Neuropathy Information

A PATIENT’S GUIDE TO NEUROPATHY

Michael Zapf, DPM, MPH, FACFAS

 

Burning, tingling and painful feet are one of the most common reasons patients visit my office, not surprising since 2 to 10 million people in the United States have these symptoms. In the recent past,  David complained that his feet are burning so much with his shoes on that he has resorted to taking  his shoes off to drive. Mel complained that his balance is thrown off because he can no longer feel the ground with his feet resulting in tripping and falling. Julie complained that it feels like there is a sock bunched under her toes but every time she looks her sock is smooth. She admits that she even feels this sensation when she is not wearing socks. David, Mel and Julie are all experiencing a phenomenon called neuropathy. When it occurs in the feet and legs (or hands and arms) it is called peripheral neuropathy (PN). Mel and Julie have such severe PN that it is causing them anxiety, depression and loss of sleep. PN often feels worst when you crawl into bed. David says his feet feel like “pins and needles” at night.

 

As common as PN is, the actual cause is often hard to pinpoint and treatments to get rid of neuropathy are few and rare.  However, there are a lot of medicines and other treatments that make the condition easier to live with. This paper will help you understand what is happening with your PN and how to make the most of a bad situation. I will tell you the current “legitimate” diagnoses and treatments and mention several of the non-traditional remedies, some which really seem to help some people.

 

SYMPTOMS

 

There are a certain few words that people with PN will use to describe their symptoms: burning, prickling, tingling, throbbing, shooting, electrical shocks, stabbing as well as a common description of the skin feeling asleep or numb. Sometimes there is extreme sensitivity to touch and an exaggerated feeling of pain to something that should not be painful (like your socks or shoes). Sometimes the muscles in the region feel weak and sometimes there is a lack of balance. It is characteristic of the condition that people will use the seemingly contradictory terms numb and painful in the very same sentence.

 

PN is sometimes associated with restless leg syndrome and foot and leg cramping. Sometimes “jumpy” and “cramping” of the legs and feet are a symptom all by themselves and sometimes they foreshadow the development of PN.

 

ANATOMY

 

Nerves are the little wires that connect the brain and spinal cord to the tips of our fingers and toes. The big ones that go from the spinal cord to the muscles are usually covered in an insulating covering called myelin. When motor nerves go bad there is weakness and difficult in moving muscles. Smaller ones go from the spinal cord to the internal organs. When these are bad the organs do not work right. There are tiny ones in the skin with endings that might detect pressure, cold, hot and pain. When these go bad you can feel your feet or hands feeling heavy, cold and painful, respectively, depending on the nerves being affected. The tiniest ones are in the feet and that is why PN often seems to start there and why we see so many people experiencing this in our podiatry office. Because they are almost as far away from the spinal cord as are the feet, hands are the second most common location of PN.

 

 

 

 

SMALL FIBER PERIPHERAL NEUROPATHY

 

Mostly, we are going to discuss the microscopic tiny little nerve fibers in the skin that start to get sick and die in PN. Before they die and stop working each nerve fiber gets sick starts firing randomly and frequently. During these death throes of a nerve, it fires so randomly and rapidly that you sense a feeling of pain even though your skin is not against anything painful. If the nerve is a heat sensing nerve you feel burning.

 

Skin Nerve Biopsy: Once a nerve dies it disappears from the skin. A skin biopsy taken 10cm above the ankle bones can be sent to a special lab where they will actually count the number of nerve fibers in a 3mm sample. The sample is taken in the office under a drop of local anesthesia and does not even require a stitch. Normally there is a range of 8 to 15 nerves in a sample. People with severe PN will often have less than 8 and, in the worst cases, none. This test measures your Small Nerve Fiber Density (SNFD) and it is the gold standard to measure neuropathy. Some treatments reportedly increase your SNFD which can be measured by repeated biopsies. We will talk about these treatments later as well as alternative ways to measure your SNFD.

 

CAUSES OF LOW SNFD

 

Many conditions and disease states cause a decrease in you SNFD. The most common is diabetes. Some estimates are that 30%-65% of people who have diabetes will develop small nerve fiber PN. Many times the development of PN precedes the diagnosis of diabetes by many years. With high blood sugars some of the excess sugar in the small nerves is converted to a chemical called sorbitol. Nerves have no way to use sorbitol and it gums up the nerve causing it to die. There have been many therapies designed to stop the conversion of glucose to sorbitol but none have achieved the goal of stopping the development.

 

If you have diabetes (or pre-diabetes which is nearly as toxic to nerves) I will ask you how you blood sugar is running. One measure of blood sugar is a fasting level drawn in the morning after 10 hours without eating. Blood sugars above 100 or 110 are suspicious of diabetes. I will also ask you about your A1c (Glycosylated Hemoglobin) level which is a measure of your average blood sugar over the last 3 months. You cannot fool the A1c test like you can a random blood sugar. A1c levels below 6% usually do not cause PN while levels above 7% are almost always to blame. Likewise, PN with A1c levels below 5.5% almost always point to another cause for your PN.

 

Other causes of the death of the tiny skin nerves include: metallic poising (lead, mercury and arsenic), chemicals found in cleaning agents and insecticides, alcohol (remember how your mom said alcohol kills brain cells? Well it kills all nerve cells so be prudent), vitamin deficiency (especially B12), vitamin excess (especially B6), HIV, and many medications, particularly cancer chemotherapy agents and the quinolone antibiotics Cipro and Levaquin. There have been cases were PN has developed after taking just a few capsules of these two antibiotics.

 

Nerve entrapment can lead to neuropathy. The analogy of a garden hose is often used to describe the effect of a nerve entrapment. When you step on a garden hose when the water is running the stream at the end trickles down until the pressure is released. The same thing seems to happen with nerves. If a nerve is trapped in the spinal cord, at the knee or on the inside or outside of the ankle the symptoms of neuropathy are often felt. This is one case where neuropathy can be reversed by releasing the entrapment. I will discuss more on this later.

 

Sadly, many times the cause of PN that is not due to diabetes is never found. These are called idiopathic which his medical-speak for “We Don’t Know.”

 

DIAGNOSIS

 

When you first come to my office I will ask you about your history of things that might be related to PM. I need to know about your symptoms, their nature and when they started and what might have caused them. I want to know about diabetes, kidney or liver diseases, medications you are or have taken, exposure to heavy metals or other toxins and your alcohol use history.

 

I will do some basic tests for nerve function. I will test your ankle and knee reflexes with a little rubber hammer. I will see if you can feel a small calibrated filament called a Semmes-Weinstein filament. If you can feel the filament then you are said to have protective sensation which means that you should be able to feel a small cut in the skin, a rock in the shoe or other potential damaging stimuli. I will bang a tuning fork against my palm and hold the end against your skin and see how long you feel the vibration. I have found that a normal person can feel it for almost 20 seconds as the vibration extinguishes. As the SNFD decreases so does the time of tuning fork extinguishing. My personal feeling after doing this for 30 years is that 10 seconds or less qualifies as PN.

 

THE INTERNIST AND THE NEUROLOGIST

 

If you have just developed PN our first stop should be your internist or family doctor. He or she will need to carefully check your diabetes status as well as your kidney and liver function.

 

If you internist gives you a clean of health your next stop will be the neurologist where you need to get three questions answered. I will ask you about these questions so please get clear and understandable answers. Take notes if you have to.

 

Question 1: What is causing my PN?

Question 2: What will happen to my PN in the future (what is the natural history of my PN)?

Question 3: Is there anything I can do to stop or reverse my PN?

 

You will likely be offered medication to control your symptoms of PN but THAT IS NOT THE SAME THING AS STOPPING OR REVERSING YOUR PN.

 

The neurologist will ask you the same questions, and maybe a few more, about your history. He or she will usually run a battery of tests often including a nerve conduction tests (NCV) and electromyogram (EMG) as well as blood and urine tests to help come up with a diagnosis and a treatment plan. Perhaps the neurologist will find that an auto-immune problem or an inherited neuromuscular condition is causing your muscle weakness or sensory changes. Occasionally a spinal tap may be used to determine if there is an autoimmune disorder. At the appointment where you discuss these findings please get your three questions answered.

 

Usually the neurologist does not measure your SNFD. This can be measured directly with a skin biopsy or indirectly by carefully measuring skin sweating. Sweat glands in the skin are innervated by the same tiny nerve fibers that carry feeling and pain messages. As the nerves die, so does the ability to sweat. Testing sweat gland function is called measuring the sudomotor function that is generally not available in most neurology offices.

 

COMMON TREATMENTS

 

Diabetes – first and foremost if you have a high A1c you need to diligently and carefully control you blood sugars as per your internist or family doctor’s instructions. This certainly involves diet and exercise (150 to 300 minutes of walking a week or more) and often involves oral or injected medication. Some of your small nerves may just be stunned and not completely dead and blood sugar control might bring them back to life. When I did my residency it was so long ago that we admitted diabetic patients three days before even a small surgery to carefully control their blood sugar. On admission the anesthesiologist thought general anesthesia would not be necessary because the feet were so numb. However, after three days of a controlled diet, the nerves would come back to life and anesthesia was needed. I was impressed by the need to control blood sugar every single day. The presence of neuropathy causes too many patients to give up on scrupulous control. Don’t be one of those people.

 

Entrapment syndromes can be treated by surgical release of the nerves, For more about this please see the web site for the association of American Extremity Nerve Surgeons (www.aens.us). What they do is truly amazing.

 

Pepper cream – there are a variety of pepper containing creams on the market that can help with pain of both arthritis and PN. The active ingredient is capsaicin which is the burning compound in chilies and pepper. When you first rub the cream on the feet and ankles you feel a warm, almost burning, sensation. If you repeat the application of this cream often enough (four times a day) you can actually drain the neurotransmitter from your burning nerves and the exhausted nerves can no longer transmit pain messages. You need to keep the treatment up to keep the nerves exhausted. Many of these creams are now over-the-counter and there is even a recipe for making it yourself using shortening or skin cream and cayenne powder. If you do try this cream please heed the warning to wash your hands before touching sensitive places like your eyes. (Then, again, you will only make this mistake once.)

 

Vitamin deficiency of B12 can be remedied with supplements and high vitamin levels of B6 can be remedied by lowering the level.

 

Aspirin and other non-steroidal medications (Naprosyn, Voltaren, Celebrex, etc.)  are considered too weak to  treat PN and they have their own side effects.

 

Opioid/narcotics like hydrocodone, morphine and codeine are not targeted to PN and they can lead to dependence.

 

Autoimmune disorders are treated with immunosuppressant medications or IV gamma globulin.

Neuromodulators are a group of medicines that do not change the level of PN but make you, the patient, better deal with the condition. They are all psychoactive and are or are vaguely (or not so vaguely) related to anti-depressants or anti-epilepsy medicine. The analogy I use for these medications is as follows. Suppose you get the last hotel room in the city over a club playing music you just cannot stand and they are playing loud and long after you need to be asleep. Yes, the perfect answer is to have the players turn down the music, but that is not likely to happen. Instead, you could use a noise cancelling headphones, play your favorite soothing music and fall quietly asleep. Neuromodulators make you less concerned about your PN and function more like you did not have it. Neurologists will invariably suggest one of these medications for you if you have PN:

 

  • Antidepressants like Prozac, Elavil, Lexapro, etc.
  • Gabapentin aka Neurontin
  • Pregablin aka Lyrica
  • Duloxetine aka Cymbalta

 

Nerve blocks  – can stop the pain for a few hours but each nerve needs to be injected. No long term help is expected from a nerve block.

 

T.E.N.S. – a trans electrical nerve stimulator is a cell phone sized pack with electrodes that are placed on the leg above the neuropathy. There are reports that the unit blocks some of the PN while it is turned on. There is no expectation that this will be long-lasting but it is a harmless remedy that you can try. We have TENS units in the office if you want to give it a try.

 

Spinal stimulator – this is similar to a TENS unit but it is implanted next to your spinal cord and works 24/7. These are administered by pain control doctors and a trial of their efficacy is usually given before their final implantation.

 

ALTERNATIVE THERAPIES

 

Physical therapy, psychological therapy, meditation, prayer, acupuncture, hypnosis, massage therapy, reflexology, magnets and biofeedback have all been reported to be helpful for some people in some studies. I am as skeptical of these as you are so be cautions that you do not spend too much money on them if you are not seeing progress.

 

NUTRITION

 

The following pages show a summary of my research on the vitamins or “food supplements” that have at least one study showing that the right doses will lessen neuropathy and, in some cases, even raise the concentration of end nerve fiber density in skin biopsies. I admit that these studies are not all of high quality and taking vitamin supplements might be just a waste of time and money. On the other hand, if you have the time and the money you just might want to investigate. Because they are vitamins they are usually not covered by insurance and the minimum cost seems to be $1 a day, although you can pay considerably more. At the end of the next section I have summarized the findings to make purchasing these supplements a little easier.

 

WHAT ARE THE SUPPLEMENTS that have sometimes been shown to reduce neuropathy

 

  1. Alpha lipoic acid                                                600mg a day
  2. B1 Benfotiamine                                                300mg a say
  3. B6 – P5P (Pyridoxyl 5-phosphate)–               35 mg a day
  4. B9 – L-methyl folate                                            3 mg a day
  5. B12 – methylcobalamin                                       1mg a day
  6. GLA – gamma linolenic acid                            200mg a day

 

 

For the first four months of vitamin therapy studies seem to suggest that you should take double dosages of these nutrients and then taper off to the amount listed above for the remainder of a year and then decide if it is helping you.

 

You do not need to take all of these – there is no proof that taking all is better than taking just three. The nutrient we sell in the office is NeuraVite and contains the proper dosage of 1,2, 3 and 5 all for $1 a day ($2 for the first 4 months) A prescription product called Metanx contains 1,2,3 and 6. Neither contains gamma linolenic acid which we sell separately in the form of Borage Oil capsules. You can, of course, buy these supplements from any health food store or the internet. We stand behind products we sell and they are all assayed by an outside independent laboratory.

 

 

 

 

THE VITAMIN SUPPLEMENTS –i.e. “NUTRITIONAL FOODS”

The claims for arresting or improving the progressively worsening symptoms of diabetic neuropathy are legion. Put neuropathy and vitamins into a search engine and there are never ending claims of relief. Many of the claims have an element of truth. For most of the dietary supplements there is a literature report somewhere that seems to possibly show a positive effect. Careful reading of the reports shows that the studies are all flawed. Sometimes the exact dose of the nutrient is not clearly stated or the end point of the study is dubious and many other times the claims at the end took an incredible leap of imagination. I am going to list the most commonly cited nutrients, the doses that seem most commonly cited in the reports that seem to have the fewest flaws. I am putting my doctoral, my public health and my statistics hat on here, although I know that every study can be doubted by scientists and doctors. If you decide to try any of these nutrients, vitamins or nutraceuticals, please feel free to run them by your family doctor first and get his or her approval.

 

Alpha-Lipoic-Acid   300mg in the morning and 300 in the evening, preferably 30 minutes before a meal. ALA, also known as thioctic acid, seems to appear more than any other nutrient. It is reported to improve nerve blood flow, nerve conduction velocity and several other functions of nerve metabolism. A review article by Papanas in Expert Opinion on Pharmacotherapy in 2014 stated “There is ample evidence from randomised (sic – they are Indian) double-blind, placebo-controlled clinical trials and meta-analysis, suggesting that ALA is efficacious and safe for the diabetic neuropathy, accomplishing clinically meaningful improvements ,,,improves paraesthesia (sic), numbness, sensory deficits, and muscle strength in addition to neuropathic pain.”  Some studies (and a lot of ads) suggest the ALA helps blood sugar control, improves brain function, promotes weight loss, eye and liver health and, I guess, promotes peace on earth. Don’t trust everything you read.

There are two forms “R” and “S”. R is more effective but expires quicker. Do not stock up on the R – it expires a year after manufacture. Most commercial ALA is a mixture of the two, R and S. Intravenous injections/infusions seem to work better but, obviously quite inconvenient for most of us. Probably 200mg of R-ALA is equivalent to 600 of the mixture of ALA. Some reports that the “S” half of the mixture ALA  is inert and does not penetrate nerves.  (Probably the dose can be halved after 4 months). The NYU Langone Medical website notes that the studies on ALA are not very scientific and that there is evidence that ALA performance is enhanced by also taking gamma linolenic acid, described below.

 

In our office we have

600mg Mixed ALA in NeuraVite 30 capsules for $30 (along with Benfotiamine, B6and B12)

[Note: on one study 21% of patients taking 1200 mg a day experienced nausea]

Benfotiamine (B1) 150mg – 600mg a day (Best is probably 300 2x a day for first 4 month and then 200 twice a day for maintenance)  — Vitamin B1 is thiamine and is quite handy to your body but, as a nutrient, is nearly not absorbed from a pill. Better is to transform the thiamine into Benfotiamine.  Balakumar in a critical review in a 2010 article in Pharmacology Research clearly states “the anti-AGE [glycation end products] property of Benfotiamine certainly makes it effective for the treatment of diabetic neuropathy, nephropathy [kidney], and retinopathy [eye].”

 

100mg in NeuraVite – 30 capsules for $30 (along with Alpha lipoic acid, B6 and B12)

 

N-Acetyl-L-Cysteine (NAC or NALC) 600-1000mg a day and N-Acetyl-L-Carnitine (250-500mg a day)

 

The NAL-Cysteine is frequently reported to reduce the phlegm of a cough and to help heal from contrast induced kidney damage. Both of these anti-oxidants have been reported to help heal from chemotherapy induced nerve damage. They has enough side effects to not be added to regular nephropathy regimens but if you buy an all-in-one mixture that has it in just look for uncommon side effects of nausea, vomiting, rash and fever. Actually look for these complications for all of the supplements listed in this article. If you have chemotherapy induced neuropathy, strongly consider trying these two supplements. We can get them for you from Pure Encapsulations.

 

Vitamin B6 (pyridoxyl 5’-phosphate, P5P, is the best form)  –  8mg at 400% daily value.

Studies show that in small doses, B6 can be very beneficial for nerve health. At larger doses, in excess of 100mg per day, it can have an adverse effect on nerves. In a 2011 paper in Rev Neurol Dis authors AM Jacobs and D. Cheng reported that 11 patients with painful diabetic neuropathy had skin biopsies to determine end nerve fiber density (ENFD) in skin samples before and after taking L-Methylfolate, methylcobalamin (methyl B12) and pyridoxyl 5’-phosphate twice a day for six months. “At the end of their treatment, 73% of patients showed an increase in calf ENFD, and 82% of patients experienced both reduced frequency and intensity of paresthesias [tingling] and/or dysesthesias [pain and burning].”   In a 2010 paper in the same journal Walker, Morris and Cheng reported on a study  involving 20 patients with symptomatic diabetic peripheral neuropathy taking a mixture of 3 mg of L-methylfolate, 2mg of Methylcobalamin (B 12) and 35 mg of Pyridoxyl 5’-phosphate. They took a double dose for 4 weeks and then a single dose for an additional 48 weeks. Their conclusion was that “this combination appears to promote restoration of lost cutaneous sensation in DPN (diabetic peripheral neuropathy)” Check with any other vitamins you are taking to make sure you do not exceed 100mg a day of B6.

 

25 mg in NeuraVite – 30 capsules for $30 (along with Benfotiamine, Alpha lipoic acid and B12)

 

Vitamin B12 – The methyl version, called methylcobalamin, is superior. In a 2011 paper in Rev Neurol Dis authors AM Jacobs and D. Cheng reported that 11 patients with painful diabetic neuropathy had skin biopsies to determine end nerve fiber density (ENFD) in skin samples before and after taking L-Methylfolate, methylcobalamin (methyl B12) and pyridoxyl 5’-phosphate twice a day for six months. “At the end of their treatment, 73% of patients showed an increase in calf ENFD, and 82% of patients experienced both reduced frequency and intensity of paresthesias [tingling] and/or dysesthesias [pain and burning].”   In a 2010 paper in the same journal Walker, Morris and Cheng reported on a study  involving 20 patients with symptomatic diabetic peripheral neuropathy taking a mixture of 3 mg of L-methylfolate, 2mg of Methylcobalamin (B 12) and 35 mg of Pyridoxyl 5’-phosphate. They took a double dose for 4 weeks and then a single dose for an additional 48 weeks. Their conclusion was that “ this combination appears to promote restoration of lost cutaneous sensation in DPN (diabetic peripheral neuropathy)”

Methyl-B12 500 mcg (1/2 of an mg) in NeuraVite – 30 caps for $30 (along with Benfotiamine, ALA and B6)

 

Vitamin D 2,000 units a day was also shown to decrease diabetic neuropathy pain by 47% after 3 months. 5000 units a day is not too much. The safety level for oral Vitamin D is very high.

 

Pure Encapsulation Vitamin D 5000 units – 60 capsules for $15.

 

B9 – L-Methylfolate Calcium (Metafolin) the active form of Folic Acid B9) – 3mg twice a day = 6mg per day. 

 

This is the same form of folic acid in the widely advertised Metanx which is sold by prescription.

 

In a 2011 paper in Rev Neurol Dis authors AM Jacobs and D. Cheng reported that 11 patients with painful diabetic neuropathy had skin biopsies to determine end nerve fiber density (ENFD) in skin samples before and after taking L-Methylfolate, methylcobalamin (methyl B12) and pyridoxyl 5’-phosphate twice a day for six months. “At the end of their treatment, 73% of patients showed an increase in calf ENFD, and 82% of patients experienced both reduced frequency and intensity of paresthesias [tingling] and/or dysesthesias [pain and burning].”   In a 2010 paper in the same journal Walker, Morris and Cheng reported on a study  involving 20 patients with symptomatic diabetic peripheral neuropathy taking a mixture of 3 mg of L-methylfolate, 2mg of Methylcobalamin (B 12) and 35 mg of Pyridoxyl 5’-phosphate. They took a double dose for 4 weeks and then a single dose for an additional 48 weeks. Their conclusion was that “ this combination appears to promote restoration of lost cutaneous sensation in DPN (diabetic peripheral neuropathy)”        

 

            Pure Encapsulation methylfolate 1mg — 90 capsules for $24.  

 

B-8 Myo-inositol 1000mg  day. This is called a vitamin but does not quite meet the definition since our bodies can make it. There are some reports that this can reduce the effects of neuropathy in some patients.  Maximum doses, according to the web site Livestrong, are 6 grams a day (6000mg) for four weeks or 4 grams (4000 grams) for 10 weeks. One gram a day seems to be quite a safe dose.

 

Pure encapsulation 500mg Myo-inositol 180 capsules for $33.

 

Gamma Linolenic Acid  400-600  mg per day   Gamma linolenic acid is an essential fatty acid found in borage oil, grape seed oil, black currant oil, and evening primrose oil that has been shown to be successful in reversing nerve damage in diabetics suffering from peripheral neuropathy. In a double-blind, placebo-controlled study using 480 mg of GLA daily, all the diabetics given the fatty acid experienced gradual reversal of nerve damage and improvement in the symptoms related to the peripheral neuropathy, while those on placebo gradually worsened. It is thought that GLA may help to rebuild the myelin sheath around the nerves. From the NYU Langone Medical Center web site; “There is some evidence that GLA can be helpful if you give it long enough to work. In one double blind placebo-controlled study, 111 people with mild diabetic neuropathy received either 480 mg daily of GLA or placebo. After 12 months, the group taking GLA was doing significantly better than the placebo group. …Diabetic neuropathy is typically treated with about 400 to 600 mg daily (about 4 to 6 grams of evening primrose oil or 2 to 3 grams of borage oil. GLA should be taken with food. Fill benefit (if there are any) may take more than 6 months to develop.”  Dose in pills is hard to calculate as the concentration in each vegetable source varies in linolenic acid concentration.

 

Pure Encapsulation Borage Oil  60 capsules for $24 or 180 for $60 200 mg of Gamma Linolenic Acid. Two capsules a day will give you the daily 400mg of GLA.

           

Biotin 10-15 mg/day was long ago studied for the treatment of neuropathy in diabetics at the University of Athens. The research showed that regular, long-term use of biotin was very effective both for improvement in nerve conduction and relief of pain. Improvement in nerve conduction occurred after only 4-8 weeks of therapy. In this study, biotin was given via daily intramuscular injection (10 mg/day) for 6 weeks; then 3 times per week (10 mg), intramuscularly, for 6 weeks; then 5 mg/day taken orally for up to two years. Biotin has also been used to strengthen nails and hair and some people report better sleeping habits.

 

We sell Pure Encapsulation Biotin 8mg 60 capsules for $10

 

You can purchase off thee nutrients from Pure Encapsulation in Sudbury, MA by calling 978-443-1999 or go to their web site PureEncapsulations.com. Use the code 3805 for a 10% discount from their regular price. You can also get these supplements from your local health food store.

 

Summary of Treating Neuropathy with Vitamins

 

Minimum – Take 1 NeuraVite a day for a year

Moderate: Take 2 NeuraVite and 2 Borage Oil capsules a day for  4 months and then one a day for a year

Maximum –  Take 2 NeuraVite a day and 2 Borage Oil capsules a day for 4 months and then one a day for a year and add 1 to 6 daily 1-mg MethyFolate tablet(s). Some studies show that 6 mg of methylfolate a day is best.

 

We always stock the NeuraVite capsules both 30 and 60 bottles.

We try to stock the Borage Oil and the MethyFolate tablets both from Pure Encapsulations (PureCaps)

 

Take the suggested amount of the six ingredients that have been shown to help neuropathy in at least one study.  Get either from your favorite health food store or order from PureCaps (Phone: 978-443-1999) or their web site www.PureEncapsulations.com.

 

è  Use CODE 3805  for a 10% discount from printed prices at PureCaps. For your convenience I listed the PureCaps product code for each supplement below.

 

Summary of the Summary

 

Nutrient Needed Daily What 2 NeuraVite gives you What to get from Pure Caps
ALA – 1200 mg a day 1200
B1 Benfotiamine – 600mg daily 600
B6 – P5P  1000 mg daily 52 (still need all 1000)
B9 L-Methyl Folate 6mg daily 0 1-6 Metafolin    Order #:  MAS9  90 for $24
B12 – methylcobalamin 2 mg daily 1mg
GLA 400-600 – daily 0 2 capsules of Borage Oil

BOG1 – 60 caps $24   BOG6 – 180 caps $65

 

PureCaps refers to the company Pure Encapsulations of Sudbury, MA. Dr. Zapf has visited the company in Sudbury, MA,  and feels confident in recommending their products. Unlike almost any other vitamin and supplement manufacturer, each and every INGREDIENT is ASSAYED BY AN INDEPENDENT OUTSIDE LABOTARORY and you can see a copy of the laboratory reports if you ask.

 

Nutrient Availability from Pure Caps Item number Pure Caps
R-alpha lipoic acid (ALA)

(regular ALA is 50% “R” form)60 caps 100-mg for $41.20

120 caps 100mg for $75.80RLA1

RLA2B1 Benfotiamine90 caps  200mg for $40.30BFM9  (BenfoMax)Vitamin D60 caps  5000IU for $15.40

120 caps 5000IU for $27

250 caps 5000IU for 448.80CD51

VD52

VD56L-methyl folate (Mentax)M90 caps  1-mg for $24MethylAssistB6 (P5) Myo-inositol60 caps 500mg for $13.90

180 caps 500mg for $35.20P51  (PSP50)

P56 (PSP50)Gamma Linolenic Acid60 caps 200 mg for $23.80

180 caps 200mg for $64.30BOG1   Borage oil

BOG6   Borage oilBiotin60 8mg caps for $10.30

120 8mg caps for 417.80BI1 (Biotin)  ß letter “B” and “I” not number 1

BI6 (Biotin)   ß letter “B” and “I” not number 1N-A-L-Cysteine  (Chemo caused) 600-1000 daily90 600mg caps for $27.20

180 800mg caps for $46.10

360 800mg caps for $81.80NA61 (NAC)

NA62

NA69N-A-L-Carnitine  (Chemo Caused) 250-500mg a day60 caps 500mg for $58.80ALC56  (Acetyl-l-carnitine)

Another brace success story…

Another brace success story….

 

 

 

One of our patients, S.J.A. is an avid walker who noticed her left ankle becoming more and more unstable. She tried changing her shoes and wearing orthotics, but her ankle still felt like it needed more support. She felt her instability was preventing her from walking long distances that she used to. After discussing her options with Dr. Zapf, she decided on being fit for a custom “AFO” brace. AFO stands for ankle-foot orthosis and is made from a mold of the foot and ankle. The brace is used to control instabilities in the lower limb by maintaining proper alignment and controlling motion. The brace is unnoticeable when worn under a pant leg and must be worn with a stable athletic shoe. The brace can be moved from shoe to shoe.

Our patient has been wearing the brace now for a few weeks and is very satisfied with the progress she has made in regards to resuming her normal walking routine. It took a few weeks to get completely comfortable wearing the brace, but now she doesn’t want to go without it.
Thanks for sharing, S.J.A.!

Advil vs. Aleve

An article posted on Healthgrades indicated that several common anti-inflammatory medications are and have been associated with high blood pressure, heart disease and stroke. Vioxx is the poster child for these medications and has already been taken off the market. The more common medications that can cause these complications are ibuprofen (Motrin) and Voltaren also called diclofenac.  Naproxen (Aleve) “was found to be relatively safe, compared with other” anti-inflammation medications. Read the following article from Healthgrades.

Several everyday medications for chronic knee pain could increase your risk for high blood pressure. This is a serious condition that affects 1 out of every 3 Americans and can lead to heart disease, stroke, and other problems.

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Many people take nonsteroidal anti-inflammatory drugs (NSAIDs) to manage the pain of osteoarthritis. They’re popular medications: About 23 million people in the U.S. use over-the-counter NSAIDs, such as ibuprofen (Advil) or naproxen (Aleve), every day. Roughly 98 million NSAID prescriptions were filled in 2012. But while NSAIDs may help your arthritis pain, they could also harm your heart.

Easing Pain—At a Price?

NSAIDs can cause a slight rise in blood pressure and may reduce the effect of certain blood pressure medications. Using an NSAID now and then won’t necessarily lead to heart problems, but elevated blood pressure is a risk factor for heart attack and stroke.

Studies have looked at regular use of certain NSAIDs and the possible related risks of dying prematurely from a heart attack or stroke. Here’s what researchers found:

  • One study found that recurrent use of ibuprofen and diclofenac was associated with a risk increase of 30% or more for complications such as heart attack or stroke.
  • Another study looked at healthy people—those who did not have a history of heart problems—and linked ibuprofen to a 29% greater risk for stroke. This same study showed that recurrent use of diclofenac was associated with a 91% increased risk of dying from heart problems. Rofecoxib (Vioxx) had a 66% increased risk. The U.S. Food and Drug Administration pulled Vioxx from the market in 2004 due to related heart risks.
  • For people who took high doses of diclofenac or rofecoxib, there was a two and three times greater risk of having a heart attack, respectively.
  • Naproxen was found to be relatively safe, compared with other NSAIDs.

Talk with your health care provider if you rely regularly on NSAIDs for treating knee pain and have concerns about possible heart-related risks. There may be other options that can reduce pain without increasing your risk for heart complications.

Exercise: A Twofold Solution

When your knees throb with pain, the last thing you want to do is get up and move around. You may even think that exercise would make your knees feel worse. But experts say that physical activity is actually a natural pain reliever. It also can improve your blood pressure. In fact, being sedentary for too long increases your risk for high blood pressure and other chronic conditions. These include obesity, type 2 diabetes, and heart disease.

Getting regular, light exercise, such as walking, can help ease pain. Daily movement can lead to less joint pain and stiffness and better flexibility and mobility. This, in turn, can lift your mood and boost your energy. Plus, blood flow to your heart improves. This is beneficial for your blood pressure. Think of exercise as a win-win for your knees, heart, and overall health and happiness.

Key Takeaways

  • NSAIDs taken for chronic knee pain could increase your risk for high blood pressure. This is a serious condition that can lead to problems, such as heart disease and stroke.
  • Regular, light exercise can help ease knee pain and improve blood flow to your heart. This is beneficial for blood pressure.
  • Talk with your health care provider if you rely regularly on NSAIDs and have concerns about heart-related risks. You may have other options for pain relief.

Achilles tendon injuries

This past weekend DeMeco Ryans of the Philadelphia Eagles became another athlete to suffer an Achilles tendon injury. It has been a rough NFL season so far with many players suffering a wide variety of injuries.  DeAngelo Hall of the Washington Redskins just tore his Achilles tendon for the second time in two months.  Other athletes from different sports who have suffered the same injury include: Kobe Bryant, David Beckham (soccer player), Vinny Testaverde (former NFL quarterback), and Ryan Howard (Phillies baseball player).

 

(L to R: Hall, Ryans, Bryant….google.com/images)

The term “torn Achilles” is often succeeded by “season ending” or “early retirement” in an injury report but the exact definition of the injury often remains ambiguous to the Sports page reader.

What is the Achilles Tendon? 

The Achilles tendon is a band of tissue that connects the calf muscle (gastrocnemius) to the heel bone (calcaneus). The Achilles tendon facilitates walking by helping to raise the heel off the ground. It is the thickest and strongest tendon in the human body.

What is an Achilles Tendon Rupture?
An Achilles tendon rupture is a complete or partial tear that occurs when the tendon is stretched beyond its capacity. Forceful jumping or pivoting, or sudden accelerations of running, can overstretch the tendon and cause a tear. An injury to the tendon can also result from falling or tripping.

Achilles tendon ruptures are most often seen in “weekend warriors” – typically, middle-aged people participating in sports in their spare time. Less commonly, illness or medications, such as steroids or certain antibiotics, may weaken the tendon and contribute to ruptures.  
The injury is also seen in high performance professional athletes whose tendons may become fatigued during a game, overused after repetitive practices or improperly warmed up before activity.

Signs and Symptoms 
A person with a ruptured Achilles tendon may experience one or more of the following:

  • Sudden pain (which feels like a kick or a stab) in the back of the ankle or calf – often subsiding into a dull ache
  • A popping or snapping sensation
  • Swelling on the back of the leg between the heel and the calf
  • Difficulty walking (especially upstairs or uphill) and difficulty rising up on the toes

(foothealthfacts.org- ACFAS)

These symptoms require prompt medical attention to prevent further damage. Until the patient is able to see a podiatrist, the “R.I.C.E.” method should be used. This involves:

  • Rest. Stay off the injured foot and ankle, since walking can cause pain or further damage.
  • Ice. Apply a bag of ice covered with a thin towel to reduce swelling and pain. Do not put ice directly against the skin.
  • Compression. Wrap the foot and ankle in an elastic bandage to prevent further swelling.
  • Elevation. Keep the leg elevated to reduce the swelling. It should be even with or slightly above heart level.

Diagnosis
In diagnosing an Achilles tendon rupture, the podiatric surgeon will ask questions about how and when the injury occurred and whether the patient has previously injured the tendon or experienced similar symptoms. The surgeon will examine the foot and ankle, feeling for a defect in the tendon that suggests a tear. Range of motion and muscle strength will be evaluated and compared to the uninjured foot and ankle. If the Achilles tendon is ruptured, the patient will have less strength in pushing down (as on a gas pedal) and will have difficulty rising on the toes.

The diagnosis of an Achilles tendon rupture is typically straightforward and can be made through this type of examination. In some cases, however, the surgeon may order an MRI or other advanced imaging tests. We have an ultrasound machine in both offices which can visualize the tendon with non-invasive imaging to see tears or a complete rupture.

Treatment 
Treatment options for an Achilles tendon rupture include surgical and non-surgical approaches. The decision of whether to proceed with surgery or non-surgical treatment is based on the severity of the tear or rupture and the patient’s health status

Physical Therapy 
Whether an Achilles tendon rupture is treated surgically or non-surgically, physical therapy is an important component of the healing process. Physical therapy involves exercises that strengthen the muscles and improve the range of motion of the foot and ankle.  We have two physical therapists in the Thousand Oaks office who specialize in foot and ankle exercises and rehab activities.

Please contact our office for more information- (805) 497-6979

Too bad we all can’t look as good as David Beckham looks in his CAM walker!

 

 

 

Get a leg up on treating chronic venous insufficiency

 *Compression stockings*
  • Many people need to wear compression stockings to assist blood and other fluid circulating in the legs to get back to the heart.
  •  A lot of times, patients are turned off by these garments because they are very difficult to put due to how tight they need to be. 
  • In order for the stockings to be effective, they need to have some degree of compression

An alternative that may be an option that was seen working for one of our patients today is a Velcro version of the stockings.

One is pictured below and is made of lycra and nylon. The material is similar to the same
material that wetsuits are made of and machine washable.

For those who don’t know what venous stasis or chronic venous insufficiency (CVI) is, or would like more information, please click here to read an article Dr. Zapf wrote:

http://www.theacorn.com/news/2013-07-18/Health_(and)_Wellness/Dont_be_vein_when_it_comes_to_healthy_feet.html

A little about nail polish…

“You guys sell nail polish?”  This is a question heard daily in our offices.  Not only do we sell nail polish, but we sell Dr. Remedy nail polish, which is made from a blend of wheat protein, tea tree oil, garlic bulb extract and lavender. There is no formaldehyde, formaldehyde resin, or toluene. This nail polish enhances the appearance of dry, discolored nails. There are over 20 colors to chose from and if you can’t decide, ask one of our Medical Assistants in the Agoura Hills or Thousand Oaks office to recommend their favorite nail polish color to you.  Have a suggestion for a new color, please let us know!

 

 

 

Please click on the link to read more about the polish: http://www.remedynails.com/askthedr.aspx

FDA warns of risk for possibly permanent nerve damage from antibacterial fluoroquinolone drugs

Safety Announcement

[8-15-2013]  The U.S. Food and Drug Administration (FDA) has required the drug labels and Medication Guides for all fluoroquinolone antibacterial drugs be updated to better describe the serious side effect of peripheral neuropathy. This serious nerve damage potentially caused by fluoroquinolones (see Table for a list) may occur soon after these drugs are taken and may be permanent.

The risk of peripheral neuropathy occurs only with fluoroquinolones that are taken by mouth or by injection.  Approved fluoroquinolone drugs include levofloxacin (Levaquin), ciprofloxacin (Cipro), moxifloxacin (Avelox), norfloxacin (Noroxin), ofloxacin (Floxin), and gemifloxacin (Factive).  The topical formulations of fluoroquinolones, applied to the ears or eyes, are not known to be associated with this risk.

If a patient develops symptoms of peripheral neuropathy, the fluoroquinolone should be stopped, and the patient should be switched to another, non-fluoroquinolone antibacterial drug, unless the benefit of continued treatment with a fluoroquinolone outweighs the risk. Peripheral neuropathy is a nerve disorder occurring in the arms or legs. Symptoms include pain, burning, tingling, numbness, weakness, or a change in sensation to light touch, pain or temperature, or the sense of body position.  It can occur at any time during treatment with fluoroquinolones and can last for months to years after the drug is stopped or be permanent.  Patients using fluoroquinolones who develop any symptoms of peripheral neuropathy should tell their health care professionals right away.

FDA will continue to evaluate the safety of drugs in the fluoroquinolone class and will communicate with the public again if additional information becomes available.

To read the article in its entirety, click on the following link: http://
www.fda.gov/Drugs/DrugSafety/ucm365050.htm

Choice Health Associates

Our own Drs. Zapf, Payne and Benson are members of Choice Health Associates. This is a group of more than 200 local doctors who have banded together to offer the best in medical service to the patients from Calabasas to Moorpark and Camarillo. We all agree to see referrals as soon as possible and the very same day if necessary. For those who need a general doctor TODAY there is an internist or family practitioner every day to see new patients immediately. In some cases these are doctors with practices closed to new patients who will agree to see whoever calls the CHA phone number. All CHA physicians are Board Certified and are the best in their field with many years (in some cases decades) of experience. This is not a collection of doctors fresh out of residency with very little real world experience. All of the doctors in CHA have the best of referrals readily available for your medical needs.