Not So Happy Feet

Mayo Clinic
Peripheral neuropathy
Peripheral neuropathy — Comprehensive overview covers diagnosis, causes and treatment of this often painful disorder.
Definition

Peripheral neuropathy often causes numbness and pain in your hands and feet. People typically describe the pain of peripheral neuropathy as tingling or burning, while they may compare the loss of sensation to the feeling of wearing a thin stocking or glove.

Peripheral neuropathy is caused by nerve damage. It can result from such problems as traumatic injuries, infections, metabolic problems and exposure to toxins. One of the most common causes is diabetes.

In many cases, peripheral neuropathy symptoms improve with time — especially if it’s caused by an underlying condition that can be treated. A number of medications are often used to reduce the painful symptoms of peripheral neuropathy.

Symptoms

Your nervous system is divided into two broad categories. Your central nervous system consists of your brain and spinal cord. All the other nerves in your body are part of your peripheral nervous system. Peripheral neuropathy affects those nerves, which include:

  • Sensory nerves to receive feelings such as heat, pain or touch
  • Motor nerves that control how your muscles move
  • Autonomic nerves that control such automatic functions as blood pressure, heart rate, digestion and bladder function

Most commonly, peripheral neuropathy may start in the longest nerves — the ones that reach to your toes. Specific symptoms vary, depending on which types of nerves are affected. Signs and symptoms may include:

  • Gradual onset of numbness and tingling in your feet or hands, which may spread upward into your legs and arms
  • Burning pain
  • Sharp, jabbing or electric-like pain
  • Extreme sensitivity to touch, even light touch
  • Lack of coordination
  • Muscle weakness or paralysis if motor nerves are affected
  • Bowel or bladder problems if autonomic nerves are affected

When to see a doctor
Seek medical care right away if you notice any unusual tingling, weakness or pain in your hands or feet. Early diagnosis and treatment offers the best chance for controlling your symptoms and preventing further damage to your peripheral nerves. If your symptoms are interfering with your sleep or you feel depressed, your doctor or pain specialist may be able to suggest treatments that can help.

Causes

It’s not always easy to pinpoint the cause of peripheral neuropathy, because a number of factors can cause neuropathies. These factors include:

  • Trauma or pressure on the nerve. Traumas, such as motor vehicle accidents, falls or sports injuries, can sever or damage peripheral nerves. Nerve pressure can result from using a cast or crutches, spending a long time in an unnatural position, or repeating a motion many times — such as typing.
  • Diabetes. When damage occurs to several nerves, the cause frequently is diabetes. At least half of all people with diabetes develop some type of neuropathy.
  • Vitamin deficiencies. B vitamins — B-1, B-6 and B-12 — are particularly important to nerve health. Vitamin E and niacin also are crucial to nerve health.
  • Alcoholism. Many alcoholics develop peripheral neuropathy because they have poor dietary habits, leading to vitamin deficiencies.
  • Infections. Certain viral or bacterial infections can cause peripheral neuropathy, including Lyme disease, shingles (varicella-zoster), Epstein-Barr, hepatitis C and HIV/AIDS.
  • Autoimmune diseases. These include lupus, rheumatoid arthritis and Guillain-Barre syndrome.
  • Other diseases. Kidney disease, liver disease and an underactive thyroid (hypothyroidism) also can cause peripheral neuropathy.
  • Inherited disorders. Examples include Charcot-Marie-Tooth disease and amyloid polyneuropathy.
  • Tumors. Growths can form directly on the nerves themselves, or tumors can exert pressure on surrounding nerves. Both cancerous (malignant) and noncancerous (benign) tumors can contribute to peripheral neuropathy.
  • Exposure to poisons. These may include some toxic substances, such as heavy metals, and certain medications — especially those used to treat cancer (chemotherapy).
Risk factors

Peripheral neuropathy risk factors include:

  • Diabetes, especially if your sugar levels are poorly controlled
  • Alcohol abuse
  • Vitamin deficiencies, particularly B vitamins
  • Infections, such as Lyme disease, shingles (varicella-zoster), Epstein-Barr, hepatitis C and HIV/AIDS
  • Autoimmune diseases, such as rheumatoid arthritis and lupus, in which the immune system attacks your own tissues
  • Kidney, liver or thyroid disorders
  • Exposure to toxins
  • Repetitive physical stress, possibly from occupational activities
Complications
  • Reduced feeling. Because parts of your body may be numb, you may be less likely to feel temperature changes or an injury.
  • Infection. Make sure to check your feet, as well as any other areas lacking usual sensation, regularly so that you can treat minor injuries before they become infected. This is especially important for people with diabetes, who tend to heal more slowly.
Preparing for your appointment

You’re likely to start by seeing your family doctor or a general practitioner. However, you may then be referred to a doctor who specializes in nervous system disorders (neurologist).

Because appointments can be brief and there’s often a lot of ground to cover, it’s a good idea to arrive well prepared. Here’s some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

  • Write down any symptoms you’re experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
  • Make a list of all medications, vitamins and supplements that you’re taking.
  • Ask a family member or friend to come with you, if possible. Sometimes it can be difficult to remember all of the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
  • Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions can help you make the most of your time together. List your questions from most important to least important in case time runs out. For peripheral neuropathy, some basic questions to ask your doctor include:

  • What’s the most likely cause of my symptoms?
  • Are there other possible causes for my symptoms?
  • What kinds of tests do I need? Do these tests require any special preparation?
  • Is this condition temporary or long lasting?
  • What treatments are available, and which do you recommend?
  • What types of side effects can I expect from treatment?
  • Are there any alternatives to the primary approach that you’re suggesting?
  • I have other health conditions. How can I best manage them together?
  • Are there any activity restrictions that I need to follow?
  • Is there a generic alternative to the medicine you’re prescribing me?
  • Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?

In addition to the questions that you’ve prepared to ask your doctor, don’t hesitate to ask questions during your appointment at any time that you don’t understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

  • Do you have any underlying health conditions, such as diabetes or kidney disease?
  • When did you first begin experiencing symptoms?
  • Have your symptoms been continuous or occasional?
  • How severe are your symptoms?
  • Does anything seem to improve your symptoms?
  • What, if anything, appears to worsen your symptoms?
Tests and diagnosis

Peripheral neuropathy isn’t a single disease, but rather a symptom with many potential causes. For that reason it can be difficult to diagnose. To help in the diagnosis, your doctor will likely take a full medical history and perform a physical and neurological exam that may include checking your tendon reflexes, your muscle strength and tone, your ability to feel certain sensations, and your posture and coordination.

Blood tests
Your doctor may also request blood tests to check your:

  • Vitamin levels
  • Thyroid function
  • Blood sugar levels
  • Liver function
  • Kidney function

Electromyography
This test measures the electrical signals in peripheral nerves, and the transfer of that signal to muscles. As a part of this test, you’ll be asked to have a nerve conduction study, which measures how quickly your nerves carry electrical signals. A nerve conduction study can be used to diagnose carpal tunnel syndrome and other peripheral nerve disorders.

Nerve biopsy
Additionally, your doctor may recommend a nerve biopsy, a procedure in which a small portion of a nerve is removed and examined for abnormalities. But even a nerve biopsy may not always reveal what’s damaging your nerves.

Imaging tests
Your doctor may also request a CT scan or MRI to look for herniated disks, tumors or other abnormalities.

Treatments and drugs

One goal of treatment is to manage the condition causing your neuropathy. If the underlying cause is corrected, the neuropathy often improves on its own. Another goal of treatment is to relieve the painful symptoms. Many types of medications can be used to relieve the pain of peripheral neuropathy:

  • Pain relievers. Mild symptoms may be relieved by over-the-counter pain medications. For more severe symptoms, your doctor may recommend prescription painkillers. Drugs containing opiates, such as codeine, can lead to dependence, constipation or sedation, so these drugs are generally prescribed only when other treatments fail.
  • Anti-seizure medications. Drugs such as gabapentin (Neurontin), topiramate (Topamax), pregabalin (Lyrica), carbamazepine (Tegretol) and phenytoin (Dilantin) were originally developed to treat epilepsy. However, doctors often also prescribe them for nerve pain. Side effects may include drowsiness and dizziness.
  • Lidocaine patch. This patch contains the topical anesthetic lidocaine. You apply it to the area where your pain is most severe, and you can use up to four patches a day to relieve pain. This treatment has almost no side effects except, for some people, a rash at the site of the patch.
  • Antidepressants. Tricyclic antidepressant medications, such as amitriptyline and nortriptyline (Pamelor), were originally developed to treat depression. However, they have been found to help relieve pain by interfering with chemical processes in your brain and spinal cord that cause you to feel pain. The serotonin and norepinephrine reuptake inhibitor duloxetine (Cymbalta) also has proved effective for peripheral neuropathy caused by diabetes. Side effects may include nausea, drowsiness, dizziness, decreased appetite and constipation.
  • Transcutaneous electrical nerve stimulation (TENS). In this therapy, adhesive electrodes are placed on the skin and a gentle electric current is delivered through the electrodes at varying frequencies. TENS has to be done frequently, but some people report this therapy improves their symptoms.
Lifestyle and home remedies

The following suggestions can help you manage peripheral neuropathy:

  • Take care of your feet, especially if you have diabetes. Check your feet daily for signs of blisters, cuts or calluses. Tight shoes and socks can worsen pain and tingling and may lead to sores that won’t heal. Wear soft, loose cotton socks and padded shoes. You can use a semicircular hoop, which is available in medical supply stores, to keep bedcovers off hot or sensitive feet.
  • Exercise. Ask your doctor about an exercise routine that’s right for you. Regular exercise may reduce neuropathy pain and can help control blood sugar levels.
  • Quit smoking. Cigarette smoking can affect circulation, increasing the risk of foot problems and possibly amputation.
  • Eat healthy meals. If you’re at high risk of neuropathy or have a chronic medical condition, healthy eating is especially important to ensure that you get essential vitamins and minerals. Emphasize low-fat meats and dairy products and include lots of fruits, vegetables and whole grains in your diet. Drink alcohol in moderation, if at all.
  • Massage your hands and feet, or have someone massage them for you. Massage helps improve circulation, stimulates nerves and may temporarily relieve pain.
  • Avoid prolonged pressure. Don’t keep your knees crossed or lean on your elbows for long periods of time. Doing so may cause new nerve damage.
Alternative medicine

Some people with peripheral neuropathy try alternative treatments for relief of their symptoms. Although these techniques haven’t been as rigorously studied as most medications, the following therapies have shown some promise in the treatment of peripheral neuropathy:

  • Acupuncture. Acupuncture involves the insertion of thin needles into various points on your body. Acupuncture may reduce symptoms in about three-quarters of people with peripheral neuropathy. However, you may need multiple acupuncture sessions before you notice improvement. Acupuncture is generally considered safe when performed by a certified practitioner using sterile needles.
  • Capsaicin. A cream containing this naturally occurring substance found in hot peppers can cause modest improvements in peripheral neuropathy symptoms. Like spicy foods, it may take some time and gradual exposure to get used to because of the hot sensation that this cream creates. Pain relief usually doesn’t occur until after you get used to the heat. Doctors may suggest you use this cream in combination with other treatments.
  • Alpha-lipoic acid. Used as a treatment for peripheral neuropathy in Europe for years, this antioxidant may help reduce the symptoms of peripheral neuropathy. Discuss the use of alpha-lipoic acid with your doctor before using it, because alpha-lipoic acid may affect your blood sugar levels. Side effects may include stomach upset and skin rash.
  • Biofeedback. During a biofeedback session, the therapist applies electrical sensors to different parts of your body to monitor your body’s physiological response to your peripheral neuropathy symptoms. The biofeedback device then teaches you how your body responds using cues such as a beeping sound or flashing lights. This feedback can help you associate your body’s response with certain physical functions. Once you begin to recognize your body’s responses, you can learn ways to lessen the reaction through techniques such as relaxation or guided imagery.
Prevention

Manage underlying conditions
The best way to prevent peripheral neuropathy is to carefully manage any medical condition that puts you at risk. That means controlling your blood sugar level if you have diabetes or talking to your doctor about safe and effective treatments if you think you may have a problem with alcohol.

Adopt healthy lifestyle habits
Whether or not you have a medical condition, eating a healthy diet that’s rich in fruits, vegetables, whole grains and lean protein can help keep your nerves healthy. For example, nerve damage is common if you have a vitamin B-12 deficiency. The best food sources of vitamin B-12 are meats, fish, eggs, low-fat dairy foods and fortified cereals. If you’re a strict vegetarian, fortified cereals are a good source of vitamin B-12 for you, but you may also want to talk to your doctor about B-12 supplements. Regular exercise also is important. If possible, try to get at least 30 minutes to one hour of exercise at least three times a week.

As much as possible, avoid things that can cause nerve damage, such as:

  • Repetitive motions
  • Cramped positions
  • Toxic chemicals
  • Tobacco smoke
  • Excessive alcohol consumption
© 1998-2010 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of these materials may be reprinted for noncommercial personal use only. “Mayo,” “Mayo Clinic,” “MayoClinic.com,” “EmbodyHealth,” “Reliable tools for healthier lives,” “Enhance your life,” and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research.

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