Transcription:
Pins & Needles & Numbness, But Why?

Scott Webb: Peripheral neuropathy can either be painful or painless. And joining me today to explain the signs and symptoms, causes and treatment options are Dr. Gurtej Singh, he's an interventional spine and pain medicine specialist and Dr. Mark Lipton, he's a podiatrist and foot and ankle surgeon, and both are with the Centers for Advanced Orthopaedics, Orthopaedic Associates of Central Maryland in practice for over 50 years.

Hi, I'm Scott Webb and I've got a bone to fix with you. So, first off, I want to thank you both for joining me today. I don't know a lot about neuropathy, but the good thing is both of you do. That's why we have on experts like yourselves. So Dr. Singh, as we get rolling here, what is peripheral neuropathy? And are there different types?

Dr. Gurtej Singh: Peripheral neuropathy is a situation where the nerves in our feet tend to stop working and functioning like they would normally do so. And so what happens is we begin to lose sensation in our toes, and then that tends to creep up into the foot and the ankle and even up into the calf. So when a patient would wiggle their toes, they wouldn't feel necessarily the skin rubbing on each other, like they had used to in the past. It's also something where it happens equally, typically, on both sides. And so it's not a situation where only one foot and leg would suffer, but where both legs do.

Scott Webb: And Dr. Lipton, what are your thoughts on this?

Dr. Gurtej Singh: There are other different causes of peripheral neuropathy, but diabetes is probably the number one cause that we see. There can be other things where people would complain of similar symptoms, such as alcoholic-related neuropathy, HIV disease, Lyme disease, cancer chemotherapy, toxic metal exposures, thyroid disease. But the number one thing that we see is the diabetic peripheral neuropathy.

I believe that most diabetics, the reason that their nerves become damaged is the elevated levels of glucose or sugar in their bloodstream. And it causes a metabolic change to the nerve and the covering of the nerve called the myelin sheath. And this is what sort of short circuits the nerves and makes them function abnormally. A lot of times patients will cut themselves or they will step on a tack and not feel that pain or all of a sudden they'll see some blood on their sock. And this is one of the initial ways that patients start to figure out that they're not feeling their toes correctly.

For me as a podiatrist, that's the most fearful situation because we sort of call that insensate or painless neuropathy and the particular sensory loss is so profound in some patients that they can walk around for days with a tack or something in their foot or even an infection starting and not realize that they have this problem and end up, you know, coming into the office with a severe infection requiring hospitalization and even surgery and could lead to loss of their further leg. And we say, at least in podiatry, that pain is a gift. And without that gift, you know, we often have devastating consequences.

Scott Webb: That's really interesting. It's sort of counterintuitive that most of us think of pain as a bad thing. But in this case, absence of pain, you know, could lead to much worse outcomes. And I guess I'm wondering, Dr. Singh is it possible that some folks actually end up having their diabetes diagnosed because they come in for what appears to be neuropathy and then find out that, "Oh, by the way we know what's causing your neuropathy, it's actually diabetes." Is that a thing?

Dr. Gurtej Singh: It is absolutely a thing. And actually some studies over the last few years have shown that physicians in orthopedic, pain management and podiatry practices are actually diagnosing patients first ahead of, typically, you know, their family medicine or their internal medicine specialist. So patients come in and, even if they were coming in for a knee surgery or shoulder surgery, something totally unrelated, when we get lab workup before we take them to the operating room, we actually find that their sugar is elevated and their hemoglobin A1c is elevated. So, something that most even physicians don't realize, the diagnosis is actually not always made by the family medicine specialist.

Scott Webb: I don't think that anybody wants to be diagnosed with diabetes. But at least in this case, you know, the neuropathy might lead to the diagnosis of the diabetes and then we can treat everything. And hopefully, we've done that early enough, of course. Dr. Lipton, I'm wondering are the symptoms of neuropathy worse at night? And if so, is it because we're lying down, we're lying flat? It feels like they would be worse at night.

Dr. Marc Lipton: Yeah, that's a common complaint. And my belief is that the neuropathy is present throughout the day, but at nighttime, we go to bed, we turn off the lights, we don't have the same sensory inputs that we do during the day. Our brain is not processing, you know, what your coworker is telling you or your spouse. And we get to bed and our body thinks of one thing and it thinks of our pain. And it's not only true for neuropathy, but I think for other painful conditions as well. Commonly, arthritis, people with painful arthritis will have more pain at nighttime as well, but I just think it's the way our mind works and gets us to concentrate on only the bad things at nighttime.

Scott Webb: Funny how that works, right?

Dr. Marc Lipton: Yeah, absolutely.

Scott Webb: Yeah. Well, sticking with you, I'm wondering why or when would a patient see a podiatrist versus a pain specialist for neuropathy?

Dr. Marc Lipton: From my perspective, I usually receive a referral from the primary care practitioner for someone with diabetes, with painful feet and oftentimes the primary care doctor has not made the diagnosis of neuropathy. The patient is just complaining to the primary care doctor that they have foot pain. They say, "Well, you need to go see the podiatrist. You're diabetic anyway. It's part of the routine." Most diabetics need to be seen on a yearly basis for sort of a baseline diabetic foot evaluation. And we get them into the office and they might be complaining of their pain and their symptoms that they talk about are burning, numbness, tingling, and maybe random sharp shooting pains and, yeah, often worse at nighttime. They also talk about a funny feeling on the bottom of their foot, like they feel like there's something there when there isn't like a rolled up sock or piece of cardboard on the bottom of the foot. And those are the key words that get me thinking, "Well, maybe they have something going on with neuropathy." We're also concerned about the presence of vascular disease in diabetics and oftentimes painful neuropathy or even insensate neuropathy could be caused by impaired peripheral circulation, history of tobacco use, if they're having sores on their feet, that don't heal, those are things that we look for.

My first question always to a diabetic is how good is their diabetic control, because we find that if they've been out of control for a long time, that is a much poor prognosis for them. If they've just recently been diagnosed with diabetes and their blood sugars do eventually come down, sometimes the symptoms will improve. And we know though, if it's been going on for a long time, that the symptoms are permanent.

I will examine them, do a basic visual inspection of their feet to make sure there are no open sores or any abnormalities. We do a neurological test. And my basic screening test is something called the 5.07 monofilament exam, which enables me to determine whether or not the patient can feel things on the bottom of their foot. We check their strength, we check their circulation. We do a musculoskeletal exam. We often will do x-rays to rule out other underlying issues, such as fractures or arthritis or anything else that could be contributing to their pain. And I may send them for further testing, like Doppler studies or nerve conduction studies.

Scott Webb: It sounds really comprehensive and thorough. And Dr. Singh, it also sounds like the two of you probably work pretty closely together, because I'm assuming, you know, if somebody comes in with pain, you probably need to treat the pain, but also maybe treat the underlying causes, which might be more in Dr. Lipton's lane. So maybe you can talk to us a little bit about how the two of you work together to both diagnose and treat neuropathy.

Dr. Gurtej Singh: Working together with my colleagues definitely helps with patient care. I can tell you that our patients really appreciate the fact that both Dr. Lipton and I communicate with one another and have each other as a resource for the different types of neuropathy that we see. One of the things that I try to do when patients see me, they typically have more of the painful peripheral neuropathy. And so they actually come in with the pain as being their number one issue. And the number one thing I try to do for them is to make sure that we have an accurate diagnosis.

So like Dr. Lipton would look at the foot, do a complete and thorough foot exam, I'm looking more at their lumbar spine or even their neck and making sure that, from a neurological perspective, that the nerves are working well from the spine down to the foot and that when they come in, it's not actually some sort of atypical spinal problem. So spine x-rays, a spine exam, sometimes even a spine MRI.

In terms of how we work together, yeah, I will offer patients far more of the pain management services. So we look at things like physical therapy, certain types of medications. Those medications can be as simple as anti-inflammatories. They can be nerve pain medications. Classic examples would be things like gabapentin or pregabalin, Depending on how severe their pain is, we may have to take them to a higher and higher dose. There are some topical creams that have been shown to be helpful. And there's also even a topical patch that can be placed on as well.

Sometimes the difficulties that we run into are the fact that these medications have a lot of side effects. And so unfortunately, I ask all of our patients to be as patient as possible as we start them on low doses, try to increase them, to get them to a sweet spot where they're feeling comfortable, they are having less pain and being able to return back to doing all the activities that they want to do.

Dr. Marc Lipton: From my perspective as a podiatrist, I look at the patient's overall foot health and its relationship to diabetes. So we want to make sure that they're having meticulous foot care, they're wearing the appropriate shoes, they're checking their fees on the daily basis to make sure they don't develop any cuts or sores. And we're providing them with the appropriate tools to do that. Maybe something as simple as having them come in every few months just to have their nails trimmed and a brief examination, or it could be something as complicated as multiple referrals to different consultants, such as vascular specialists and pain management, even prosthetists and other personnel to help with treating them.

I will, when they come in with painless neuropathy, try my best to get them to understand the things they have to avoid to stay out of the trouble, as well as stress the importance of good glucose control. But we will occasionally with someone who's complaining of painful diabetic neuropathy, maybe start them off on some of those topical medicines that Dr. Singh mentioned like capsaicin or topical lidocaine, which are helpful for many people. Sometimes we'll add vitamin supplements, like vitamin B or alpha-lipoic acid, which can be helpful. But the ones who are very difficult to manage, as far as controlling their pain, I will then pass on to pain management, someone like Dr. Singh, who could take it from there and help them even more than the simple things that I started off with will help.

Scott Webb: As we get close to wrapping up here, Dr. Singh, what would be your takeaways about neuropathy? Is it, you know, one of those things where it could be other things? So of course, a thorough patient history and examination, and all of this is really key in sort of narrowing it down, right? That it is in fact neuropathy and what are the underlying causes, but I'll leave it to you in your words. What would you most want folks to know about neuropathy?

Dr. Gurtej Singh: The number one thing that patients should know about neuropathy is if they are feeling changes in their feet, whether it is they're not feeling their toes like they normally do, or they're feeling lots of pins and needle or burning fire sensation, an evaluation with an interventional specialist and an evaluation with a trained podiatrist are essential in helping to find the right diagnosis and then get them on the right treatment.

Unfortunately, the number of patients who are going to experience some form of peripheral neuropathy and Dr. Lipton laid out all the different types earlier, is going to go up in the country, right? Unfortunately, the amount of diabetes that's happening is going up. The number of cancer treatments that are helping to save lives unfortunately also cause some secondary problems. So this isn't a problem unfortunately that's going to go away. So for patients to know who's the right resource, to know that there are first-line treatments like a quality exam and some topicals, to know there are second-line treatments like medications and even newer third-line treatments where we stimulate the nerves to block the pain. We've got great things to offer patients. You just want to make sure that they get in and have that property evaluation.

Scott Webb: Yeah, as you say, you know, this is unfortunately very common. It's not going to go away magically, but there are lots of options. And you all and your approach is very comprehensive and thorough and interdisciplinary, if you will, collaboration between docs with different specialties and trying to identify what is this exactly and how are we going to treat it. And I'll give last word to you, Dr. Lipton. As the podiatrist in the room, if you will, what are your thoughts and takeaways about neuropathy and how you can help folks?

Dr. Marc Lipton: Part of my job is to make sure that people enjoy their feet for as long as their life lasts so they can keep on walking and carry out with their daily functions without difficulty. But we also want them to know that pain is not good, especially with diabetics. It drives their blood sugars up even higher. The stress of living with pain really drives their disease as well. And it's important to control that stress and that will help them control their disease.

So living with pain is not the ideal thing. I'd rather have people with good glucose control, no sensitivity problems. But we know we live in an imperfect world and that's not the case. We really want to help these people and save their limbs and make their lives as best possible. So either way, painless or painful neuropathy, we have to not ignore it. It has big implications on these people's lives.

Scott Webb: Yeah, it really does. And I love the way you put that. You know, enjoy our feet. And if we're having issues, pain, numbness, whatever it might be, we need to speak up and speak to our doctors, be referred to specialists, let them do their thing. Let doctors like yourself do your thing. You know, our quality of life doesn't have to suffer. And we hope folks learned as much as I did from this podcast today. So thank you both and you both stay well.

Dr. Gurtej Singh: Thank you so much.

Dr. Marc Lipton: Thank you.

Scott Webb: That's Dr. Gurtej Singh, an interventional spine and pain medicine specialist, and Dr. Mark Lipton, he's a podiatrist and foot and ankle surgeon, and both are with the Centers for Advanced Orthopaedics ,Orthopaedic Associates of Central Maryland in practice for over 50 years.

Host: Find out more about us online at mdbonedocs.com. And please remember to share and subscribe to this podcast. That's all for today. I'm Scott Webb and that was a bone that's fixed.