Sam Greenberg (Host): Welcome to the Living Well with Eisenhower Health podcast, healthcare as it should be. I'm Sam Greenberg. And joining me is neurologist Dr. Wael Richeh from Eisenhower Health as we talk about new treatments for neuropathy and how advanced testing and therapies are changing what's possible for patients. Dr. Richeh, thank you so much for your time.

Dr. Wael Richeh: Thank you so much for having me over.

Host: Of course. So, Dr. Richeh, you lead the Eisenhower Neurology and Neuromuscular Specialty Clinic. Can you tell me a little bit more about what you do exactly and how the clinic may be different than other neurology clinics?

Dr. Wael Richeh: Of course. The neuromuscular clinic is a specialized medical practice dedicated exclusively to diagnosing and managing the disorder of the peripheral nervous system and muscle, and that includes the nerve that travels from the spine to the limbs, the muscle themselves, and the neuromuscular junction where the two connect.

Host: Sure. And what makes your clinic a little bit different than other neurology clinics specifically?

Dr. Wael Richeh: This clinic focus on treating specific conditions, including but not limited to peripheral neuropathy, motor neuron disease, conditions like ALS or what we call amyotrophic lateral sclerosis, muscle disorders or myopathies, which is a conditions that cause primary muscle weakness, neuromuscular junction disorder, which is an autoimmune neurological disorder that cause weakness, swallowing problem, and fatigue, as well as treating the nerve damage coming from a pinched nerve on the cervical or lumbar spine. So, we are more specialized in the peripheral nervous system compared to other neurology clinic where they treat more Parkinson disease or dementia or seizures.

Host: Sure. And so, with those more specialized focuses, there's more specific testing. And can you explain a little bit what are electromyography and the nerve conduction velocity test?

Dr. Wael Richeh: Absolutely. In neuromuscular clinic, we have these two tests performed on a daily basis. The nerve conduction study measures how well and how fast the nerve can send and transmit an electrical signal. The way it works, in simple words, small electrodes are taped to the skin over specific nerve. Then, we deliver a tiny, mild electrical pulse to the nerve, and then we record how the nerve responds. What it reveals, it tells the doctor if the nerve is damaged, if the protective coating, what we call myelin, is down, or if the nerve is compressed, like in the case of certain conditions, like carpal tunnel syndrome. So, it usually assesses the wiring that connects the spinal cord to the muscle.

Speaking of the other major test we do, which is called electromyography, or the abbreviation stand for is EMG. The way it works, this one measures the electrical activity of the muscle at rest and when they are contracting. The way it works, a very thin, sterile needle electrode is inserted directly into the muscle while we ask the patient to relax the muscle, then contract it. And the needle acts like a microphone listening to the electrical signal that a muscle produces. What it reveals, it helps determine if the muscle is responding correctly to the nerve signal, and it also can show if the muscle itself is diseased, if there is any damage to the muscle itself.

Host: Doctor, who are the patients that most commonly need these types of diagnostic tests?

Dr. Wael Richeh: The patient who needs those kind of diagnostic tests are the patient who have persistent numbness, tingling, or pins and needle in their arms or their legs. The patient who experiences muscle cramps or spasm or twitching; the patient who has difficulty performing fine motor task, like buttoning a shirt, writing, gripping objects; and the patients who notice sharp pain or pins and needle pain in their arms and their legs.

Host: Absolutely. And zooming back out a bit, how do you define neuropathy itself?

Dr. Wael Richeh: A neuropathy is a general medical terminology that refers to damage or dysfunction of the nerves outside of the brain and the spinal cord. It's an umbrella term, I would like to call it, meaning it's describing a wide range of condition rather a single disease. Because the nerve acts like a wiring of the body, when they are damage, they cannot properly transmit the signal from the brain and the spine to the rest of the body and vice versa.

Host: A little bit like we talked about with the EMG and nerve conduction tests for neuropathy. Who gets neuropathy? Is it limited to certain types of patients or certain age groups, or could it be just about anybody?

Dr. Wael Richeh: Neuropathy can affect anyone, but it is much more common in certain groups of people, because the peripheral nerves are sensitive to metabolic, environmental, and physical stress. So, the risk increases when those symptoms are compromised. So for example, number one reason of neuropathy in the United States and North America is diabetes.

People with diabetes who have high blood sugar, over time, that causes damage to the nerve throughout the body. And it's estimated that 50% of people with diabetes will eventually develop some form of neuropathy. Other adults with neuropathy, we found them with people who have autoimmune condition, like patients with rheumatoid arthritis, lupus, Sjogren's syndrome, Guillain-Barre syndrome. This hyperactive immune system causes damage to the nerve and cause neuropathy.

Other reason of neuropathy is what we call it nutritional deficiency, which is usually lack of essential vitamins, including but not limited to vitamin B1, B12, B6, and folic acid. Also, a main reason I want to mention for neuropathy is previous and current exposure to chemotherapy. Many chemotherapy drugs are neurotoxic, which mean patients who are receiving chemotherapy for cancer treatment may experience neuropathy.

One other reason I want to mention to add is chronic alcohol use. Chronic and significant alcohol use cause direct damage to the wellbeing of the nerve and cause neuropathy.

Host: So, can neuropathy be cured or is the main goal really to control symptoms and prevent progression?

Dr. Wael Richeh: Peripheral neuropathy is sometimes curable and sometimes it's not. It really depends on the cause. Neuropathy from vitamin deficiency, for example, may be corrected very easily with the replacement therapy. Neuropathy from mechanical compression of the nerve can be corrected surgically. Neuropathy from autoimmune inflammatory disorder that we mentioned, the lupus, rheumatoid arthritis, whenever those underlying reasons are being treated properly, that helps the nerve to heal.

On the other hand, we have certain types of neuropathy that are really non-curable. Of course, earlier treatment gives a better chance of improvement. In some cases, we see partially reversible neuropathy.

Host: Focusing in on those treatments, how is neuropathy treated? And Dr. Richeh, with everything changing so frequently in the medical space and the neurological space, are there some newer treatments with results that you're encouraged by or new treatments that you're excited by?

Dr. Wael Richeh: Absolutely. I always say thank goodness for medicine being a progressive science because we always have a newer treatment, a newer approach to help our patient deal with their symptoms and reduce the symptoms. So, I am very interested and excited about a new treatment that we've been using in Eisenhower Neuromuscular Clinic for precisely two types of neuropathy.

One of them is the diabetic peripheral neuropathy induced by diabetes, and the second type is what we call post-herpetic neuralgia pain, and that's a type of neuropathy as a result of shingles infection, as after shingles, a patient may have severe pain due to nerve damage. And in those two conditions specifically, we do have a newer treatment called Qutenza, and it's based on capsaicin 8% patches that we apply on the affected area in the clinic, and we repeat this treatment every twelve weeks. And this treatment is really showing significant improvement of the pain.

Host: Are those patches approved by the FDA and covered by insurance, or are there often large out-of-pocket expenses?

Dr. Wael Richeh: Absolutely. They are approved by the insurance, by all insurances, federal and commercial, for the right diagnosis, which is the diabetic neuropathy and the post-herpetic neuralgia. And I can tell you based on the retrospective study that, for diabetic neuropathy in a clinical study, the patient reported an average decrease in the pain over a 12 weeks period by more than 30%, three-zero.

And in post-herpetic neuralgia, there was reduction in the pain by more than 33%. And overall, whenever we monitor them more, there was at least pain improvement in 66% of the patients.

Host: Wow. I can see why you're excited by those results and why you are focusing on these patch-based therapies. Those are some staggering numbers.

Dr. Wael Richeh: It is really impressive, and especially those two types of neuropathy are usually resistant to oral treatment, like, the golden standard of gabapentin and pregabalin and amitriptyline. But thankfully, we start seeing good improvement. Now, we really typically need to repeat this treatment every 12 weeks because the relief is temporary. So, we usually try to repeat this treatment every twelve weeks, and we do it here at our neuromuscular clinic, and the therapy session usually lasts 30 minutes.

Host: So, people are coming in with more hope by the day with these newer treatments, and everyone coming into your clinic knows that you're on the forefront and keeping an eye on those things down the road, which is very encouraging.

Dr. Wael Richeh: Absolutely. And I really need to emphasize that this is a good option, because it's a non-oral neuropathic pain treatment. It's not a daily pill. And also, most side effects are really topical and transient, so they do not carry any cognitive side effect. They do not carry any long-term side effect. So, we are seeing good benefit with very minimal side effect profile.

Host: Well, Dr. Richeh, this has been fantastic. I know I learned a lot, and I can take that information. I'm sure everyone who is maybe struggling or wondering whether to come into the clinic can be much more educated. Thank you again for your time and your expertise.

Dr. Wael Richeh: Thank you so much for having me over. And it's always an honor and privilege to be with you guys. Thank you.

Host: Of course. For more information, go to eisenhowerhealth.org. If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest. I'm Sam Greenberg. This is Living Well with Eisenhower Health.