Richard G. Petty, MD

T’ai Ch Ch’uan and Your Feet

One of the worries about getting older is that aging can adversely affect our balance and increases the chance that we can slip and fall. This is even more of a problem in people with loss of sensation in the soles of the feet due to diabetic peripheral neuropathy and other diseases. T’ai Chi Ch’uan has previously been shown to improve balance in healthy elderly adults.

A new study from the Biomedical Engineering Program, Milwaukee School of Engineering, Milwaukee, Wisconsin was just published in the journal Diabetes Technology and Therapeutics. 

The aim of the study was to see if T’ai Chi improved both balance and sensory perception in the soles of the feet in healthy elderly adults and elderly adults with diabetes and sensory loss in the feet. Eighteen elderly people with a mean age of 73.1 years were tested for sensation and balance before t’ai chi training and again after 6 months of weekly sessions. Participants were grouped by their initial scores on tests of sensory perception, in order to calculate the effects of t’ai chi on sensory perception.

Plantar (soles of feet) sensation results showed that all the participants showed significant improvement in sensory ability with the 6 months of t’ai chi training. All groups also had a general improvement in all balance measures, with the greatest improvement seen in those subjects with large sensory losses. Hemoglobin A1c measurements – a standard way of estimating control of blood glucose - also decreased as a result of the intervention.

The study was small, but the effectiveness of t’ai chi training as a method of improving plantar sensation and balance in elderly adults with sensory loss, with and without diabetes, was impressive.

Another one of those things that is supposed to be impossible!

Even Neurons Need Friends

In many neurological diseases, including multiple sclerosis (MS) and some types of neuropathy, myelin - the insulation that covers and surrounds most of the larger nerves - is damaged or deranged.

Scientists at the Weizmann Institute of Science in Rehovot, Israel, working with colleagues in the United States, recently reported finding an important new line of communication between cells in the nervous system that is crucial to the development of myelinated nerves. This new discovery may eventually help us to restore the normal function of the affected nerve fibers.

Nerve cells (neurons) have long, thin extensions called axons. The longest of these axons is in the verves supplying the feet, and they can be over three feet or more in length. The larger axons are covered by myelin, which is formed by a group of specialized cells called glia.

Glial cells move around the axon, laying down the myelin sheath in segments, while leaving small nodes of exposed nerve in between. Myelin provides protection for the delicate axons, and it also allows nerve signals to jump rapidly between the gaps or nodes, increasing the speed and efficiency of the transfer of electrical signals down the axon. When myelin is missing or damaged, the nerve signals cannot skip down the axons, leading to abnormal function of the affected nerve and eventually the now naked nerve may degenerate and die.

In research published in Nature Neuroscience, Elior Peles, Ivo Spiegel and their colleagues in the Molecular Cell Biology Department at the Weizmann Institute and in the United States, provided a new insight into the mechanism by which glial cells recognize and myelinate axons.

They found a pair of proteins that pass messages from axons to glial cells. These proteins, called Necl1 and Necl4, belong to a larger family of cell adhesion molecules. The whole class of cell adhesion molecules does exactly that: they sit on the outer membranes of cells and provide the glue that helps them to stick together. Even when removed from their cells, Necl1, which is normally found on the surface of the axon, and Necl4, that is found on the glial cell membrane, adhere together very tightly. When these molecules are in their natural homes of the axon and glial cell, they not only create physical contact between axon and glial cell, but also serve to transfer signals to the interior of the glial cells, initiating changes needed to undertake myelination.

The scientists found that production of Necl4 in the glial cells rises when they come into close contact with an unmyelinated axon and as the process of myelination begins. If Necl4 is absent from the glial cells, or if they blocked the attachment of Necl4 to Necl1, the axons that were in contact with the glial cells did not myelinate.

This is an exceptionally important discovery. Most of the approaches that we use for treating MS, peripheral neuropathy and other degenerative diseases, can often help with symptoms and may slow but not cure the diseases. But if we can understand the mechanisms that control the process of wrapping the axons by their protective sheath, we may be able to recreate that process in patients.

Diabetes, Inflammation and the Heart

One of the most worrying signs in people with type 1 diabetes is damage to the nerves supplying the heart. This is called cardiovascular autonomic neuropathy, and one of its first signs is a reduction in the normal heart rate variability (HRV).

It has been known for many years that people with both type 1 and type 2 diabetes have low grade inflammation, and inflammation can have profound effects on the activity of the autonomic nervous system.

A study from Sabadell in Spain has tried to sort out these links in a study of 120 people with longstanding type 1 diabetes.

They measured a great many things including tumor necrosis factor, alpha-receptors 1 and 2, IL-6, and C-reactive protein; insulin resistance and HRV in response to deep breathing and the Valsalva maneuver" forcibly exhaling against with mouth and nose closed.

They did indeed find a link between low-grade inflammation and early alterations in the nerve supply to the heart.

This is important information: when we proposed that inflammation might be an important player in diabetes back in the 1980s, it was greeted with disbelief. Twenty years on it looks as if we might have a whole new line of treatment on the horizon, which will include nutrition and exercise as well as supplements and medications.

Acupuncture and Peripheral Neuropathy

Neuropathic pain is one of the toughest problems to deal with.

I have had more relative failures in trying to help this problem than any other.

So I was very interested to see a pilot study that has evaluated the therapeutic effect of acupuncture on peripheral neuropathy (PN) as measured by changes in nerve conduction and assessment of subjective symptoms.

One hundred and ninety-two consecutive patients with PN as diagnosed by nerve conduction studies (NCS) were evaluated over a period of 1 year. Of 47 patients who met the criteria for PN of undefined etiology, 21 received traditional Chinese acupuncture, while 26 received medical care but no specific treatment for PN. 76% of the acupuncture group improved symptomatically and objectively as measured by NCS, while only 15% of the control group did so. 14% of the acupuncture group showed no change and 10% showed an aggravation, whereas in the control group 27% showed no change and 58% an aggravation. Subjective improvement was fully correlated with improvement in NCS in both groups.

These numbers are stunning. I might have some small quibbles about the way that the study was dne, but the results are impressive.

A second study compared Chinese and Japanese acupuncture for treating painful diabetic neuropathy. Both treatments improved pain, but only the Chinese style produced an objective improvement in the ability to feel in the affected areas.

These findings are remarkable: peripheral neuropathy can be a bear to treat, and according to the received wisdom, neither the pain nor the sensation should be able to get better. In the second study the patients were only treated once a week for ten weeks. In China such patients get daily treatments, and people in the West who treat neuropathy with acupuncture normally recommend treatments at least two or three times a week.

Both of these studies were small, but they are very encouraging.

If they are confirmed, we may to re-think another one of those, "Everyone knows that.." statements. This one about neuropathy: That is supposed to be untreatable and irreversible.

That is why the next set of studies will be super-rigorous,

They need to be.

If confirmed, we are going to be re-writing the textbooks.

Neurological Complications of Gastric Bypass Surgery

Our bodies are highly complex systems. They are not just bags of randomly assorted organs. So tinkering with one part of the system can have an impact in an entirely different part of the body. Many of us have worried for some time about the long-term consequences of gastric bypass surgery for weight loss. We know that some people who have had the surgery develop “substitution addictions.” If they had a real addiction to food before the surgery, after it they may begin to develop an addiction to something else, such as drugs or alcohol.

Now neurologists at the University of Arkansas for Medical Sciences (UAMS) in Little Rock have reported the results of a ten-year study found a link between gastric bypass surgery and several serious neurological conditions.

The study was published online May 22 in the medical journal Neurology and concludes that patients who undergo gastric bypass surgery, also known as bariatric surgery, are at risk for long-term vitamin and mineral deficiencies and as a result may develop a variety of neurological symptoms.

We know that ever more of these operations are being done every year, and so long as people are motivated they are usually successful in reducing weight. But they are not without risk, and we always have to balance that risk against the risk of being morbidly obese. This work is important because it suggests that there is an extra risk about which we previously knew very little.  Many of the complications that patients experience affect the nervous system, and they are often disabling and irreversible.

More than 150 patients who came to the UAMS Neurology Clinic following gastric bypass were included in the report. In 26 of these patients a link between the surgery and their neurological condition was found.

All of the patients involved in the study had previously undergone what is known as the Roux-en-Y gastric bypass procedure in which a small stomach pouch is created by stapling part of the stomach together and bypassing part of the small bowel, resulting in reduced food intake and a decreased ability to absorb the nutrients in food. The interval between surgery and onset of neurological symptoms ranged from 4 weeks to 18 years.

The neurological problems involved many different parts of the nervous system, and the symptoms included confusion, auditory hallucinations, optic neuropathy, weakness and loss of sensation in the legs, and pain in the feet, among other conditions. None of the patients had prior neurological symptoms.

Many of the patients also experienced multiple nutritional abnormalities, especially low serum copper, vitamin B12, vitamin D, iron and calcium.

This study underlines something very important. Many heavy people are actually malnourished, because they eat the wrong things and an excess of fat in the diet can create problems in the absorption of some vitamins and minerals. In addition, surgery like this can cause a form of malabsorption.

It is therefore essential to make sure that people who have this kind of surgery have an adequate long-term intake of vitamin and mineral supplements to prevent these neurological complications. It is important for everyone to know about these potential problems and to be on the lookout for neurological symptoms.

Carpal Tunnel Syndrome and Diabetes

Carpal tunnel syndrome is a relatively common neurological problem in which the median nerve is compressed in the wrist.

The classical symptoms are:

• Tingling, numbness or burning in the fingers or hand, especially thumb, index, middle or ring fingers, but not your little finger. It is most typically present on waking, but can occur after using the hands. Some people "shake out" their hands to relieve their symptoms.
• Pain radiating or extending from the wrist up the arm to the shoulder or down into you’re the palm or fingers, especially after forceful or repetitive use.
• A sense of weakness in the hands and sometimes a tendency to drop things
• Numbness, especially in the tips of the thumb, index, middle and ring fingers.
• Eventually the small muscles that control the thumb, index and middle fingers can weaken and atrophy.

In many people there is not obvious cause, although it is more common in women approaching menopause, and these days it can be one of the problems associated with using a computer mouse of keyboard for long periods. Every student of health care learns that there is a great long list of causes including:

• Pregnancy
• Rheumatoid arthritis
• Trauma
• Hypothyroidism
• Diabetes
• Amyloidosis
• Acromegaly
• Myeloma
• Tumors

Although I was taught about carpal tunnel syndrome not just as a cause but also as a predictor of diabetes more than 30 years ago, it has been forgotten by some non-specialists.

There is some new research from King’s College in London that has suggested that carpal tunnel syndrome may be a harbinger of diabetes.

As many as 20% of people with diabetes have a compression neuropathy such as carpal tunnel syndrome, and in people with limited joint mobility – a complication of diabetes - the incidence may be as high as 75%. The new research indicates that carpal tunnel syndrome may precede the diagnosis of diabetes by up to 10 years. The work was based on an analysis of 2,655 people who were diagnosed with type 2 diabetes in 2003-2004. The researchers excluded people with other known risk factors for carpal tunnel syndrome. The relative risk for subsequently developing diabetes was 1.63.

This research shows once again that diabetes can sometimes make its presence felt years before it has been formally diagnosed. A study published in 2003 found that 56% of people with peripheral neuropathy of unknown cause actually had abnormal glucose tolerance tests.

Earlier this year, researchers form the Netherlands did a retrospective review of 516 people with carpal tunnel syndrome, and found only two people with diabetes. They therefore recommended that routine screening for diabetes was not worthwhile in otherwise typical carpal tunnel syndrome.

I disagree with them.

I think that it would be wise to screen people with carpal tunnel syndrome for any disturbances of glucose metabolism, including insulin resistance, and if they are at a particularly high risk of developing diabetes, it would be worth going ahead and doing a glucose tolerance test. We don’t often do them these days, but this would be one of those times.

Multiple Sclerosis

Multiple sclerosis (MS) can be a horrible illness that does not respect age or class. Neil Cavuto, Captain Beefheart and Montel Williams are just three well-known people who have said that they have the illness. Here is a list of many other sufferers.

MS is a chronic, inflammatory disease that affects the central nervous system (CNS). MS can cause a wide variety of symptoms, including changes in sensation, visual problems, muscle weakness, depression, difficulties with coordination and speech, severe fatigue, and pain. The classic pathology is what is known as demyelination (loss of the myelin that insulates nerve cells). Since myelin is white, the lesions are typically fuond in the white matter of the CNS.

The cause remains unknown, though I shall have more to say about some of the MS theories. Amongst the candidates have been autoimmunity, slow viruses, myelinic enzymes and polio vaccination.

Most people begin to experience symptoms between 20 and 40 years old, and rarely after 50. The onset is usually insidious, though every now and then someone starts with sudden onset of a catastrophic neurological or visual problem. Symptoms are usually vague and the diagnosis is often missed in the early stages. Females are affected slightly more than males. MS seems to be a disease of temperate latitudes in both the Northern or Southern hemispheres and is rarely seen in equatorial regions. This association with latitude has fueled some of the viral theories as well as ideas to do with the impact of decreasing sunlight on vitamin D and cell membrane function.

One of the things that makes the disease such a great masquerader is that it is typically marked by apparently random exacerbations and remissions. As the disease progresses, the remissions become less complete and permanent deficit more apparent.

There is an enormous research literature on MS: over 35,000 papers at last count. But there have been some recent highlights.

There has recently been a major breakthrough in discovering the mechanism by which myelin forms. The finding from the Keck School of Medicine of the University of Southern California and the Institut de Recherches Cliniques de Montreal in Canada, could have a major impact on the treatment of multiple sclerosis and demyelination as a result of spinal cord injuries.

Jonah Chan and his colleagues showed that a protein, Par-3, is at the base of the myelination process. This protein becomes localized to one side of the myelin-forming cells that are known as Schwann cells, upon contact with the axon that is to be myelinated. Par-3 acts like a kind of molecular scaffold to set-up an "organizing centre" that brings together the key proteins essential for myelination, in particular a receptor for a molecule that is secreted by the neurons.

The researchers found that when they disrupted this organizing centre, cells could not form myelin normally. Importantly, their discovery demonstrates that Schwann cells need to become polarized so that they know which side is in contact with the axon to initiate wrapping and to bring essential molecules to this critical interface.

These studies open up some new possibilities that should help to identify other components that are recruited at the organizing center set-up by Par-3. In multiple sclerosis, or after injury, Schwann cells can re-myelinate axons of the central nervous system to some degree. Therefore, these experiments bring about the possibility that manipulating the Par-3 pathway might allow for more efficient re-myelination of damaged or diseased nerves.

In a separate study researchers from the Virginia Commonwealth University researchers have identified a unique mechanism of action of a new drug that shows great promise for the treatment of MS.

The researchers reported the unique action of FTY720, or Fingolimod, an immunosuppressant drug that was already known to affect the functioning of the immune system by preventing the egress of white blood cells from the lymph nodes into the blood. The article was published in Blood: The Journal of the American Society of Hematology, that appeared online on Sept. 28.

In this study, the research team found that FTY720 also inhibited the activity of a key enzyme called cPLA2, which is necessary for the production of inflammatory mediators, known as eicosanoids. Eicosanoids drive inflammatory disorders such as asthma and multiple sclerosis.

The inhibition of cPLA2 would shut down the entire inflammatory pathway, possibly without the side-effects caused by medications such as Vioxx, that have been withdrawn from the pharmaceutical market.

FTY720, is a drug developed by Novartis, has shown considerable therapeutic effects in a recent small, placebo-controlled clinical trial involving patients with relapsing multiple sclerosis. The study was published in the September 2006 issue of the New England Journal of Medicine by an international research team.

I could easily select a dozen more important papers published in the last year, but I am particularly interested in basic research that teaches us something new, and treatments that could fit into a comprehensive Integrated plan of treatment.

I am going to post more about the causes of this illness as well as less orthodox approaches to help the physical, psychological, social, subtle and spiritual aaspects of these illnesses.

Arsenic and Water Safety

Here is a new study that may turn out to be one of the most important of the year.

Tens of millions on people around the world, most particularly in Bangladesh, are forced to drink water containing dangerously high amounts of arsenic. The very same stuff that has been used by countless poisoners.

The classic symptoms of arsenic poisoning are:

• Headache
• Abdominal pains
• Vomiting
• Difficulty breathing
• Light headedness
• Delirium
• Neuropathy
• Stroke
• Skin lesions: usually thickening of the skin of the palms and soles with wart-like excresences
• Reduced production of red and white blood cells
• Increased risk of cancers of the lung, skin, bladder, liver, kidney and prostate
• Death

The exact pattern of symptoms depends on the acuity of the exposure, the amount of arsenic to which a person is exposed and the individual's own makeup.

The new research - published this week in the journal Science - is from Rice University's Centre for Biological and Environmental Nanotechnology in Texas, and it may give us a quick and cheap way of getting most of the arsenic out of drinking water. The investigators used minute particles of iron oxide - very similar to common rust - to bind large amounts of arsenic. The iron oxide particles are really tiny: just 12 nanometres (billionths of a metre) across, about 5,000 times smaller than the width of a human hair. When mixed into contaminated water, the tiny crystals became coated with the poison and began behaving like iron filings. The iron oxide/arsenic combination can then be removed from water using a simple hand-held magnet.

One of the investigators, Professor Doug Natelson had this to say, "The idea of using magnetic particles to filter and clean water is not particularly new. The trick here is that these particles are very, very small, which means they're essentially all surface. So the arsenic sticks to the surface of the particles, and what we've found is that when the nanoparticles are in the right range of sizes, you can pull them out of solution with a relatively small magnetic field gradient that you could get from, say, a permanent magnet."

As an additional refinement, the scientists needed to develop a technology that would be usable in one of the poorest parts of the world. In one experiment flakes of rust were made into nanoparticles by heating them in coconut or olive oil at 350C. They could then be used in water purification.

This is excellent news, and if confirmed, it could save hundreds of thousands if not millions of livees, and unspeakably awful chronic ill health.

Recognizing Restless Legs

I've recently written a couple of articles about restless legs syndrome (RLS), following which I got this question:

"Dear Dr. Petty, I've thought that I've got RLS, and so did my doctor, but I've just heard about something called akathisia, and another doctor has told me that I might have that instead. Is there any way to tell them apart? The doctor seemed to think that they were the same thing. Have you heard of akathisia, and are there any tips for working out what I've really got?"

Yes, I do indeed know what akathisia is, and this is a good question. I've seen  many experts who have mixed up the two conditions. Both may be present in the same person, and there may be some small degree of overlap, but an experienced neurologist should be able to tell them apart without too much trouble.

Akathisia is most commonly seen in people taking certain types of medication that act on the brain. However something indistinguishable from akathisia was described three hundred years before we had any of these medicines. So medications are most certainly not the only cause.

I'd like to direct you to a new article by our friends over at Psychiatric Resource Forum, where you will find an article that goes through the clinical features and causes of akathisia and the nine classical features that distinguish akathisia from RLS.

Let me know if that does not give you the answer that you need, and I'll happily write a more detailed account of how to distinguish the two.

Good luck, and let me know if I can help you further.

Peripheral Neuropathy and Integrated Medicine

We have already discussed some of the causes and conventional treatments for peripheral neuropathy.

Unfortunately many people are not much helped, and it is good to know what else may assist them. And also what may not: sadly people suffering from chronic illnesses often become the victims of people selling treatments that may have scant chance of success.

There is not much research to support most of these approaches, which we use in tandem with conventional medicine. However, I’ve used all of these approaches and found that each has helped some people. The problem, as with most of conventional medicine, is in knowing who will respond to what. Often the key is to use several approaches in combination. That is where you need a specialist in Integrated Medicine who can put together the right “package” of treatment for the individual. What we don’t want to do is use a kind of “blunderbuss approach,” where we hit people with everything at once.

1. Diet and exercise may help, particularly in diabetic neuropathy, where improved metabolic control will reduce – but not abolish - the risk of neuropathy, and may improve pre-existing neuropathic pain.
2. Some naturopaths in Europe recommend using parsley, celery and carrot juices. Not something that I’ve seen work, but some people tell me that they’ve found them helpful.
3. There has been a lot of research on the use of alpha lipoic acid and vitamins B and E, particularly in diabetic neuropathy: some positive and some negative. Each has sometimes helped in clinical practice, though you have to be a little careful with vitamin E: it can impair the clotting system, and cause diarrhea and transient elevations in blood pressure.
4. Acupuncture – traditional Chinese, “Western Medical,” and electro-acupuncture - have been used a lot in peripheral neuropathy. There have been some positive studies in painful diabetic,  HIV-associated and chemotherapy-induced neuropathy. None of the studies has been perfect, but they tend to support the clinical impression that man people are helped – some greatly - but few are cured with acupuncture. There have also been negative studies. There are also some positive studies from China, but only a few have been translated in their entirety. There are often two big problems with research done in China: many Chinese investigators feel that it’s unethical to include a control group, and their studies tend to use endpoints like “cured” or “partially cured,” rather than objective rating scales. I have used it in peripheral neuropathy, but it’s extremely important to use scrupulous technique, since people with neuropathy are at increased risk of getting skin breakdown and ulcers, especially if they also have any vascular compromise. Many of us have also found that it can be helpful in compression neuropathies, like carpal tunnel syndrome. There’s recently been some fascinating research using brain imaging in acupuncture treated carpal tunnel syndrome.
5. Herbal remedies are used by about a fifth of people with neuropathy, but I’ve never had much luck with them. Some herbalists tell me that they have good results with an array of different herbs, though there is little objective evidence that they work.
6. There have been clinical reports and at least one research study on the use of magnet therapy in neuropathy. Earlier this year there was an article in the British Medical Journal that was critical about magnet therapy in general. The article provoked one of the most vigorous debates that I've seen in  along time. I’ve not seen it help, but there are some people who swear by it. And other who swear at it!
7. There have been many attempts to use electrical fields to help neuropathy, from the conventional transcutaneous electrical nerve stimulation (TENS) boxes, to yet more variations on electro-acupuncture. Some people are helped, and these are good extra tools.
8. Many homeopathic remedies have been used in neuropathy. Homeopathy is a highly individualized form of therapy: no two patients will get the same remedies. But some of the most commonly used remedies are Agaricus, Alumina, Arsenicum album, Natrum muriaticum, Phosphorus and Plumbum. If you live somewhere that there are good homeopaths, homeopathy is an option to consider, despite the dearth of good research into its use in neuropathy.
9. It is important not to neglect the psychological aspects of neuropathy: people can become profoundly depressed by the intractable pain, and sometimes psychotherapy and antidepressants can be a helpful.


10. Finally, ask yourself what the neuropathy is trying to teach you. There is no problem that comes out of a clear blue sky, and it is always valuable to look beyond the physical problem itself to its meaning and purpose. 



If you are not having success from conventional medicine alone, or if you don’t care for conventional medicine, then discuss these options with a professional, use your intuition to guide you, and let us know if you have success.

Peripheral Neuropathy

Treating peripheral neuropathy can be one of the toughest problems facing a clinician. Peripheral neuropathy simply means disease affecting the peripheral nerves.

There are a great many cause of peripheral neuropathy. This is just a partial list to give you an idea of the things that a clinician has to think about before starting treatment:

1. Metabolic illnesses: Diabetes mellitus; porphyria; chronic renal failure; amyloidosis and disturbances in circulating proteins
2. Vitamin deficiencies: Vitamins, B1, B3, B6 and B12
3. Drugs and chemicals: Alcohol; Heavy metals like arsenic, lead and mercury; organic pesticides; several drugs used in cancer chemotherapy; isoniazid; nitrofurantoin
4. Infections: Lyme disease; Herpes zoster (shingles); Diphtheria; Brucellosis; Leprosy; Tetanus; Botulism
5. Malignant illnesses
6. Inflammatory and autoimmune illnesses: Rheumatoid arthritis; Systemic lupus erythematosus; Polyarteritis nodosa; Sarcoidosis; Guillain-Barre syndrome; Celiac disease
   
7. Physical injury: Trauma, stretching and compression of nerves, which can include things like carpal tunnel syndrome.
8. Congenital illnesses

Many causes of peripheral neuropathy, particularly diabetes, may also damage the autonomic nervous system that controls the heart, blood pressure, swallowing, intestinal and bladder function.

Neuropathic symptoms typically start in the feet, because the nerves running down there are longer and more vulnerable than the ones going to the hands.
The most common symptoms are:

1. Numbness
2. Tingling
3. Abnormal sensations called dysesthesias
4. A characteristic form of pain, called neuropathic pain or neuralgia: people usually describe it as “pins and needles,” a steady burning sensation or “electric shocks.” These pains can be difficult to describe: typically pains, like stubbing your toe or stepping on something sharp, are transmitted through pain fibers. Neuropathy also involves other neurological pathways, so that the brain receives impressions that it cannot process.

There has been a revolution in out understanding of neuropathic pain in recent years. It is now considered to be a disease rather than a symptom. Normal pain is designed to protect you: you put your foot on a hot plate and you pull it away immediately. Neuropathic pain is different: it is non-protective and it persists and therefore behaves like a disease.

Multiple different classes of medications have been shown to be effective in some people with neuropathic pain, though most are not approved for use by the Food and Drug Administration:

1. Lidocaine patches and creams
2. Capsaicin creams
3. Opioid analgesics
4. Tricyclic antidepressants
5. Serotonin-norepinephrine reuptake inhibitors (SNRIs)
6. Anticonvulsants: Carbamazepine; gabapentin; pregabalin

Earlier this week, data presented at the European Federation of IASP (International Association for the Study of Pain) Chapters (EFIC) indicated that an innovative combination of painkillers might hold the key to unlocking the severe and relatively untreatable pain of peripheral neuropathy.

Dr Magdi Hanna, Director of Pain Clinical Research Hub at King's College Hospital in London, has been studying the combination of the strong opioid oxycodone (OxyContin) with gabapentin (neurontin) in over 300 patients with severe diabetic neuropathy. This combination demonstrated a significant 33% improvement on top of the best pain relief achievable using the maximum tolerated dose of gabapentin as monotherapy. The study was part funded by one of the medicine manufacturers.

This study is good news, but even in this study there were a great many people who were not helped. In another blog item, I’m going to talk about some of the unorthodox approaches that have helped some people.

Restless Legs Syndrome

Restless legs syndrome (RLS) is a common (3-15% of the population) and sometimes very unpleasant problem in which people have uncontrollable urges to move their legs. If they do not move, they will begin to feel uncomfortable, painful or odd sensations in their legs, and sometimes also in other parts of the body. The restlessness may last for minutes or even hours. Movement affords people very temporary relief. The sensations are usually between the ankle and the knees, but they can also involve the thighs. If other parts of the body are involved it always makes us question the diagnosis.

The severity of the problem is highly variable, running from a mild annoyance to an incapacitating problem. In most people the symptoms are worse when sitting or at night, and often lead to loss of sleep. Not surprisingly many people feel of exhausted and irritable during the day.

With such enormous variations in the severity of the problem, and even the parts of the legs affected, it is highly likely that RLS is a symptom of a group of illnesses.

The International Restless Legs Syndrome Study Group (IRLSSG) identified four criteria that must be present for an RLS diagnosis:

1. An urge to move, usually due to uncomfortable sensations that occur primarily in the legs.
2. Motor restlessness, expressed as activity, that relieves the urge to move.
3. Worsening of symptoms by relaxation.
4. Variability over the course of the day-night cycle, with symptoms worse in the evening and early in the night.

About 80% of the people with restless legs syndrome also suffer from a separate condition called periodic limb movements in sleep (PLMS). Periodic limb movements in sleep are involuntary jerking movements in extremities, usually the legs. You can have PLMS without having RLS, and vice versa.

RLS may start at any age, including early childhood, and is a progressive disease for a certain percentage of sufferers, although it has been known for the symptoms to disappear permanently in some sufferers. The condition runs in families; children of RLS sufferers are more likely than other people to develop RLS.

It has some similarities to a syndrome known as akathisia that occurs in people taking some medications that work in the dopamine pathways of the brain. There are some subtle ways of telling the two apart, but RLS also seems to be caused by disturbances in one of the dopamine pathways of the brain.

It has been known for many years that there is an association between RLS and iron deficiency, but this link is probably not causal: just giving iron only helps a proportion of sufferers. But because of this link, everyone with RLS should have their ferritin levels tested; ferritin levels should be at least 75 mcg for those with RLS. If it’s below this level, iron supplements may help, but they are best administered by a physician, because ferritin needs to be monitored and there are down sides to taking too much iron. In a moment I'll tell you about some very new research on iron and RLS

Caffeine and other stimulants usually make RLS worse. Restless legs syndrome frequently occurs during pregnancy. About 15% of pregnant women develop RLS symptoms during the last few months of their pregnancy. The sensations usually stop after the woman delivers the baby.

We normally divide RLS into primary and secondary. Primary RLS usually starts before age 40 and the onset is often slow. The RLS may disappear for months, or even years. But it can be progressive and get worse as the person ages.

Secondary RLS often had a sudden onset and may be daily from the very beginning. Apart from pregnancy, secondary RLS is a result of a number of medical conditions, so it is always important to rule them out. They include:

1. Iron deficiency anemia
2. Macrocytic anemia due to folate or vitamin B12 deficiency
3. Diabetes mellitus
4. Peripheral neuropathy
5. Alcohol abuse
6. Some types of cancer, particularly of the lung
7. Celiac disease
8. Renal failure
9. Inflammatory arthritis

There have been reports of associations of RLS with other illnesses, but most seem rare. Interestingly people who undergo surgery often find that RLS symptoms become worse, which may be another clue as to the cause of the problem.

An international conference entitled SLEEP 2006, the 20th Anniversary Meeting of the Associated Professional Sleep Societies took place from June 17-22, 2006 in Salt Lake City, Utah. There were a great many interesting papers this year, including several on RLS

An international group of collaborators presented the results of the first population-based pediatric RLS survey. They used the National Institutes of Health pediatric RLS diagnostic criteria and collected data from over 10,000 families. The criteria for definite RLS were met in 1.9% of 8- to 11-year-olds and in 2% of 12- to 17-year-olds. Two different papers explored the value of using a single screening question to identify possible RLS patients. Those who answered, “Yes,” then answered more detailed questions to determine whether they met the International RLS Study Group diagnostic criteria.

A single screening question can eliminate people without RLS rapidly and direct appropriate subjects to further evaluation. Two groups of researchers found a high level of sensitivity with the question, "When you try to relax in the evening or sleep at night, do you ever have unpleasant, restless feelings that can be relieved by walking or movement?"

As I mentioned, it has been known for decades that RLS may be associated with low iron, and especially with low ferritin levels. These may be present in symptomatic RLS patients during pregnancy and in people with iron-deficiency anemia and end-stage renal disease. Previous studies had suggested that supplemental iron was beneficial for RLS patients with low ferritin levels. One paper presented further evidence of the possible efficacy of supplemental iron in the treatment of selected RLS patients with a prospective, randomized, placebo-controlled, double-blind study of RLS patients with low to normal ferritin levels (15-75 mcg/L). The RLS subjects were given either placebo or iron 325 mg twice daily and were monitored with a validated RLS symptom scale. The preliminary findings showed that the iron supplementation group had significant increases in their ferritin levels and had improved quality of life compared with those on placebo; however, the interim data presented did not show a significant change in the RLS symptom score. The study is ongoing.

Treatment for RLS is based on how disruptive the symptoms are. Apart from iron, people should review their lifestyle and see what changes could be made to reduce or eliminate their RLS symptoms. These include: Finding the right level of exercise (too much worsens it, too little may trigger it)
Eliminating caffeine
Stopping smoking
Reducing alcohol intake

Several drugs have been tried for RLS: Some of the same medications used in Parkinson's disease, benzodiazepines, anticonvulsants like carbamazepine and gabapentin.

Last month saw the publication of an important paper indicating that the medicine pramipexole, another anti-Parkinsonan drug, helps many people with RLS

In the next article I shall review some of the other approaches used by Integrated Medicine.

A New Way of Looking at – and Treating - Inflammation

Diseases of both large and small blood vessels are two of the biggest problem facing people with diabetes. Not only is it a huge clinical challenge, but also nature sometimes does our experiments for us. The high rates of coronary and peripheral vascular disease in diabetes can be seen as a kind of experiment of nature: a recognizable set of chemical abnormalities that might shed light on vascular diseases in general. It was those twin factors: a huge clinical problem, and an experiment of nature, that lead me to pick the topic of my research doctorate. 

When I was working on my research doctorate in the mid 1980s, I came across a lot of old research that seemed to show links between inflammatory and autoimmune conditions like systemic lupus erythematosus and rheumatic fever, and the eventual development of coronary artery disease. There was also a lot of old and largely forgotten research about the link between some viral infections and the development of coronary artery disease and acute coronary artery occlusions, because some infections can make blood more “sticky.” Inflammation evolved as one of the body’s defence mechanisms.

So I made the proposal – revolutionary at the time – that diabetes, coronary artery disease and a range of other illnesses might be inflammatory rather than degenerative. I soon found inflammatory markers in people with diabetes, that helped predict when someone was running into trouble with their eyes, kidneys or heart.  Even with stacks of data, I had to spend a lot of time defending that position, because it also implied that some illnesses thought to be irreversible might not be.

With the passage of time, it has tuned out that I was probably correct. Chronic inflammation, wherever it starts, mat have long-term effects on the body and on the mind. Chronic inflammation increases the risk of diseases of many blood vessels, as well as causing anemia, organic depression and cognitive impairment. Here is a partial list of common conditions in which inflammation is a prominent factor:
1.  Rheumatoid arthritis
2.  Systemic lupus erythematosus
3.  Fibromyalgia
4.  Chronic infections
5.  Insulin resistance or metabolic syndrome
6.  Arteriosclerosis
7.  Diabetes mellitus
8.  Hypertension
9.  Asthma
10. Inflammatory bowel disease
11. Psoriasis
12. Migraine
13. Peripheral neuropathy
14. Alzheimer’s disease
15. Autism
16. Gingivitis
17. Cystitis

The reason for raising the issue is not to say “told you so!”

It is instead that we need to think about inflammation a little differently. There is a mountain of information about the physical aspects of inflammation. We can stop at the simple description of inflammation as a condition in which part of the body becomes reddened, swollen, hot, and usually painful, or we can look below the surface: we can examine inflammation not only as a physical problem, but also as a psychological, social, subtle and spiritual problem. Why bother? Because the deeper approach allows us to understand and to treat and transcend inflammation as never before.

I am going to write some more about specific ways to address inflammation and what it means in future articles. I would also like to direct you to the book Healing, Meaning and Purpose, in which I talk about specific approaches in more detail.

But I would like to start with this.

In Ayurvedic and homeopathic medicine, inflammation is a sign of an imbalance in the vital forces of the body, and the traditional Chinese system agrees: here inflammation is usually a manifestation of an excess of Yang Qi, or a deficiency of Yin Qi. Most of our lives are seriously out of balance: Yang Qi is like a rampaging lion that has been stimulated by:
Acidic foods;
Environmental toxins;
Unwanted sexual stimulation:
Noise;
Discordant music:
Constant demands from others:
Toxic relationships;
Years spent in front of television sets and limitless multi-tasking.

It should be no surprise to learn that all of these inflammatory conditions are increasing rapidly throughout the Western world. Not because we are getting better at identifying them, or we are living longer, but genuinely increasing.

It is wrong to put all the blame on poor diets or inadequate exercise. The problem is more subtle and is a reflection of distorted Information being fed to our bodies, minds, relationships, subtle systems and spiritual relationships.

The great news is that this simple conceptual shift gives us a whole load of new tools for handling these problems, and for using them as catalysts to growth.

In the next few weeks, I am going to drill down and give you some specific guidance that ties into the material in Healing, Meaning and Purpose and the next two that are on the launch pad.

Fasten your seat belt!

Technorati tags: Inflammation Aging Alzheimer's disease Arteriosclerosis Neuropathy Autism Arthritis Systemic lupus erythrmatosus Fibromyalgia Inflammatory bowel disease Gingivitis