My dad has diabetic neuropathy and I’ve seen all the therapies he has tried (mostly oral meds of various classes as well as various topical creams).
I don’t know the anatomy of the foot, but is using a nerve block like ablation therapy, botox or cryoneurolysis on the nerves in the lower leg a way to prevent pain signals from being transmitted from the foot to the brain? Like do doctors damage the nerve in the ankle that sends pain signals from the foot to the brain as a treatment option?
Has he tried Gabapentin? I take 900mg (three 300mg caps) per day, and it really helps. It doesn’t get rid of the pain entirely, but it’s bearable.
I’d be wary of using a nerve block. Don’t you need to have pain receptors in your foot? And what happens when he gets neuropathy in his hands? Will you block the nerves there too?
Mom was told they work for a while, but wear off, and that each time you get them, they may last less long.
Fortunately, it turns out the worst of her nerve pain was actually a bad hip, which she got replaced.
Note this was backs and hip area, not a foot.
Well, sort of…
Pain is a warning signal, and a nerve block de-activates it. It’s not that you are more likely to injure your foot once you do that, it’s that you won’t notice the damage done and properly attend to it without the pain signal which can lead to raging infections and even amputation. Especially in diabetics, who have trouble healing injuries due to the diabetes and are more vulnerable to certain types of infections.
I’ll also point out that lack of pain when a limb is injured is the primary reason lepers wind up losing bits and pieces and not the leprosy disease itself. People born with the inability to feel pain have similar problems.
It’s not inevitable that things will get out of hand - my late spouse had little feeling in his lower limbs, and essentially none at all below the knees, and managed to get through life without losing toes or worse. He also had an elaborate examination ritual for his feet that he followed religiously and dealt with problems promptly. Also did not have diabetes until the last ten years of his life so in his younger and more active years had fewer problems with healing any damage that did occur than an older diabetic individual would have. By the time he did have diabetes the foot examination habits were well ingrained.
But it remains that while using a nerve block is likely to solve a diabetic nephropathy problem it creates a different vulnerability that can have serious consequences. It would be a mater of weighing the benefits and risks of both the initial problem and the issues that would arise from the treatment.
My impression is he has used anticonvulsants, opioids and various topical creams for it.
While I agree that a good analgesic opens up the opportunity for new injuries to develop, isn’t this a risk with any analgesic therapy? Also for many patients the negative effect of pain on quality of life seems to outweigh the increased risk of an injury. Plus many diabetics have a lot of numbness in addition to pain, so their sensation is already low.
“Analgesic” usually implies pain reduction, not sensory reduction. Aspirin/acetaminophen/paracetamol/ibuprofen/NSAID’s reduce pain and in some cases inflammation and thus are analgesic, but if you cut yourself while taking those you’ll still feel some pain. Your sensory nerves are not disabled. If you hurt yourself you’ll know it, even if the input may be somewhat reduced.
A nerve block, on the other had, cuts the sensory input. You don’t feel pain, pressure, heat, cold, or other sensation that could warn you of damage.
Nerve blocks are not recommended for diabetic neuropathy. Nerve blocks are most effective in the cases where one or two particular nerves are causing the problem. Diabetic neuropathy involves virtually all the nerves in a particular region, despite the fact that they come from several different nerve roots.
If medications are needed, the hallmarks of therapy are meds such as Amtriptyline, venlafaxine, duloxetine, and pregabalin. There’s controversy about how effective gabapentin is, and it has been associated with an increase in bad outcomes (like sudden death) so its use has been de-emphasized. Opioids are generally to be avoided, as they don’t stay effective over time without significant dose elevations, and have other problems.
Topical treatments like capsaicin cream, lidocaine patches, and isosorbide dinitroglycerine sprays are seen as helpful So are TENS units.
Spinal cord stimulators and alpha lipoic acid infusions are also being explored as possibly helpful treatments.
I’ve read about the question of gabapentin’s effectiveness, but it most certainly worked for me for severe back pain due to stenosis/sciatica. I couldn’t walk all the way across a room without help until I went on it. No side effects after the first week. I was on it for 2-3 years. I was up to 2400 mg/day until I finally had surgery a year ago, and tapered off over the next few months. I don’t take anything now.
It really surprises me to read lately that its effectiveness is doubted. I would surmise that the questionable study results are due to people whose pain would have resolved on their own anyway, which is a good percentage of people with nerve pain, and people for whom it never really worked anyway except for placebo effect.
From UpTodate
make of it what you will.
So glad to hear it’s now working for you, panache45! I remember you posting awhile back that it wasn’t doing you any good (presumably at a lower dose? ). I reached a point where I wasn’t getting any more pain relief beyond 2400mg/day, then stayed there for a year or so.
if one takes more than 2400 a day, very very little of it is absorbed. Higher doses don’t make much sense, given that situation.
Gabapentin has always helped my neuropathy, but it has absolutely no effect on my spinal stenosis pain.