Transcription:
Treatments for Pain Caused by Peripheral Diabetic Neuropathy

Joey Wahler: Peripheral diabetic neuropathy is a type of nerve damage that affects many diabetic patients causing a variety of uncomfortable symptoms. So we're discussing this condition and its treatment options. Welcome to the Live Greater Podcast Series, information for a healthier you from the University of Maryland Medical System. Thanks for listening. I'm Joey Whaler. Our guest, Dr. Brian Block anesthesiologist and pain management expert at Maryland Pain Specialists and the university of Maryland St. Joseph medical center, a member of the Spine Network, Dr. Block, thanks for joining us.

Dr. Brian Block: Oh, thanks for having.

Joey Wahler: So first off, simply put what is peripheral diabetic neuropathy and what are the usual symptoms of it?

Dr. Brian Block: So diabetes mellitus is the cause of it. Diabetes is a very common metabolic disease with affecting many Americans and at the heart of diabetes is inadequate control of the amount of glucose or sugar in the blood. The high glucose stays in the blood and it causes problems. It causes vascular problems and heart problems, but particularly it causes nerve problems. The high blood sugar over years actually damages the nerves in the body along with other tissues. Those nerves send signals with sensation and pain and muscle function from the feet, all the way to the head, and the long nerves over years get damaged.

And so people end up with primarily a sensory problem. So they don't feel their feet. If it's severe, it can progress to the hands as well, but they don't feel their feet terribly well. And then a subset of the patients who have both a sensory problem will also have pain, first in the feet and later in the hands. About 20% of people with diabetes will develop some peripheral neuropathy symptoms over time.

Joey Wahler: And so just to backtrack for a moment, what's actually in layman's terms, going on in the body, that's causing that condition, once you have diabetes?

Dr. Brian Block: Blood sugar is just a little too high or in some cases, a lot too high. And the. The sugar or the glucose and the blood circulate, and it actually injures the nerves. We see it in the eyes. That's a supper topic where people develop cataracts, because the glucose actually bonds to the proteins in these tissues and the nerves in particular. And it bonds to the proteins and makes them not work so that you'll see actual depletion or dying off of the nerve endings and the extremities and the hands and the feet.

Joey Wahler: Is that also what contributes to causing pain?

Dr. Brian Block: Yes. So they'll have decreased sensation and pain. Interestingly and importantly, the pain is not dependent on activities. So patients will have burning feet all the time. It's maddening.

Joey Wahler: I would imagine. So, are you saying that this can be an issue even if your diabetes is otherwise under control?

Dr. Brian Block: It can be, although the core prevention of any of this is good glucose control. So having your diabetes under control makes it much less likely that you would have this problem developed.

Joey Wahler: Gotcha. So let's talk about treatment options. What are the usual ones and which ones work best?

Dr. Brian Block: Sure. Like I said, the number one is to control the diabetes with diet, exercise, and medications. But over time that's difficult and challenging. So when those lifestyle options are not enough. We can use medications. There really isn't anything terribly good over the counter. Most of the over the counter analgesics like ibuprofen and acetaminophen, not terribly useful. There are some prescription drugs like pregabalin and Gabapentin and also duloxetine that are used pretty routinely to treat this pain. None of them improve the sensation, but they're very helpful in reducing the pain.

Joey Wahler: And so beyond that, what would be a next step?

Dr. Brian Block: For patients who don't get enough pain relief with just medications and control their diabetes, the newest exciting treatment is the use of spinal cord stimulation for treatment of the foot pain. Spinal cord stimulation's kind of high tech, it's been around since the eighties for treating pain more commonly in, in the us, at least with folks who have pain after back surgery. But just last year, one of the devices that we used pretty routinely was really proven to be helpful for patients with diabetic foot pain.

Stimulator is a small wire that's put in the spine and I kind of liken it to the old world war II movies when we're gonna jam the signals of the radar. A little bit of electricity causes some of those painful signals that were coming from the feet up to the brain, not to get there. And so the stimulator takes the pain signal away and patient's pain goes away. It's done pretty easily outpatient procedure and patients get to try it out which is really nice before they get up any kind of permanent implant.

The data from the study was very impressive with 85% of patients having, dramatically reduced pain without medication side effects. It's not a big surgery, so it doesn't have any severe risk. What was really exciting from the study was that spinal cord stimulation not only relieved the pain of the diabetes but also improved sensation, which was completely unexpected. So patients who hadn't been able to feel their feet terribly well were demonstrably better in terms of sensation and in pain.

Joey Wahler: Before we go any further. When you talk about not being able to feel your feet, those of us, that haven't experienced, that I'm wondering, what do patients say that's it and how do they deal with it?

Dr. Brian Block: For patients with just a sensory deficit they complain about it. Some it's upsetting to not be able to feel your toes to see them, but it has real world consequences in that patients who have sensory loss when you cut your toe on the beach, you don't feel it. That's one of the main reasons why diabetic patients have a real emphasis on foot care because when you don't have good sensation in the feet, you don't know when you cut your foot, you don't know when it's infected.

You don't know when you've injured it and you don't seek treatment, because it doesn't hurt. Or you don't feel it. And then when you do seek treatment you need a whole lot more Treatment and a lot more invasiveness than you had good sensation to start with.

Joey Wahler: Is it surprising to diabetic patients when they learn from you that they may need a spinal cord treatment? Because I would think that's not something they would necessarily associate with their condition, unless they're looking ahead doing research, that type of thing.

Dr. Brian Block: Oh, that's a hundred percent on target. Patients with diabetes really. Haven't had this therapy available to them, so they don't know about it. They haven't had a back surgery. So, this treatment has really been more in the realm of people like myself, who do interventional pain care or the spine surgeons. So the diabetic patients, they just don't know about it. And it isn't really that we're treating the spine it's that we're treating the nerves.

So the damages to the nerves from the elevated blood sugars, the treatments are all related to the nerves, whether it's using a medicine like pregabalin, which is also called Lyrica, or whether we're treating the nerves in the spinal cord with a little bit of electricity. The whole point is to treat the nerve pain with nerve treatments.

Joey Wahler: And then regarding, again, those who can't feel their feet, we sometimes hear or see stories in the news about people that have to have a foot or a toe amputated because of diabetes, is that in some cases because of this type of a condition, that's gotten to a point where it's no longer treatable?

Dr. Brian Block: Absolutely. The nerves are damaged. People usually have amputations, not because of the nerve damage, but because of the infection or the injury that happened afterwards, because you couldn't feel your feet, you didn't know it was infected. And then when you do go and see the doctor or the hospital, the infection is spread much more, then it would've been otherwise if would've known it had been infected two weeks ago.

Joey Wahler: So because you can't feel this when we're talking about this particular foot sensation or lack thereof, how important is it doctor for diabetic patients to get checked out on a regular basis to make sure that something that's this potentially dangerous, isn't sneaking up on them?

Dr. Brian Block: Very important, but that's also a key part of good diabetic care. Primary care docs and podiatrists and endocrinologists along with working on glucose control, with diet and medication, you know, severe diabetic patients will have someone who looks at their feet daily. And it's just having somebody look at them because you can't feel it. So you need someone else to put eyes.

Joey Wahler: Any other new technologies available now, or maybe in the on deck circle, so to speak for treatment and how might those work?

Dr. Brian Block: It's nothing new, more in the on deck circle. I'd say we're definitely going to be looking further at how to use spinal cord stimulation to treat the foot pain, to best optimize where to put the wires and how to use the stimulation and to really characterize how much function patients might expect to have returned to their lives.

Joey Wahler: Couple of other things, you touched earlier on the importance of diabetic patients, I guess simply put, continuing to do what they know they need to do to provide relief from this neuropathy condition. But maybe beyond the obvious, is there something as someone like you, that deals with this a lot, something you can advise them that maybe they forget about, but that can contribute good or bad to that condition on their own?

Dr. Brian Block: On their own, it's maintenance of routine activity. I think patients, when you can't feel your feet or when you have pain it, it tends to get you down. Getting outside, being active. Those are things that are good for your mood. They help your blood glucose and your diabetes, but just being out, and out and about the world and maintaining as much physical activity as is tolerable is good for your mood and your health and your diabetes. Makes it less likely you'll need further care.

Joey Wahler: Is it true that those with peripheral diabetic neuropathy tend to have it worsen at night?

Dr. Brian Block: It can be patients. We'll complain more about at night and if the sheets will bother them. And I think it has a lot to do with just the less other stimulation going on, your brain can focus really on your feet that burn.

Joey Wahler: Gotcha. And so in closing here, doctor, what's your main message for those listening regarding peripheral diabetic neuropathy? Or is there anything else you'd like to add?

Dr. Brian Block: The standard message that they've heard for years, which is, the cornerstone of this is good diabetic care and good blood glucose control. But the second message is, if you've tried everything, there's new treatments that are highly effective that can really improve pain and function.

Joey Wahler: Understood. Well, valuable information, certainly. And folks we trust you're now more familiar with peripheral diabetic neuropathy, Dr. Brian Block, thanks so much again.

Dr. Brian Block: Thank you.

Joey Wahler: And you can find more shows just like this one at umms.org/podcast. umms.org/podcast . And thanks for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We look forward to you joining us again, hoping your health is good health. I'm Joey Wahler.