Kidney disease is a major issue in healthcare and can also cause peripheral nerve damage.
We get a fair number of patients with peripheral neuropathy that also happen to have kidney disease. Reports vary, but upwards of 60-100% of uremic (patients with kidney disease) patients have peripheral nerve damage from their kidney disease!

That is a larger percentage than diabetic neuropathy!

From what I have read, there are at least two main thoughts on why this may occur. The first is that with the suboptimal filtering of the blood there are higher concentrations of “toxic” elements in the blood and these physically damage the nerves themselves and/or the small blood vessels that supply the nerves.
The other is that the improper maintenance of electrolytes such as potassium (K+) cause a disruption of normal function in the nerve cell membrane. Keeping it in a constant depolarized, or fired, state. So those affected nerves are always firing abnormally. They are just existing in a fired state. Not good at all. Here is a quotation below:
“Nerves of uremic patients have been shown to exist in a chronically depolarized state prior to dialysis, with subsequent improvement and normalization of resting membrane potential after dialysis. The degree of depolarization correlates with serum K+, suggesting that chronic hyperkalemic depolarization plays an important role in the development of nerve dysfunction in ESKD. These recent findings suggest that maintenance of serum K+ within normal limits between periods of dialysis, rather than simple avoidance of hyperkalemia, is likely to reduce the incidence and severity of uremic neuropathy. Muscle Nerve, 2006”
If you think about that it makes a lot of sense. One of the main things for nerve cell membrane activity is called a sodium potassium pump. Having issues with too high of potassium levels outside of the nerve might create a pressure gradient that “holds” that cell in a constant state of firing.

Interesting right? They still had neuropathy, but it was not quite as severe

Too much persistent potassium pressure?

If you are someone with kidney dysfunction do not take this as a recommendation to change your diet. As always, follow your physician’s recommendations as far as diet and lifestyle.

What about kidney transplant?

There are also multiple citations that showed that there was an improvement in nerve function following a kidney transplant. They did the typical EMG/NCV studies and showed a trend towards better nerve function after successful kidney transplant. Then some of those same people had their transplanted kidney fail and their nerve function got worse again. They received another (lucky them!) new kidney and the nerve function again improved a bit. So, unsurprisingly, for those patients who have neuropathy secondary to kidney disease a new functioning kidney made their nerves function better.

Once again, they still had neuropathy, but it was not quite as severe

As I was browsing journals I noticed there were quite a few dedicated to restless leg symptoms in uremic (kidney problem) patients. That was interesting as we do get asked about restless leg symptoms along with neuropathy from patients. There are more study articles for uremic patients (patients with kidney dysfunction) and restless leg syndrome than I remember reading with other peripheral neuropathies. I also can recall quite a few (although a bit less than our overall success rate with pain/numbness/balance) stating that as their “normal” neuropathy symptoms improved their RLS symptoms improved as well.

So, it may not be that uncommon to have restless leg symptoms along with peripheral neuropathy

Once thought to be more of a separate condition and part of a central nervous system type dysfunction might be more common with peripheral neuropathy than once thought.

Timothy Kelm DC is one of the clinicians at Realief Medical PA. Since 2007 (or as he would put it, before you ever saw an advertisement for neuropathy therapy) he has worked with many patients with peripheral neuropathy. He also trains new clinicians for Biolyst LLC, a medical company working for solutions to peripheral nerve damage. He has presented at the University of Minnesota Gynecological Oncology Research Symposium, has participated in Tier One research with neuropathy therapy for laser treatment for neuropathy symptoms. He also lectures in the US to patients on peripheral neuropathy and neuropathy relief. He can be reached by contacting his patient coordinator via email, [email protected] or by phone 952-658-6354.

Why is it so hard to get help with peripheral neuropathy?

In 2007 we began working with peripheral neuropathy patients. One thing that has not changed is how we hear over and over how difficult it is to get help. The struggle to improve their quality of life, to avoid a decline in what they can do; a mental break from worrying about their future.

Some relief from the constant symptoms.

This might be old news to those who suffer from neuropathy, but even getting a diagnosis can be difficult. First, there is usually a mention of the “thick” sensation under the toes to your General Practitioner. Then, the diagnostic testing in the Neurologist’s office. For those on chemotherapy, you might be asked if you have symptoms during active chemotherapy by your Nurse or Physician. The usual testing (and this should be done, make no mistake) of nerve conduction and electromyelogram can pick up large fiber neuropathy with fairly good accuracy. Occasionally, it can also give the examiner an idea if there is any nerve root involvement from low back problems as well. It does not pick up small fiber neuropathy!

Small fiber neuropathy can be diagnosed with a small tissue biopsy.

This biopsy is sent to a lab for analysis. The lab will actually count the nerve fibers in the sample. Peripheral neuropathy would lower the number of fibers in the sample and confirm the small fiber neuropathy diagnosis. There is also some additional testing to check for autonomic or autoimmune neuropathy (especially if you have redness or swelling in the extremities) and potential additional treatment options for the autoimmune neuropathy.

Many times, however, your doctor will make the assumption that you have small fiber neuropathy based on your medical history and typical exams. If you have all the symptoms of small fiber neuropathy and you have negative NCV/EMG tests, in all likelihood they would think you have small fiber neuropathy. They may not want to make you go through a biopsy even though it really is not that bad of a procedure. The most likely reason being that it really is not likely to change the course of care for you unfortunately. It still might be a good idea to get the biopsy so you have an actual firm diagnosis for insurance reasons, time off work etc.

Almost all roads lead to the same treatments.

And these treatments include but are not limited to:
“¢ Therapy options are pretty limited (make sure to state it is not a comprehensive list)
o Neurontin/Gabapentin
o Lyrica
o Anti-depressants
o Opioids (potentially)
o For autoimmune immunoglobulin infusion
 Expensive though for insurers so…
o PT for balance/strength complaints
o Topical compounded pharmacy creams
 These can have some of the medications above along with ketamine or lidocaine or some other analgesics
So it all boils down in the literature to treatments with the first 4 on the list 90% of the time. Click the image to enlarge the view.

Duloxetine is trademarked as Cymbalta. Amitriptyline is trademarked as Elavil. Pregabalin is also known as Lyrica although many clinicians will also prescribe Neurontin or its generic Gabapentin.

So as patients search for better results with care, they should know that if they are on these medications unfortunately there will not be a whole lot else out there in regards to front line medication management for neuropathy pain.
That’s why patients bounce around from doctor to doctor because they have already tried Cymbalta, they are currently on Gabapentin and it’s not cutting the mustard for symptom relief.

The other crazy thing is the emphasis on neuropathic pain, diabetic pain, pain pain pain. Many people with peripheral neuropathy DON’T HAVE PAIN!

They may have some discomfort but what really is concerning to them is the advancing numbness, weakness and loss of body position awareness in their feet which negatively affects their balance and mobility. Since the majority of length dependent neuropathies manifest in the feet first, especially in the balls of the feet, the ability to drive safely is a real and significant concern.
There are no drugs that can “numb” numbness. So those patients without significant pain can oftentimes feel even more out of luck as the medications prescribed for neuropathy only target pain.

After trying for so long and often being disappointed, some people go into a spiral of inactivity.
As a clinician with Realief, I advise people with neuropathy to keep searching for treatments and therapies. We often say in the clinic that anything that helps is a blessing! At the Realief Clinic we address almost all of the symptoms of neuropathy including pain, numbness and balance concerns.

Timothy Kelm, DC, is one of the clinicians at Realief Medical PA. Since 2007 (or, as he would put it, before you ever saw an advertisement for neuropathy therapy) he has worked with many patients with peripheral neuropathy. He also trains new clinicians for Biolyst LLC, a medical company working for solutions for peripheral nerve damage. He has presented at the University of Minnesota Gynecological Oncology Research Symposium and participated in Tier One research with neuropathy therapy for laser treatment for neuropathy in regards to symptom control. He also lectures in the US to patients on peripheral neuropathy and neuropathy relief. He can be reached by contacting his patient coordinator via email, [email protected] or by phone 952-658-6354.

(Quotations in this post are from the excellent article at the bottom of this page)

Here is what to read if none of your peripheral neuropathy symptoms fit in the normal box of numbness, tingling, burning, cold, strength, and balance.  What if you have redness?  Swelling?  Blotchy skin?  Hair loss? 

Peripheral neuropathy can damage sensory fibers which cause symptoms like pain, tingling, balance issues and numbness.  It can damage motor peripheral fibers which result in weakness and balance issues.  It can also damage your autonomic fibers.  These are called your sympathetic and parasympathetic fibers and they control things like blood pressure, heart rate, sweating etc.

“Diabetic autonomic neuropathy (DAN) is a serious and common complication of diabetes but remains among the least recognized and understood”₁

Keep in mind that diabetic neuropathy is likely the most studied systemic neuropathy but that in practice these same symptoms are common in other causes such as chemotherapy, autoimmune or even idiopathic (unknown) neuropathy.

“”¦and autonomic neuropathy (AN) is not unique to diabetes”¦”₁

Here is a picture of what the two branches of your autonomic nervous system control. Image courtesy of:
https://en.wikipedia.org/wiki/Dysautonomia

Can this swelling or redness be caused by my neuropathy?Since I don’t want to write a graduate thesis on things, I will focus on two that we hear questions about the most.

In a nutshell, it can.  Since the autonomic nerves control the microvasculature (capillaries), autonomic dysfunction can cause what is called “neuroedema” and “neuroischemia”.  In other words, swelling and insufficient oxygen from a neurological cause instead of a vascular blockage.  This does not mean that you can’t have swelling from a host of other causes like kidney or heart issues but that autonomic neuropathy can cause swelling as well.

I lost my hair on my legs / my toenails look funny

Autonomic neuroischemia affecting your capillaries ability to deliver oxygen and nutrients to the hair follicles can result in a loss of hair.  Same thing for the nail beds.

The common presence of autonomic nerve involvement in peripheral neuropathy opens the door for the explanation of a host of symptoms outside just the sensory and motor fibers.

*Many quotations and information for this post come from this very excellent paper:

1NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

De Groot LJ, Beck-Peccoz P, Chrousos G, et al., editors. Endotext [Internet]. South Dartmouth (MA):

MDText.com, Inc.; 2000-.

Diabetic Neuropathies

Aaron Vinik, MD, Carolina Casellini, M.D., and MarieLaure

Nevoret, M.D.

Timothy Kelm, DC, is one of the clinicians at Realief Medical PA.  Since 2007 (or, as he would put it, before you ever saw an advertisement for neuropathy therapy) he has worked with many patients with peripheral neuropathy.  He also trains new clinicians for Biolyst LLC, a medical company working for solutions to peripheral nerve damage.  He has presented at the University of Minnesota Gynecological Oncology Research Symposium and participated in Tier One research with neuropathy therapy for laser treatment for neuropathy in regards to symptom control.  He also lectures in the US to patients on peripheral neuropathy and neuropathy relief.  He can be reached by contacting his patient coordinator via email, [email protected] or by phone 952-658-6354.

Peripheral neuropathy, regardless of cause, is a nerve issue. Some damage process, whether that is from diabetes, chemotherapy, autoimmune issues, heavy metal poisoning or some physical damage, hurts the nerves. Since the nerves are responsible for so many things when they are not working, they can cause a variety of symptoms.

But that does not mean it is the cause of all of your symptoms

In our clinic, we see primarily non-compressive peripheral neuropathy patients. But many times there can be other issues going on at the same time. Here is a list of a few:

-Low back issues like sciatica or an irritated nerve root (not always accompanied by acute low back pain)

-Plantar fasciitis

-Bunion

-Balance issues from inner ear or blood pressure problems

-Cellulitis

-Osteoarthritis

-Achilles tendonitis

-Various vascular issues like PAD and symptoms of intermittent claudication

-Pure muscular things like weakness from atrophy or contracture (tightened tissues)

You are entitled to have multiple things going on at the same time!

I would guess that since our average patient age is close to 70 around 20-30% of our patients who come to us for help have a nerve issue with the ends of the nerves as well as some nerve root (by the spine) problem as well.

As I write this this week (It’s only a Tuesday) I have had two patients where their neuropathy symptoms are pretty much under control but they had acute pain, one described it as burning and one as just tight sharp pain, on the outside of one heel.

It’s easy to fall into the trap of thinking there is one cause for everything!

In both cases we did just a little easy mobilization of the heel bone area and they had immediate relief. I showed their significant other (who were with them in both cases) how to do it at home and they both left happy as clams.

Now just doing the mobilization alone wouldn’t have solved their other symptoms of numbness, tingling etc. since there was a foot/ankle structure issue in addition to the neuropathy.

Some clues that I have found helpful in figuring out what combination of things are affecting our patients are listening to the patient history. Testing is useful but a huge part of diagnosis is just listening to the patient. To a competent clinician, Achilles tendon pain and compartment syndrome as described by a patient sound different than peripheral nerve complaints.

Surface area of complaint is a giveaway as well. Things that are generally in a “strip” of symptoms often times can be coming from the low back. So we can have a patient that has a typical axonopathy presentation starting in the toes/balls of the feet and progressing upwards along with a typical L5/S1 dermatomal presentation along the outside of the leg.

Thank you to http://www.physio-pedia.com/Sciatica for the dermatome image.

One thing I teach new therapists or clinicians is that with neuropathy there are more “ands” than “ors”. Many times it is X condition AND Y condition that are giving a patient their symptoms.

Timothy Kelm, DC, is one of the clinicians at Realief Medical PA. Since 2007 (or, as he would put it, before you ever saw an advertisement for neuropathy therapy) he has worked with many patients with peripheral neuropathy. He also trains new clinicians for Biolyst LLC, a medical company working for solutions to peripheral nerve damage. He has presented at the University of Minnesota Gynecological Oncology Research Symposium and participated in Tier One research with neuropathy therapy for laser treatment for neuropathy in regards to symptom control. He also lectures in the US to patients on peripheral neuropathy and neuropathy relief. He can be reached by contacting his patient coordinator via email, [email protected] or by phone 952-658-6354.

Most clinicians who work with peripheral neuropathy begin to adopt the mindset that if anything (legal!) helps a patient feel better they should do it. If it can provide some peripheral neuropathy relief and still be safe it may be worth a try.
In our practice working with hundreds (maybe thousands by now?) we have had reports of many things that patients have felt helped at least a little.
You will see that most options are for patients that have pain with their neuropathy. More evidence points to there being a large population of patients that have non-painful neuropathy. These patients unfortunately have even fewer options as the medications have no way to “numb” their numbness. And you can’t medicate to better balance. Here I write about the numbness and mobility side of neuropathy if you care to take a look.

As always, before messing around with some of these, especially with the supplements, ask your doctor for the ok to try these.

In no particular order and my comments are in quotations and bold:
“¢ Amino acids
“¢ Alpha Lipoid Acid
“¢ Acetyl L Carnitine
“Amino acids are the building blocks of protein and these two in particular have a decent amount of research on them with regards to nerve function. Worth a try IMO.”
“¢ EPA/DHA or Fish Oils
“I tend to like these. Like the amino acids above, anything (anti-oxidant) that tends to lower the oxidative stress on the body could be helpful in reducing the pain side of the neuropathy.”

For more information on Realief Centers visit our website www.realiefcenters.com/

Neuropathy messes with your strength and balance

I could have also titled this, “I exercise, but I seem to be getting weaker” or, “I did physical therapy, but didn’t get as good of results as I would have hoped.”

In this post we spoke a bit on how neuropathy can cause pain, numbness, or even both at the same time. This time we’ll talk about a huge part of neuropathy.

• Strength
• Balance
• Mobility

Sensory nerves discussed here tell you about your environment. They tell you your gloves are nice and soft or that the dog has definitely been on the sofa because that one cushion is still warm.

Motor nerves control your muscles for mobility.

Neuropathy damages whatever nerves it wants. In one person it ravages the sensory nerves and that person has pain. In another, it damages these motor nerves and can lead to mobility, strength, and balance concerns. (And if it’s feeling nasty it can damage all of them at once)

Motor nerves are large diameter fiber nerves that control your muscles. With peripheral neuropathy, many times the entire muscle is not shut off, just the bits and pieces within. Your muscles are made up of a bunch of individual muscle fibers, like a bundle of straws or a handful of spaghetti. When you move, these muscle fibers bunch up and shorten, allowing you to move your arm, hand, leg, etc.

If you were to chop through a muscle and look at the cut ends, they should look like this:

From here: http://emedicine.medscape.com/article/1923188-overview

With a peripheral neuropathy patient that has motor nerve damage, the muscle looks like this:

From: http://neuropathology-web.org/chapter13/chapter13bDenervation.html

You have areas that are still big and round, which means they are likely still working to move you through the grocery store. They also have areas that are not working (because their motor nerve ending has been damaged by the neuropathy) and that area has atrophied (shrunk).

So unless there is an improvement in nerve function (like we do in our clinic), it is very difficult to improve the strength needed to improve mobility.

I was thinking that many times underneath a blog, you have a little blurb about the author that is basically a way to get in touch with them/their business. Here is a shot at my blurb.Timothy Kelm DC is a clinician at Realief Centers of Minneapolis. Since 2007 he has worked with patients with peripheral neuropathy. He is also Chief Medical Officer and trains in new clinicians for Biolyst , a medical company working for solutions to peripheral nerve damage. He has presented at the University of Minnesota Gynecological Oncology Research Symposium, has participated in Tier One research with peripheral neuropathy and lectures in the US to patients on peripheral neuropathy. He also lectures in the US to patients on peripheral neuropathy and neuropathy relief. He can be reached by contacting his patient coordinator via email, [email protected] or by phone 952-658-6354.

Negative EMG/NCV so I don’t have neuropathy? Not so fast!!

(You can skip to the chase here – you CAN have peripheral neuropathy with a normal EMG/NCV)

A very common method of testing for peripheral nerve damage are electromyelegrams (EMG) and nerve conduction velocity (NCV) tests, they are called electrodiagnostic tests as well. A good way to think about how they work is that they shoot electrical impulses into one end of your nerves and measure how fast and how “big” the impulses come out of the other end.

Based on this testing, the clinician might be able to get a sense of whether the damage is to the ENDS of the nerves (like the hands/feet) or if the problem is at the BEGINNING of the nerves (like a herniated disc by the spine).

You are entitled, however, to have multiple things wrong with you

Keep in mind that there is no limit on what you can have wrong with you. Can anyone think of a reason why you couldn’t have a nerve issue up top (like sciatica or a “pinched” nerve) as well as some damage at the ends of the nerves? Nope! You are entitled to have many things wrong with you at once.

Off of the top of my head I would guess that about 20% of the patients that I see in my practice have issues at the ends of their nerves (from peripheral neuropathy) as well as some problems at the beginning of their nerves (like disc degeneration or lumbar stenosis or something).

But many times it is one or the other or the symptoms are from mostly one or the other. These tests can help determine if it’s one or the other or both.

But what if you have a “negative” EMG/NCV?

Does that mean that you don’t have neuropathy? Not necessarily. You see, these two tests are only good for nerves that have a myelin sheath. Think of myelin as the insulation around an electrical wire. Its purpose is to speed up nerve impulses for things that have to go FAST like all of the quick corrections we do to stand and walk upright, feel touch, vibration, etc. In general, these types of nerves are called large diameter nerve fibers. Large fiber damage will mostly give symptoms of numbness, tingling, weakness, and loss of coordination (the body loses track of its feet/parts).

If there are large diameter nerve fibers, there must be small diameter nerve fibers right?

Right.

And problems with these nerves are not picked up by the EMG/NCV tests.

John Hopkins School of Medicine website lists the symptoms of small fiber neuropathy as:

That covers a lot of symptoms right?

Confusingly enough there is overlap between the symptoms caused by small fiber damage and large fiber damage. This overlap is not normally a major issue, as many times there is both large and small fiber damage. Here; however, we are addressing someone that might have only small fiber damage.

Since the EMG/NCV only picks up large fiber dysfunction, one can certainly have a negative EMG/NCV and still have peripheral neuropathy.

Just small fiber peripheral neuropathy – not large fiber peripheral neuropathy.

If someone has the signs and symptoms of peripheral neuropathy and they get a normal EMG/NCV, there is testing that can be done for small fiber neuropathy. It’s a tissue biopsy where a small plug of tissue is taken and sent off to a lab. In the lab the tissue is stained and the small fibers are literally counted under a microscope. (Sounds like a thrilling job)

With small fiber neuropathy there will be FEWERnerve fibers than normal. Counterintuitive right? Well neuropathy is weird.

At my clinic, we treat both large and small fiber neuropathies. The small fiber folks see a reduction in intensity and surface area symptoms. The same goes for those with large fibers in regards to numbness, but they have additional work to do on some of the strength and coordination issues. Many patients have both small and large fiber damage and have pain AND numbness.

How on earth can you have pain AND numbness? If you are going numb then why does it hurt?

I write about that here

Citations

http://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/peripheral_nerve/conditions/small_fiber_sensory_neuropathy.html

Am I insane? I have pain and I feel like I’m going numb.

No, you are not insane because you have pain and numbness. Peripheral neuropathy, when it is damage to the ends of the nerves, can pick and choose which nerve endings to damage.

Your symptoms depend on which nerve endings are damaged.

Think of your peripheral nerves. They have a main cell body coming right off of the spinal cord. Inside they have many individual nerve fibers, like a coaxial cable is made up of many individual wires twined together.

Eventually these individual nerve “wires” end. Some end up and make a muscle fiber fire. Some make you cry like when you read your phone bill. Some tell your glands to squirt hormones into your bloodstream. And some tell you how soft the puppy’s ear that you are petting is.

The ends of the nerves are specialized and basically have one job each. One job! So if a bunch of the nerves for feeling warmth are damaged, you will have a tough time feeling warmth. If they really get damaged they can send the sensation of heat when they are not supposed to.

Here is a chart from https://www.dartmouth.edu/~rswenson/NeuroSci/figures/Table_1.htmwith some more detail on the individual nerve endings and what they do.

So whichever nerve endings the neuropathy decides to damage gives you your symptoms. Look at the chart above. The second group from the top does touch sensation. If they are damaged, you get numb-ish. The bottom group does burning pain. If they are damaged, he or she gets a burning type pain. If both groups are damaged, then that patient has both numbness and burning pain.

And that’s just the sensory nerves. There are also motor nerves, previous blog, that you use for movement and balance.