Dr. Alan Zacharias: “Peripheral neuropathy is treatable, but often not curable.”

Peripheral neuropathy is a common nerve damage condition with more than 20 million Americans afflicted by it. Those experiencing peripheral neuropathy will first notice their toes become numb and tingly. As the damage progresses, people describe the pain as burning or feeling like “pins and needles.” Luckily, it’s easily diagnosed, and there are effective treatments to help ease these symptoms.

As a board-certified neurologist, Alan Zacharias, MD of Associated Neurologists specializes in neurophysiology and electrodiagnostic medicine, treating conditions such as stroke, memory loss, multiple sclerosis, Parkinson's disease, migraine and peripheral neuropathy. During a Boulder Community Health (BCH) online lecture, he shared the causes of peripheral neuropathy and the most current treatments available to relieve the painful symptoms associated with this condition. 

Dr. Zacharias noted, “There is a large spectrum of diseases that contribute to the development of peripheral neuropathy. Often, however, these causes are elusive. While neuropathy is treatable, it’s often not curable.” He added, “Peripheral neuropathy can also result from a genetic disorder passed down from one generation to the next.”

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Watch: “Latest Treatments for Aching Nerve Damage: Understanding Peripheral Neuropathy”

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What is peripheral neuropathy?

Peripheral nerves carry information to and from the brain. They also carry signals to and from the spinal cord to the rest of the body. 

“Peripheral neuropathy refers to abnormal nerves of the peripheral nervous system, meaning peripheral nerves aren’t working properly. A classic symptom is loss of reflexes,” Dr. Zacharias explained.

Possible causes

There are many types and causes, including:

• Diabetes is the most common cause of this type of nerve problem. “We know that diabetes, particularly poorly controlled diabetes, is highly associated with nerve damage. High blood sugar levels over a long time can damage your nerves,” said Dr. Zacharias.

• Vitamin deficiencies, especially B 12, which is necessary to support a healthy nervous system, can cause peripheral neuropathy. 
• Chemotherapy involves toxic drugs that kill cancer cells; however, it may also kill normal cells. “It’s often a necessary risk patients are willing to take,” said Dr. Zacharias, “but it can cause peripheral neuropathy.”
  • According to Dr. Zacharias, platinum-based drugs and immune checkpoint inhibitors (also used for chemotherapy) can pose serious consequences for the peripheral nervous system.
• Chronic alcoholism may cause nerve damage potentially due to the direct poisoning of the nerve by the alcohol combined with poor nutrition associated with alcoholism. “The exact cause however is unknown,” said Dr. Zacharias.
• Autoimmune diseases like lupus and sarcoidosis can be associated with peripheral neuropathy.
• Infections such as COVID, West Nile Virus and Lyme disease are on the list of things to consider that may cause peripheral neuropathy.
• Compression (carpal tunnel syndrome), if compression occurs over a long period of time it can result in permanent nerve damage. 
• Amyloidosis, both acquired and familial, occurs when amyloid proteins get into our nerves and cause damage. This can result from a variety of conditions such as leukemia, but it can also be inherited.

Exams and tests

Your health care provider will examine you and ask about your health history and symptoms.

“If we're examining you in the office, we'll use tools such as a little sharp object to touch the skin or put a tuning fork over a toe or a finger to see if you feel the vibration. We might move your finger or toe, and see if you can tell us whether it's moving up or down. If you can't tell where your toe is in space, that's often a sign that you've lost nerve input and that's a sign of neuropathy,” Dr. Zacharias stated.

Your provider may also recommend:

• Electromyography (EMG): “This is an electrical test that’s our quantitative way to inspect electrical activity in muscles beyond our physical examination,” Dr. Zacharias explained. “We know what normal responses are, and then we can document if it's affecting the nerves that carry signals to muscles or nerves carrying sensory signals, or both. We can also determine if it's mild, moderate or severe case based on what we know is a normal value.”
• Nerve conduction studies: to see how fast signals travel along nerves.
• Nerve biopsy:  to look at a sample of a nerve under a microscope.
• Skin biopsy: to see if there are a normal number of nerve endings in the skin.
• Blood tests: may be done to look for causes of nerve damage.

Treatments

Dr. Zacharias explained, “We will always want to treat the underlying disease when we can.” He added, “For about 25% of cases, however, we really don’t know the cause.” Treatment options include:

• Exercise, along with physical and occupational therapy, to keep muscles active.
• Stimulation devices to stimulate nerves and override uncomfortable sensations.
• Decompression surgeries such as removing a disc that’s compressing a nerve.
• Hot and cold therapy varies by person, whichever they prefer. Dr. Zarcharias noted there are a number of online treatments such as boots that send cooling sensations to the feet.
• Acupuncture can be helpful. According to Dr. Zacharias, it doesn’t solve the issue and would need to be done repeatedly, but it can work for those who are trying to avoid medications.
• Mind and body approaches include mediation techniques to calm our nervous system. According to Dr. Zacharias, this is a meaningful approach to add to our other strategies.
• Medication is often prescribed for peripheral neuropathy. Dr. Zacharias said, “Long term, once you have this condition, it won’t go away. It’s irritating, but you can still continue to do what you love: hike, bike, ski and so on. We can manage the symptoms with medications to improve your quality of life.” Options include:
  • Acetaminophen and ibuprofen to relieve pain.
  • Antidepressants are helpful for suppressing nerve pain.
    •  Examples: amitriptyline, duloxetine
  • Anticonvulsants can suppress excessive discharges to the brain, thus relieving some pain.
    • Examples: gabapentin, pregabalin
  • “Topicals,” Dr. Zacharias said, “need to be applied throughout the day, and they don’t work that well. Patches can be applied that are less messy than the cremes and can work if localized treatment is necessary.”
    • Examples: capsaicin, compounded options
  • “Narcotics are controversial and not something we like to prescribe unless they are necessary. However, under proper supervision there is no reason they can’t be considered,” said Dr. Zacharias.
    • Examples: morphine or equivalents

Treatment with supplements

Dr. Zacharias said, “Definitive studies are lacking for supplements, but the potential benefits are typically reasonable with relatively low risks.” He said the following supplements have proven to be helpful in a variety of nerve conditions:

• Alpha lipoic acid (mainly for diabetic neuropathy)
• B-vitamins (B1, B6, B9, B12)
• Vitamin D
• Zinc
• Magnesium
• Curcumin from turmeric
• St. John’s Wort

Resources

Dr. Zacharias is optimistic about the new strategies that are evolving for treating peripheral neuropathy. In the meantime, he provided resources that he recommends for helping you understand peripheral neuropathy and why your feet might be tingling. 

• The Foundation for Peripheral Neuropathy is an up-to-date resource on the subject, and it can be found at: FoundationForPN.org 
• The Numb Foot Book, McLellan and Spitz
• The published article entitled Nutritional supplements for the treatment of neuropathic pain, Biomedicines, 2021 Jun: 9(6):674

Schedule an Appointment

Call 303-415-8800 or visit click here to schedule an appointment with neurologist Alan Zacharias, MD at Associated Neurologists.

Click here to view/download a PDF of slides shown during the lecture.

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