Diagnosing Neuropathy A Challenge For Doctors

In the same way that general information articles about neuropathy are regular necessities for newcomers here on the blog; ways and means of testing for it and the process of diagnosis are equally important. Today's longer but comprehensive post comes from http://www.agingwellmag.com (see link below). Good doctors will listen to your story and pretty much make a diagnosis there and then (the symptoms are pretty much unique to neuropathy) but will generally send you to a neurologist for an EMG and other basic tests to confirm the diagnosis. After that, further tests are not always necessary. However, about a third of all neuropathy patients are determined to have 'Idiopathic' neuropathy, which means they can't find a reason for your problem. That does not mean to say that the problem is between your ears - far from it - your neuropathy symptoms are as real as the next man's so don't be discouraged. Generally, from your story and experiences and maybe general health picture, the cause can be determined but even then, it's difficult to be 100% sure. Other articles about testing can be found in the aphabetical list to the right of the blog.

Diagnosing Peripheral Neuropathy
By David Yeager
Aging Well
Vol. 5 No. 4 P. 14

The diagnosis for older adults can be particularly challenging. Physicians need to become more efficient in their patient workups.

Peripheral neuropathy afflicts as many as 8% of people over the age of 55, and the numbers are increasing.1) There are more than 100 known causes, and each type has its own characteristic symptoms, development pattern, and prognosis.2) For this reason, confirming a diagnosis and developing a treatment plan can be highly challenging.

To complicate matters, there are only a few diagnostic tests for peripheral neuropathy that are supported by significant research-based evidence, and there is no standard diagnostic protocol. Faced with an indeterminate set of symptoms, physicians may be inclined to order a wide variety of tests, sometimes at great expense and with little clinical benefit. In fact, physicians often forgo less expensive, more reliable tests when attempting to confirm a peripheral neuropathy diagnosis.

A University of Michigan Medical School (UMMS) study of 1,031 patients with confirmed neuropathy diagnoses published in the January 23 issue of the Archives of Internal Medicine found that 23.2% of patients received an MRI of the brain or spine, contributing to significant expenditures during the diagnostic phase of neuropathy treatment. More surprisingly, only 1% of patients received inexpensive and far more reliable blood glucose tolerance tests. The study also found that physician test-ordering patterns were highly variable.3)

Know the Patient’s History
If peripheral neuropathy is suspected, it may take some detective work to determine the underlying cause. The first step is to take a thorough patient history. Many underlying causes can be deduced just by asking questions.
“Far and away, the most important thing is a good history,” says Brian Callaghan, MD, an assistant professor of neurology at UMMS and lead author of the recent study. “The vast majority of causes are determined based on talking with the patient and, if you don’t figure it out based on talking to patients, the chance that testing is going to help with the diagnosis is small.”

Factors such as alcohol use, vitamin B12 deficiency, heredity, and diabetes can influence whether a person develops peripheral neuropathy. Diabetes is a particularly significant factor; it’s estimated that as many as one-half of people with diabetes develop some form of neuropathy.4)

Callaghan says some of the common, relatively inexpensive tests that can detect some of these problems, such as glucose tolerance testing, serum B12 testing, and serum protein electrophoresis (SPEP) with immunofixation electrophoresis (IFE), are the ones with the strongest clinical evidence to support their use in diagnosing peripheral neuropathy. Screening for common causes improves care and reduces treatment costs by diminishing reliance on more expensive tests and reducing treatment costs over time.

“If those disorders are picked up early, and that’s usually through a primary care physician, then [the patient] may never need to see a specialist. And also, if these diseases are picked up early, then the morbidity decreases,” says Annabel Wang, MD, an associate professor of neurology and director of the Neuromuscular Diagnostic Laboratory at the University of California, Irvine ALS and Neuromuscular Center. “Whereas, if you’re an unrecognized diabetic, it could take four or five years for someone to figure out that you have diabetes; then you have four or five years’ additional damage and therefore more complications and more secondary issues that develop.”

Common symptoms of peripheral neuropathy are pain; tingling; loss of sensation, usually more in the toes than the fingers; distal weakness; and difficulty walking. However, symptoms may not be as straightforward in older patients. Observing a patient’s difficulty extending the toes, flexing the foot, or determining whether the toes are moving up or down could be indicative of peripheral neuropathy. A diminished ability to feel cold or a pinprick or the absence of normal reflexes is also consistent with a neuropathy diagnosis.
If the history and exam point to peripheral neuropathy, the goal is to clinically characterize it as much as possible. Determining whether it’s acute or chronic is straightforward: if the symptoms have progressed during a period of time that exceeds three to six months, it’s chronic. The next step is to determine whether the neuropathy is axonal or demyelinating, which can partly be determined by electrodiagnostic studies. Frequently, an electromyogram (EMG) is used to test nerve conduction.

“EMG does not have to be performed in a patient who has a typical presentation and is, for example, diabetic,” says Gil I. Wolfe, MD, FAAN, chair of the department of neurology at the Jacobs Neurological Institute of the University at Buffalo School of Medicine, State University of New York. “There is a typical clinical pattern for the most common form of diabetic neuropathy, a distal axonal polyneuropathy, which is readily recognized by neuropathy experts. One can argue that you don’t have to do an EMG in this situation. Not only is this of economic benefit to the overall health system, but it also eliminates subjecting our patients to what can be a painful test. But in many other situations, EMG provides crucial information in characterizing neuropathy, especially whether it is an axonal or demyelinating process.”

Once it has been determined whether the neuropathy is axonal or demyelinating, the search for an underlying cause can continue. Wolfe says it’s important to note that many medications can cause an axonal neuropathy pattern, even commonly used ones such as antibiotics, so taking a detailed medication history is of the utmost importance.

Digging Deeper
Because there are different types of neuropathy, patients may exhibit a wide variation in symptoms. Wolfe says most neuropathies are axonal, which generally requires more diagnostic evaluation to determine the cause. Deciding which tests are appropriate depends on the suspected cause.

“I think the most important thing is to remember that there are different types of neuropathies. Neuropathies can be only sensory and only cause symptoms or they can also be only motor so they only cause weakness without sensory symptoms,” Wang says. “And then there’s an entity called small fiber neuropathy, where there may be pain and temperature loss or just a lot of pain, and the changes in vibration or the reflexes may be absent. Those are the cases that perhaps are missed and perhaps are very early neuropathies.”

Neuropathies may be classified as primarily small fiber; primarily large fiber, which includes loss of position sense, loss of vibratory sense, and some degree of loss of light touch; or both. Small vs. large fiber can be identified to some degree based on the patient’s history and examination. In addition, Wolfe says fasting glucose/two-hour glucose tolerance tests, HIV tests, urine protein electrophoresis tests, hepatitis B and C serologies, thiamine/pyridoxine tests, and celiac serologies may be used to diagnose small fiber neuropathies. Those tests, as well as vitamin B12 testing with methymalonic acid/homocysteine levels, SPEP with IFE testing, metabolic panels, lipid and cholesterol levels, syphilis serologies, Lyme serologies, urine heavy metal levels, and many others can be used to test for suspected large fiber neuropathies.

However, aside from the glucose, B12, and SPEP tests, none of these tests is supported by the American Academy of Neurology (AAN) Practice Parameter for evaluating distal symmetric neuropathies.5 Wolfe says the only reason to use some of these tests is if the neuropathy is unclassified and cancer or an immune-related condition is suspected. They should never be used on a routine basis.
Another important factor to consider is heredity. The AAN Practice Parameter supports some genetic testing but only in cases where certain hereditary causes are suspected.5) In older patients who develop neuropathy, heredity’s role can be easy to miss.

“There is a sector of these late-onset neuropathies that on initial inspection may look acquired, but very well may be hereditary,” Wolfe says. “And you shouldn’t discard the possibility that a neuropathy is hereditary just because it started in somebody after age 50. Some of those patients may very well have a hereditary process, either because of certain ion channel mutations or because of Charcot-Marie-Tooth disease type 2.”

Beware of Diminishing Returns
Because physicians try to render treatment based on the symptoms’ origin, many will continue to order tests when a cause is not found. But despite all of the tests that could potentially be ordered, Wolfe estimates that 20% to 25% of neuropathies end up being unclassified, and most unclassified neuropathies are seen in older patients. Although there are some factors associated with neuropathy that have only recently been understood, such as copper deficiency, most of the increase in neuropathy cases is due to diabetes.

“We can sometimes get in more trouble by ordering more tests,” Callaghan says. “We really need to focus on diabetes and taking a good history from our patients. Those are the things that are really going to make a big difference.”
The most important consideration in deciding which tests to order is how they will affect patient care. Unfortunately, other than treating pain, there are not many treatments for neuropathy. Callaghan says most of the 40 to 50 tests that can be given for neuropathy are very low-yield tests. Many not only have minimal influence on how treatment is rendered, but they don’t even affect the way the physician thinks about the patient’s condition. He cites MRI as the top example because it looks at the central nervous system and is rarely indicated for a patient with a peripheral nerve problem.

Thyroid and rheumatological studies are also relied on too heavily. Although these tests are frequently ordered, Callaghan says they rarely affect patient management. In the near future, he will be publishing a paper with his findings.
Callaghan says too much testing can make it more difficult to determine an underlying cause, especially if a test has a high false-positive rate or multiple tests produce conflicting results. One problem he has noted in his research is that physicians are apt to order a battery of tests as a rule rather than as the exception. He recommends sticking with the tests that have the best levels of evidence and ordering additional testing only if something unusual is suspected.

“For example, there are some warning signs that you might not be dealing with a garden-variety neuropathy, such as if the neuropathy comes on quickly, is very asymmetric side to side, or involves weakness more than sensory changes. Those are examples of things that might make you order more diagnostic testing,” Callaghan says. “But in most patients, the current evidence would suggest that you probably should only get a few tests.”

One factor that may help to reduce unneeded testing is patient education. Wang says it’s important to address patient questions about diagnosis and treatment as completely as possible. Patients who don’t fully understand the condition and how it’s treated may have more anxiety about it, which may make them more likely to push for additional testing.

“The fear is not knowing what’s going to happen to them, and that probably creates a lot of unnecessary workups,” Wang says. “Whereas, if they had an evaluation and they feel that they understand what their disease process is, they don’t feel that they’ve been abandoned. That in itself can save a lot of money.”

However, the main responsibility in the use of testing lies with physicians. Wolfe says physicians need to become more efficient in working up patients. Many lab tests currently ordered on a routine basis have low clinical efficacy and therefore low cost-efficiency. He believes this is an area that can be improved with better research into which tests are effective.

Callaghan agrees that much more research is needed to define the roles of all diagnostic tests that are ordered for peripheral neuropathy. He says the AAN guidelines are highly useful and that physicians should avoid using nonrecommended tests for routine screening. However, physicians can be slow to change the way they practice, especially if a new approach calls for doing less rather than more. Even though guidelines are available, many physicians continue to routinely order high-cost, low-yield tests.

“I think there are two big obstacles. One is defining what really should be the best diagnostic approach, and No. 2 is altering physician behavior. And those are both difficult to do,” Callaghan says. “Despite the guidelines that are out there, we’re not necessarily practicing according to those guidelines.”
— David Yeager is a freelance writer and editor based in Royersford, Pennsylvania.

Tips for Evaluating Peripheral Neuropathy
Because peripheral neuropathy is extremely common in older patients and may produce a wide variation in symptoms, it can be difficult to diagnose. Adding to the challenge is the dizzying variety of tests that can be done to check for underlying causes. The following basic principles, however, can help physicians provide more effective care:

• A thorough patient history and examination are likely to provide the most useful information for determining whether the patient has peripheral neuropathy. Alcohol use, heredity, new medications, and especially diabetes can be contributing factors. Pain, tingling, loss of vibratory sense, loss of temperature sense, loss of proprioception, and distal weakness are common symptoms.

• Follow the American Academy of Neurology (AAN) Practice Parameter for evaluation of distal symmetric polyneuropathy when ordering tests. Currently the AAN guidelines support the use of fasting glucose/two-hour glucose tolerance testing, vitamin B12 testing with methymalonic acid/homocysteine levels, and serum protein electrophoresis with immunofixation electrophoresis testing for initial investigation of peripheral neuropathy.

• Order additional testing only if an extenuating circumstance, such as cancer, is suspected or if the patient exhibits atypical symptoms. Testing outside of these parameters is unlikely to improve clinical outcomes or change patient care. Twenty percent to 25% of neuropathies will have undetermined causes.

• Communicate with patients throughout the evaluation process. Patients’ anxiety may lead them to request additional testing if they don’t understand the appropriate steps for diagnosis and treatment or how those steps relate directly to their personal care.
— DY

References
1. Martyn CN, Hughes RA. Epidemiology of peripheral neuropathy. J Neurol Neurosurg Psychiatry. 1997;62(4):310-318.
2. Peripheral neuropathy fact sheet. National Institute of Neurological Disorders and Stroke website. http://www.ninds.nih.gov/disorders/peripheralneuropathy/detail_peripheralneuropathy.htm - 183563208. Updated August 10, 2011.
3. Callaghan B, McCammon R, Kerber K, Xu X, Langa KM, Feldman E. Tests and expenditures in the initial evaluation of peripheral neuropathy. Arch Intern Med. 2012;172(2):127-132.
4. Lin HC. Diabetic neuropathy. Medscape Reference website. http://emedicine.medscape.com/article/1170337-overview. Updated November 1, 2011.
5. England JD, Gronseth GS, Franklin G, et al. Practice parameter: evaluation of distal symmetric polyneuropathy: role of laboratory and genetic testing (an evidence-based review). Report of the American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Academy of Physical Medicine and Rehabilitation. Neurology. 2009;72(2):185-192.

http://www.agingwellmag.com/archive/070912p14.shtml

Doctors And Patients Alike Can Be Guilty Of Dangerous Assumptions

Today's short post from kevinmd.com (see link below) is a timely reminder that the relationship between doctor and patient is always a fragile one, influenced by suppositions and assumptions, on both sides. With a disease like neuropathy, where the boundaries are vague and diagnoses and treatments less than 100% reliable, it's vital that there's mutual give and take. Far too often doctors send nerve damage patients home with the cliched; 'You'll have to learn to live with it', leading to frustration and anger and unresolved medical issues. In that case, the doctor is wrong and deserves to be called on his/her bedside manner. However, patients are equally guilty when they self-diagnose, or demand certain treatments, or come to the surgery without a coherent story. The point is that there's room for a little humility and 'counting to ten' on both sides. This article illustrates that perfectly and is a lesson for both doctor and patient. In the case of neuropathy, there's often no right and no wrong but the middle ground must be found in order to provide the best possible treatment for the patient. That demands a preparedness for the long haul...on both sides, with patience and respect as prerequisites on the side. Well worth a read.

You think the patient is difficult? Maybe it’s you.
Jordan Grumet, MD | Physician | April 28, 2017

I have come to believe that humility is an essential component of wisdom. Never have I found this truer than in the practice of medicine. In fact, for almost every atrocious professional error in judgment I have made, I can pinpoint the exact moment where I stopped being humble.

Yet time and time again, humility quickly disappears when dealing with the difficult patient. In fact, the label “difficult” assumes the problem lies within the patient and not the technique being utilized by the care provider. Already, blame is turned outward and personal responsibility abandoned.

A few years ago, when I was in a group practice, one of the senior partners had a particularly needy patient that somehow showed up on all our schedules from time to time. Her aged joints carried her into the exam room to in a particularly hobbled rhythm. She paused before each sentence, her voice barely above a whisper.

Her litany of issues was long and nonsensical. And this was always the precise moment when humility left the room. We all became convinced that her complaints were psychosomatic. And we were right. It still amazes me at how cavalier I can be when I think a solution is either simple or nonphysiologic.

It was only after several visits that the need for a thorough exam became apparent. I tapped my feet and waited outside the door for what seemed like an eternity as she undressed and climbed into the gown. My stethoscope stumbled over the heart as if its mighty muscle had not thumped hundreds of thousands of beats. I auscultated the lungs absentmindedly untouched by the unmeasurable volumes that glanced the porous surface.

My hands fumbled over the fibrosed joints that absorbed the shock of a child’s prance, a young athlete’s stride and,now, an ancient shuffle.

My conceit, however, unshakable as it was, was shattered by the faded serial number tattooed on her forearm.

And my humility, once again, was restored to a respectable level.

Jordan Grumet is an internal medicine physician who blogs at In My Humble Opinion. Watch his talk at dotMED 2013, Caring 2.0: Social Media and the Rise Of The Empathic Physician. He is the author of Five Moments: Short Works of Fiction and I Am Your Doctor: and This Is My Humble Opinion.

http://www.kevinmd.com/blog/2017/04/think-patient-difficult-maybe.html

Medical Cannabis For Nerve Pain What Doctors Must Decide

Today's post from journalofethics.ama-assn.org (see link below) is an advisory article for doctors considering whether to prescribe medical cannabis for their neuropathic patients in severe pain. The article comes from 2013 and you probably don't need reminding that the case for medical marijuana use for chronic pain has become significantly stronger since then. It's an interesting and well-balanced article that will give us an insight into what considerations doctors must take before prescribing it but may also give you a little more confidence in deciding whether its a safe and/or desirable option in your own particular case. Worth a read.
 

Medicinal Cannabis and Painful Sensory Neuropathy
Igor Grant, MD Virtual Mentor. May 2013, Volume 15,

Painful peripheral neuropathy comprises multiple symptoms that can severely erode quality of life. These include allodynia (pain evoked by light stimuli that are not normally pain-evoking) and various abnormal sensations termed dysesthesias (e.g., electric shock sensations, “pins and needles,” sensations of coldness or heat, numbness, and other types of uncomfortable and painful sensations). Common causes of peripheral neuropathy include diabetes, HIV/AIDS, spinal cord injuries, multiple sclerosis, and certain drugs and toxins. Commonly prescribed treatments come from drugs of the tricyclic and selective serotonin reuptake inhibitor (SSRI) antidepressant classes, anticonvulsants, opioids, and certain topical agents. Many patients receive only partial benefit from such treatments, and some either do not benefit or cannot tolerate these medications. The need for additional treatment modalities is evident.

Animal studies and anecdotal human evidence have for some time pointed to the possibility that cannabis may be effective in the treatment of painful peripheral neuropathy [1]. Recently, the Center for Medicinal Cannabis Research (CMCR) at the University of California [2] completed five placebo-controlled phase II clinical trials with smoked or inhaled cannabis [3-7]. Another study reported from Canada [8]. Patients included people with HIV neuropathy and other neuropathic conditions, and one study focused on a human model of neuropathic pain. Overall, the efficacy of cannabis was comparable to that of traditional agents, somewhat less than that of the tricyclics, but better than SSRIs and anticonvulsants, and comparable to gabapentin (see figure 1).




Figure 1. Common analgesics for neuropathic pain.

*to achieve a 30% reduction in pain.

Number needed to treat (NNT) = 1/(E-P), where E is the proportion improved in experimental condition and P is the proportion improved on placebo. Example: If 60% “improve” (according to a given definition) in the experimental condition, while 30% “improve” in the placebo condition, then NNT = 1/(.6-.3) = 3.3. Data adapted from Abrams et al. [3] and Ellis et al. [4].

The concentrations of tetrahydrocannabinol (THC) in these studies ranged from 2 to 9 percent, with a typical concentration of 4 percent resulting in good efficacy. Side effects were modest and included light-headedness, mild difficulties in concentration and memory, tachycardia, and fatigue. Serious side effects (e.g., severe anxiety, paranoia, psychotic symptoms) were not observed. Mild cognitive changes resolved within several hours of drug administration.

While these were short-term trials with limited numbers of cases, the data suggest, on balance, that cannabis may represent a reasonable alternative or adjunct to treatment of patients with serious painful peripheral neuropathy for whom other remedies have not provided fully satisfactory results. Because oral administration of cannabinoids (e.g., as dronabinol, marketed as Marinol) can result in inconsistent blood levels due to variations in absorption and first-pass metabolism effects, inhalational (or potentially sublingual spray, e.g., nabiximols, marketed as Sativex) administration remains preferred to oral administration.

Cannabis as a smoked cigarette, while demonstrating efficacy, poses a number of challenges, inasmuch as it remains illegal under federal law, even though it is permitted in an increasing number of jurisdictions on physician recommendation. Figure 2 provides a schematic approach for physician decision making in jurisdictions where medicinal cannabis is permitted [9]. See figure 2 



This decision tree suggests key points that a physician should consider in making a determination. In the case of a patient assumed to have persistent neuropathic pain, the first determination to be made is that the patient’s signs and symptoms are indeed consistent with a diagnosis of neuropathy. Assuming a patient does not respond favorably to or cannot tolerate more standard treatments (e.g., antidepressants, anticonvulsants) and is willing to consider medicinal cannabis, the physician proceeds to compare risk and benefit. Among these considerations is whether the patient has a history of substance abuse or a serious psychiatric disorder that might be exacerbated by medicinal cannabis. Even the presence of such a risk does not necessarily preclude the use of medicinal cannabis; rather, coordination with appropriate substance abuse and psychiatric resources is necessary, and, based on that consultation, a risk-benefit ratio can be formulated. In patients for whom the ratio appears favorable, the physician should discuss modes of cannabis administration including oral, smoked, or vaporized. Once risks and benefits are evaluated and discussed with the patient, cannabis treatment may commence as with other psychotropic medications, with attention being paid to side effects as well as efficacy. Attention must also be paid to possible misuse and diversion, which can then trigger a decision to discontinue the treatment.

In summary, there is increasing evidence that cannabis may represent a useful alternative or adjunct in the management of painful peripheral neuropathy, a condition that can markedly affect life quality. Our society should be able to find ways to separate the medical benefits of making a treatment available to improve lives when indicated from broader social policy on recreational use, marijuana legalization, and unsubstantiated fears that medicinal cannabis will lead to widespread cannabis addiction [10-12].

References
Joy JE, Watson Jr SJ, Benson JA, eds. Marijuana and Medicine: Assessing the Science Base. Washington, DC: National Academies Press; 1999.
Center for Medicinal Cannabis Research. http://www.cmcr.ucsd.edu.
Abrams DI, Jay CA, Shade SB, et al. Cannabis in painful HIV-associated sensory neuropathy: A randomized placebo-controlled trial. Neurology. 2007;68(7):515-521.
Ellis RJ, Toperoff W, Vaida F, et al. Smoked medicinal cannabis for neuropathic pain in hiv: a randomized, crossover clinical trial. Neuropsychopharmacology. 2009;34(3):672-680.
Wallace M, Schulteis G, Atkinson JH, et al. Dose-dependent effects of smoked cannabis on capsaicin-induced pain and hyperalgesia in healthy volunteers. Anesthesiology. 2007;107(5):785-796.
Wilsey B, Marcotte T, Deutsch R, Gouaux B, Sakai S, Donaghe H. Low-dose vaporized cannabis significantly improves neuropathic pain. J Pain. 2013;14(2):136-148.
Wilsey B, Marcotte T, Tsodikov A, et al. A randomized, placebo-controlled, crossover trial of cannabis cigarettes in neuropathic pain. J Pain. 2008;9(6):506-521.
Ware MA, Wang T, Shapiro S, et al. Smoked cannabis for chronic neuropathic pain: a randomized controlled trial. CMAJ. 2010;182(14):E694-E701.
Grant I, Atkinson JH, Gouaux B, Wilsey B. Medical marijuana: clearing away the smoke. Open Neurology J. 2012;6:18-25.
Kleber HD, DuPont RL. Physicians and medical marijuana. Am J Psychiatry. 2012;169(6):564-568.
Harper S, Strumpf EC, Kaufman JS. Do medical marijuana laws increase marijuana use? Replication study and extension. Ann Epidemiol. 2012;22(3):207-212.
Grant I, Atkinson JH, Gouaux B. Research on medical marijuana. Am J Psychiatry. 2012;169(10):1119-1120.

Igor Grant, MD, is a professor and executive vice chair of the Department of Psychiatry and director of the HIV Neurobehavioral Research Program (HNRP) at the University of California, San Diego School of Medicine. Dr. Grant is the founding editor of the Journal of the International Neuropsychological Society and founding co-editor of the journal AIDS and Behavior.

http://journalofethics.ama-assn.org/2013/05/oped1-1305.html

Can Doctors Feel Your Pain

Today's interesting post from healthland.time.com (Time: Health and Family, see link below) talks about whether doctors truly can empathize with their patient's pain. Many people living with neuropathy get the impression that their doctors are responding more from the text book to their symptoms, than from genuine sympathy and understanding and may even feel disbelieved, or that they are overreacting. This article shows that that may not be true at all and that doctors understand our pain better than we think.

Can Doctors Feel Their Patients’ Pain?
By Alexandra SifferlinJan. 30, 2013


A study shows physicians may care more than you think about their patients’ pain.In spite of studies showing that the relationship between a doctor and patient can influence healing, the interaction isn’t known for its expressions of outward empathy. But a new study takes a closer look at the biology of the exchange and found some revealing surprises.

Using brain scans, researchers from Massachusetts General Hospital (MGH) and the Program in Placebo Studies and Therapeutic Encounter (PiPS) at Beth Israel Deaconess Medical Center/Harvard Medical School showed that that when doctors believe they are treating patients, they can feel their pain and also empathize with their patients’ relief after the treatment.

In the study, published in the journal Molecular Psychiatry, 18 doctors simulated treating a patient while in a functional MRI (fMRI) scan. They used what they believed to be an electric pain-relieving device on two female actors pretending to be patients.

(MORE: White Coats, White Lies: How Honest Is Your Doctor?)

To convince the doctors that they were relieving the patients’ pain, the study authors gave each doctor a dose of “heat pain” to their forearms and then simply reduced the amount of heat when they touched them with the fake pain relieving device, therefore simulating treatment. While they were being tested, the researchers scanned the doctors’ brains to see which regions reacted to the heat pain stimulation.

Each doctor was then introduced to one of the patients, and performed a standard clinical examination. The doctor and patient then moved into a room with the scanner where the doctors were provided with a remote control that could activate the pain relief device. The room contained mirrors so the doctor could maintain eye contact with the patient, who was hooked up to both the heat pain stimulator and the pain relief device.

The doctors, who were in the fMRI machine, were then instructed to either treat the patient’s pain or press a control button that provided no relief. The doctors watched the facial reactions of their patients as they “felt” pain and when they felt relief. Throughout the experiment, the researchers image the brains of the physicians.

(MORE: Reality Strikes: A Doctor-In-Training Encounters Her First Patient)

The researchers focused on two parts of the brain connected to pain perception: the right ventrolateral prefrontal cortex (VLPFC) and the rostral anterior cingulate cortex (rACC). The VLPFC region is associated with pain relief and the rACC region is associated with reward. Both regions generally become more active when patients undergo placebo therapies, or think they are receiving benefit of some kind. The researchers found that these same areas were activated in the doctors’ brains when they thought they were providing effective treatment.

That’s in line with previous research on the placebo effect, which shows that belief in an effect can activate brain responses. The results are the first, however, to implicate the placebo effect in physicians who connect with their patients, and may provide new insight into the biology of caregiving. “This is a scientific-centric medical system. Unfortunately it is not as human-centered as we want it,” says senior author Ted Kaptchuk, associate professor of medicine at Harvard Medical School and director of the PiPS at Beth Israel Deaconess Medical Center in Boston. “One of the things we are seeing is that these intangibles that we call ‘the art of medicine’ are just as tangible and important as the tricks in the black bag.”

(MORE: Can Patients Handle the Truth? Getting Access to Doctors’ Notes)

The study is reassuring in that way, since it potentially provides a foundation on which physicians can build a more understanding relationship with their patients, which will ultimately make them better physicians.

It may even be possible, says Kaptchuk, to find a biological model for high quality care. He hopes to repeat the study and take simultaneous brain scans of both patients and their doctors. “We are actually in a position that at some point, maybe we can measure the provision of care between a physician and patient,” he says. “That will allow us to actually model and develop and actually educate optimal provision of care. This is a study that has potential in those directions. We see this an a really interesting first step. It certainly doesn’t answer all the questions, but it’s a first step that no one has ever taken before.” And one for which patients are grateful.

http://healthland.time.com/2013/01/30/can-doctors-feel-their-patients-pain/#ixzz2JTN7mz4r

Foot Neuropathy A Doctors Response

Today's post from uexpress.com (see link below) is the initial conversation you would want to have with your doctor, if you turned up at the surgery with neuropathic symptoms. Unfortunately not all doctors are as clear as this during their consultation and many patients leave feeling confused and frustrated that they're not being told what's going on with their nerves. Communication is key with neuropathy. You need to get an umbrella view first and with that information in hand, move on gradually onto the treatment ladder. If you know of someone who is at their wits end as to what their problem is, show them this doctor's response - it's by no means comprehensive but at the beginning it doesn't need to be. At least the patient will have a good idea of what he or she is dealing with.

Foot Neuropathy Isn't 'Major' Problem, but It Sure Can Hurt - Ask Doctor K by Anthony Komaroff Apr 17, 2015

DEAR DOCTOR K: I have neuropathy pain in my feet. What can I do to relieve it?

DEAR READER: Neuropathy, or nerve damage, is a remarkably common problem. I get asked lots of questions about it -- both from readers of this column and from readers of the Harvard Health Letter, which I edit. It isn't considered a "major" health problem by many doctors, because it isn't potentially fatal. But, like many other problems not labeled as major by doctors, it sure can make people miserable and interfere with their lives.

Fortunately, there are several treatments that bring relief to most people who suffer with this condition. There are different types of neuropathy, but I'll assume you have the most common type, called axonal neuropathy.

Neuropathy affects many of the nerves in your body. Each nerve is like a highway that connects your brain to the rest of your body. Signals from your brain travel down the nerves sending orders, such as the order for your muscles to move different parts of your body. Signals from your body travel up the nerves to your brain. When your fingers touch something, for example, signals from your fingers tell the brain how cold and how hard that thing is, and whether touching it causes pain.

The longer a nerve is, the more likely it is to be affected by neuropathy. The nerves connecting your brain to your legs and feet are the longest, so the symptoms of neuropathy almost always begin in and are worst in the feet.

The most common symptoms of neuropathy are numbness, burning, or unpleasant sensations that people have a hard time describing. The loss of sensation in the feet can cause problems with balance when walking. If you can't tell where your weight is being carried (is it on your heels or the balls of your feet?), your brain gets confused.

Among the most common causes of neuropathy are diabetes, alcohol abuse, an underactive thyroid gland and some types of cancer chemotherapy. However, about one out of every four people with neuropathy has none of these known causes.

If you have any of the known causes of neuropathy, the first thing to do is treat the cause. If you're diabetic, do everything you can to lower your blood sugar. If you drink too much, cut down. If you have an underactive thyroid, take your thyroid pills as directed and get regular thyroid blood tests.

The most widely used medicines for reducing symptoms are an anticonvulsant -- either gabapentin (Neurontin) or pregabalin (Lyrica) -- and tricyclic drugs, including desipramine. Other anticonvulsants and drugs that decrease the number and severity of muscle spasms also can be helpful, including phenytoin, carbamazepine, topiramate and baclofen.

Not all of these drugs help for everyone. But if you work closely with your doctor, the odds are good that you can find one that will give you considerable relief.

http://www.uexpress.com/ask-dr-k/2015/4/17/foot-neuropathy-isnt-major-problem-but