well.

This page offers two ways to ask questions: either, questions in general for us to put into our Blog, or “Quick/Short Questions;” for “Ask the Grumpy Neuropathist!”

This site is not intended to diagnose or give medical advice in any way, shape or form. It is strictly to be used as an informative site to help explain some of the ‘myths’ regarding neuropathy, and actual treatments/modalities which are available through some doctors, neuropathists or physical therapists.