Neuropathy "The Painful Enigma"

For individuals dealing with chronic pain conditions can having a better understanding of pain management specialists help in developing effective multidisciplinary treatment plans?

Pain Management Specialists

Pain management is a growing medical specialty that takes a multi-disciplinary approach to treating all types of pain. It is a branch of medicine that applies scientifically proven techniques and methods to relieve, reduce, and manage pain symptoms and sensations. Pain management specialists evaluate, rehabilitate, and treat a spectrum of conditions, including neuropathic pain, sciatica, postoperative pain, chronic pain conditions, and more. Many primary healthcare providers refer their patients to pain management specialists if pain symptoms are ongoing or significant in their manifestation.

Specialists

Healthcare providers specializing in pain management recognize the complex nature of pain and approach the problem from all directions. Treatment at a pain clinic is patient-centric but depends on the clinic's available resources. Currently, there are no set standards for the types of disciplines needed, another reason treatment options vary from clinic to clinic. Experts say that a facility should offer patients:

• A coordinating practitioner specializing in pain management and consulting specialists on the patient's behalf.
• A physical rehabilitation specialist.
• A psychiatrist to help the individual deal with any accompanying depression or anxiety, especially when dealing with chronic pain. (American Society of Regional Anesthesia and Pain Medicine. 2023)

Other Medical Specialties

Other specialties represented in pain management are anesthesiology, neurosurgery, and internal medicine. A coordinating healthcare provider may refer an individual for services from:

• Occupational medicine specialists
• Social workers
• Alternative medicine practitioners
• Complementary medicine practitioners (American Academy of Pain Medicine. 2023)

A healthcare provider should have completed additional training and credentialing in pain medicine and be an MD with board certification in at least one of the following (American Board of Medical Specialties. 2023)

• Anesthesiology
• Physical rehabilitation
• Psychiatry
• Neurology

A pain management physician should also have their practice limited to the specialty they hold the certification.

Management Goals

The field of pain management treats all types of pain as a disease. Chronic, such as headaches; acute, from surgery, and more. This allows for applying science and the latest medical advances to pain relief. There are now many modalities, including:

• Medication
• Interventional pain management techniques - nerve blocks, spinal cord stimulators, and similar treatments.
• Physical therapy
• Alternative medicine

1. The objective is to minimize and make symptoms manageable.
2. Improve function.
3. Increase the quality of life. (Srinivas Nalamachu. 2013)

A pain management clinic will go through the following:

• Evaluation.
• Diagnostic tests, if necessary.
• Physical therapy - increases the range of motion, strengthens the body, and prepares individuals to return to work and daily activities.
• Interventional treatment - injections or spinal cord stimulation.
• Referral to a surgeon if indicated by the tests and evaluation.
• Psychiatry to deal with depression, anxiety, and/or other issues that accompany chronic pain symptoms.
• Alternative medicine to support and enhance the other treatments.

Individuals who do well with a pain management program

Individuals who have:

• Back pain
• Neck pain
• Had multiple back surgeries
• Failed surgeries
• Neuropathy
• Individuals determined that surgery does not benefit their condition.

A better understanding of pain syndromes by communities and insurance companies and increased pain studies will help increase insurance coverage for treatments and technology to improve interventional outcomes.

Chiropractic Care for Leg Instability

General Disclaimer *

The information herein is not intended to replace a one-on-one relationship with a qualified healthcare professional or licensed physician and is not medical advice. We encourage you to make healthcare decisions based on your research and partnership with a qualified healthcare professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from various disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the injuries or disorders of the musculoskeletal system. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and directly or indirectly support our clinical scope of practice.* Our office has reasonably attempted to provide supportive citations and identified the relevant research studies or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request.

We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, don't hesitate to contact Dr. Alex Jimenez or contact us at 915-850-0900.

Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN*

email: coach@elpasofunctionalmedicine.com

Licensed in: Texas & New Mexico*

References

American Society of Regional Anesthesia and Pain Medicine. (2023). The specialty of chronic pain management.

American Academy of Pain Medicine (2023). About the American Academy of Pain Medicine.

American Board of Medical Specialties. (2023). The Most Trusted Medical Specialty Certification Organization.

Nalamachu S. (2013). An overview of pain management: the clinical efficacy and value of treatment. The American journal of managed care, 19(14 Suppl), s261–s266.

American Society of Interventional Pain Physicians. (2023). Pain Physician.

The spine consists of multiple vertebral bones separated by gel-like discs. The discs are the shock absorbers, cushioning the vertebrae. Normal wear and tear, underlying conditions, and injuries can cause the discs to crack, tear, and leak out, also known as a slipped or herniated disc, which is the most common cause of sciatica. In certain cases, physicians are using a medication that is used to control seizures known as gabapentin. Gabapentin is an anticonvulsant used to treat nerve-related back pain, like sciatica.

First Line Medications

• Doctors' first-line medications for sciatica include anti-inflammatories/NSAIDs such as naproxen or ibuprofen and corticosteroids.
• Back spasms can accompany sciatica, increasing the sensations and pain; a muscle relaxer could be added.
• If these treatments do not provide adequate symptom relief, a combination of gabapentin, naproxen, ibuprofen (NSAIDs), corticosteroids, and Tylenol could be recommended.
• Before going to bed is the recommended time for taking the meds because of the potential for drowsiness.
• This allows the patient to be more comfortable and get better sleep.

Gabapentin

Gabapentin is a non-narcotic prescription medication that is part of the anticonvulsant family. FDA approved for the following:

Seizures

• It can be used with other medications for controlling epileptic seizures.

Postherpetic Neuralgia

• Painful blisters caused by reactivation of herpes zoster virus, aka shingles.

Off-label uses include:

Nerve Pain

• Treats sharp burning nerve pain often experienced from:
• Shingles outbreak
• Diabetes
• Spinal cord injury

Restless Legs Syndrome

• Manages the various sensations commonly experienced with the condition.

Fibromyalgia

• It can be effective in treating pain symptoms.

Brain Signals

Gabapentin alters the way the brain and body transmit signals. It works by blocking the pain-causing neurotransmitters to calm the pain signals to the nerves. This is why it is used for sciatica and neurogenic pain. Individuals dealing with nerve pain, numbness, and tingling in the legs from sciatica or have diabetic neuropathy benefit the most. It is not recommended for chronic, non-specific low back pain. Gabapentin may take up to a month to provide maximum relief; individuals may start to experience some relief within the first week. However, notify a physician if significant pain persists after using Tylenol, NSAIDs, corticosteroids, and gabapentin.

What To Expect

• The medication is available in a capsule, tablet with immediate or extended release, and liquid form.
• Starting dosage is 300mg once a day.
• A physician may increase the dosage up to three times a day.
• The medication needs to be taken as prescribed.
• Treating neuropathic sciatic pain with gabapentin is standard practice.
• This is an off-label usage meaning the FDA has not determined if the medication is safe and effective for sciatica.

Side Effects and Interactions

The most common side effects include:

• Dizziness
• Fatigue
• Tremors

Due to these potential side effects, Individuals should not drive or operate heavy machinery while taking gabapentin. Rare but more serious side effects can include:

• Vision changes
• Confusion
• Trouble breathing
• Behavioral changes or suicidal ideation
• Swelling

In 2019, the FDA released a statement cautioning the elderly and those with significant breathing conditions, such as chronic obstructive pulmonary disease/COPD, to use extreme caution when taking gabapentin and similar medications. Elderly individuals are more likely to experience side effects due to age-related changes, decreased kidney function, poor balance, and mobility issues. There is an increased risk of experiencing breathing problems when taking gabapentin with any of the following:

• Alcohol
• Opioids
• CNS/Central Nervous System depressants slow brain activity for sleep, anxiety, and panic disorders.

The consumption of alcohol, opioids, or CNS depressants while taking gabapentin can increase the sedating effects of each substance and lead to respiratory depression. It is imperative that your physician knows all prescription and non-prescription medications, herbal supplements, and vitamins to prevent negative interactions between medications.

Does Gabapentin Work?

General Disclaimer *

The information herein is not intended to replace a one-on-one relationship with a qualified healthcare professional or licensed physician and is not medical advice. We encourage you to make healthcare decisions based on your research and partnership with a qualified healthcare professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from a wide array of disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the injuries or disorders of the musculoskeletal system. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and directly or indirectly support our clinical scope of practice.* Our office has reasonably attempted to provide supportive citations and identified the relevant research study or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request.

We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900.

Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN*

email: coach@elpasofunctionalmedicine.com

Licensed in: Texas & New Mexico*

References

Center for Drug Evaluation and Research. (n.d.). Serious breathing difficulties with gabapentin and pregabalin. U.S. Food and Drug Administration. Retrieved September 30, 2022, from https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-serious-breathing-problems-seizure-and-nerve-pain-medicines-gabapentin-neurontin

Grice, Gloria R, and Marsha K Mertens. "Gabapentin as a potential option for treatment of sciatica." Pharmacotherapy vol. 28,3 (2008): 397-402. doi:10.1592/phco.28.3.397

U.S. Department of Health and Human Services. (2022, March 22). Prescription CNS depressants DrugFacts. National Institutes of Health. Retrieved September 30, 2022, from https://nida.nih.gov/publications/drugfacts/prescription-cns-depressants

U.S. National Library of Medicine. (n.d.). Gabapentin: Medlineplus drug information. MedlinePlus. Retrieved September 30, 2022, from https://medlineplus.gov/druginfo/meds/a694007.html

U.S. National Library of Medicine. (n.d.). Pregabalin: Medlineplus drug information. MedlinePlus. Retrieved September 30, 2022, from https://medlineplus.gov/druginfo/meds/a605045.html

Yasaei R, Katta S, Saadabadi A. Gabapentin. [Updated 2022 May 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493228/

Nutraceuticals can help relieve several different types of chronic pain, including sciatica or sciatic nerve pain. Stephen DeFelice, MD, coined the term in 1989, which is a combination of the words nutrition and pharmaceutical. He defined nutraceuticals as food that offers a variety of health benefits as well as prevention and/or treatment of health issues. Although these foods are considered to be natural products, it’s essential to discuss nutraceutical options for chronic pain, including sciatica or sciatic nerve pain, with a healthcare professional to avoid any side-effects or interactions with drugs/medications.

Several nutraceuticals are also considered to be dietary supplements. According to the Dietary Supplement Health and Education Act (DSHEA) is a product that is taken orally in pill, capsule, tablet, or liquid form which is made-up of any chemical ingredient that adds to what a person normally gets in their diet, including vitamins, minerals, amino acids, and herbs as well as substances made from organs or glands and enzymes. Dietary supplements can also be an extract or concentrate. Several examples of dietary supplements include vitamin C, vitamin D, calcium, and fish oil, best known as omega-3 fatty acids.

Nutraceuticals aren’t only limited to dietary supplements, as Dr. Stephen DeFelice previously described. It can also include genetically engineered food, such as food with added antioxidants, vitamins, and minerals. Nutraceuticals offer people extra nutrients that the body needs to use as fuel for energy. Nutrients, such as proteins, fats, and carbohydrates are broken down by the body’s metabolism, a process that uses energy to regulate breathing and heartbeat, among other essential bodily functions. In the following article, we will discuss how nutraceuticals can help improve sciatica or sciatic nerve pain.

Noninvasive treatments like chiropractic care, non-surgical decompression, massage therapy, non-steroidal anti-inflammatory drugs/NSAIDs, targeted/specific exercises, and ice/heat therapy successfully treat most cases of sciatica. However, more aggressive treatment could be necessary for severe cases, and this is where sciatica nerve block injections come in. The Injury Medical Chiropractic team can help you understand the diagnosis and explain the benefits.

Sciatica Nerve Block

Sciatic nerve block treatments can provide profound relief for intense, non-stop symptoms. The procedure can also provide important diagnostic information to help the spine specialist locate the exact nerve fibers contributing to the symptoms.

• The nerve block stops sciatic pain signals from transmitting.
• The procedure involves injecting an anesthetic and a steroid into the nerve roots.
• The steroid reduces inflammation.
• The anesthetic prevents nerve impulses from reaching the central nervous system - CNS.
• If the procedure is successful, surgery could be avoided altogether.

What to Expect

Individuals undergoing a sciatic nerve block will be awake during the procedure. Individuals that rather be sedated are recommended to speak with their healthcare provider during the planning phase.

• When the procedure begins, a nurse sterilizes the area around the injection site and applies a local anesthetic.
• The nurse will check the injection area for numbness.
• Then the spine physician inserts a needle using direct visualization from an ultrasound, fluoroscope, or CT scan and then injects the medications.
• After the procedure, the individual is moved to a recovery area and monitored.
• Most individuals can walk almost immediately after the injection, and vigorous exercise can be resumed a few days following the procedure, depending on the injury and what the spine specialist recommends.

Possible Complications

The procedure is done under direct visualization to minimize the risk of complications. However, possible complications could present and are usually linked to the needle insertion into the spinal column. These include:

• Bleeding
• Nerve Injury
• Infection

Complications are rare, but side effects like soreness around the injection site, nausea, and a headache are common and only last a little while.

Candidates

Individuals with underlying conditions and that are taking various medications may not qualify for a sciatic nerve block or have to consult their doctor for reasons that include the following:

Long-Term Anticoagulant Use

• Individuals taking blood thinners like daily aspirin, Plavix, or coumadin, will need to stop taking these medications before the procedure.

Allergy to Contrast Dye

• Sciatic nerve blocks are done using contrast dye or ultrasound.
• Individuals with an allergy to contrast dye will need to verify with their doctor or surgeon the feasibility of only using ultrasound guidance.

Abnormal Spinal Anatomy

• Individuals with abnormal spine anatomy have an increased risk for complications and are recommended not to have the procedure.

Morbid Obesity

• Morbid obesity is a significant risk factor for developing sciatica.
• The pain and symptoms often improve with weight loss.

Infection

• Inserting a needle with an injury, wound, or active infection near or around the injection site could cause spreading.

Treatment Duration

There is a wide range of responses to sciatic nerve blocks.

• Most individuals experience pain and symptom relief between two weeks and two to four months.
• Some individuals have a long-term resolution of their symptoms.
• However, it is also possible for the nerve block to be unsuccessful.

Unsuccessful Outcomes

The sciatic nerve is the longest in the body, and there are multiple potential sites for an anesthetic blockade.

• If a sciatic nerve block does not work, the spine specialist will reanalyze the diagnosis and see if the injection site was correct.
• Identifying the exact section of the nerve to anesthetize can be difficult and may require multiple nerve block attempts.

Individuals who continue to experience debilitating sciatica symptoms after a sciatic nerve block could be recommended to undergo surgical procedures.

• Sciatic nerve ablation is a procedure that destroys nerve pathways identified to cause pain and can provide long-term relief.
• If sciatica is caused by misalignment of the vertebrae or intense external pressure on the sciatic nerve, surgery to correct the underlying cause could offer a permanent solution.

Sciatica Syndrome

General Disclaimer *

The information herein is not intended to replace a one-on-one relationship with a qualified healthcare professional or licensed physician and is not medical advice. We encourage you to make healthcare decisions based on your research and partnership with a qualified healthcare professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from a wide array of disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the injuries or disorders of the musculoskeletal system. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and directly or indirectly support our clinical scope of practice.* Our office has reasonably attempted to provide supportive citations and identified the relevant research study or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request.

We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900.

Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN*

email: coach@elpasofunctionalmedicine.com

Licensed in: Texas & New Mexico*

References

5 Questions to Answer Before Considering Sciatica Surgery, Johns Hopkins Medicine, accessed September 28, 2022, https://www.hopkinsmedicine.org/health/conditions-and-diseases/back-pain/5-questions-to-answer-before-considering-sciatica-surgery.

Jönsson, B et al. “Diagnostic lumbar nerve root block.” Journal of spinal disorders vol. 1,3 (1988): 232-5.

Kanaan, Tareq, et al. “The Efficacy of Therapeutic Selective Nerve Block in Treating Lumbar Radiculopathy and Avoiding Surgery.” Journal of pain research vol. 13 2971-2978. 18 Nov. 2020, doi:10.2147/JPR.S276331

Rodziewicz TL, Stevens JB, Ajib FA, et al. Sciatic Nerve Block. [Updated 2022 June 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470391/

Sciatica: Harvard Health Publishing, (2016, February 19), accessed September 28, 2022, of all the nerve https://www.health.harvard.edu/pain/sciatica-of-all-the-nerve.

Senthelal S, Dydyk AM, Mesfin FB. Ablative Nerve Block. [Updated 2022 April 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499975/

Sciatica is a radiculopathy, which is irritation of the nerve as it exits the spine and is typically caused by compression/pinching along the nerve's path. Most sciatica cases improve within a few weeks of the injury incident. Left untreated, it can become chronic sciatica and can have long-term repercussions and effects. A herniated disc is the most common cause if it bulges next to the nerve; it can pinch off the nerve or leak fluid onto the nerve, causing inflammation, swelling, pain, numbness, and weakness. Another common cause is spinal stenosis. As the body ages, the canal through which the nerve and spinal cord run can begin to narrow, placing pressure on the nerves. Then there are muscle spasms, spinal fractures, and spinal cancer. Anything that changes the curvature of the spine, including pregnancy, can cause sciatica.

Repercussions From Sciatica

The repercussions can vary or be a combination that includes:

Chronic Pain

The pain can be anywhere along the nerve; typically, it travels from the lower spine through the buttocks, down the back of the leg, and into the foot.

• The condition can cause various types of pain: Burning, electrical, or shooting pain in the low back.
• Symptoms can come and go and may present only when sitting, standing, lying, or engaged in a particular activity.
• The severity of the pain can vary from mild to severe, mildly uncomfortable, to limiting function.

Posture Problems

• When the body experiences chronic pain in a localized area, the body's natural reaction is to avoid placing pressure, twisting or bending, or using a specific body part, manipulating healthy posture or walking gait to protect the low back or legs from pain.
• This is referred to as muscle/posture guarding, which removes pressure from the site but alters the body's natural alignment, affecting the spine's characteristics and causing adverse side effects, like upper back and neck pain, headaches, and fatigue.
• Unhealthy and awkward postures can negatively affect digestion, organ function, and breathing.

Loss of Balance

• Sciatica commonly causes numbness and tingling in the leg, calf, foot, and toes.
• The hidden danger behind numbness; it alters the body's proprioception or awareness of its position.
• When proprioception becomes inhibited or altered, communication signals from the body to the brain/vice versa get jumbled/interrupted, confusing the brain, throwing the body off balance.
• This can result in falling injuries.

Numbness or Weakness

• Sciatica is more problematic if the pain comes with neurological symptoms like numbness, muscle, or leg weakness.
• This means there is an increased level of possible nerve damage if muscular weakness, which requires aggressive treatment.

Declining Reflexes

• Depending on where the nerve is compressed, pain and numbness can affect the lower leg area and feet.
• Damage to the nerve can cause the inability to flex the foot up.
• The knee-jerk reflex, known as the patellar reflex, is the kicking motion of the lower leg when tapped on the patellar tendon.
• Sciatica can numb the area, causing a delayed reaction or severe unresponsiveness to stimulation.

Permanent Nerve Damage

• If left untreated, neurological symptoms like numbness and leg weakness can progress to permanent nerve damage.
• However, this happens rarely but explains the importance of taking the injury seriously so full recovery is achievable.

Non-Surgical Sciatica Relief

General Disclaimer *

The information herein is not intended to replace a one-on-one relationship with a qualified health care professional, or licensed physician, and is not medical advice. We encourage you to make your own healthcare decisions based on your research and partnership with a qualified healthcare professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from a wide array of disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the injuries or disorders of the musculoskeletal system. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and support, directly or indirectly, our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. We provide copies of supporting research studies available to regulatory boards and the public upon request.

We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900.

Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN*

email: coach@elpasofunctionalmedicine.com

Licensed in: Texas & New Mexico*

References

Berry, James A et al. "A Review of Lumbar Radiculopathy, Diagnosis, and Treatment." Cureus vol. 11,10 e5934. Oct 17 2019, doi:10.7759/cureus.5934

Davis D, Maini K, Vasudevan A. Sciatica. [Updated 2022 Feb 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507908/

Giuffre BA, Jeanmonod R. Anatomy, Sciatic Nerve. [Updated 2021 Jul 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482431/

Nori, Subhadra L. and Michael F. Stretanski. "Foot Drop." StatPearls, StatPearls Publishing, Dec 15, 2021.