In an older article, I wrote about the benefits and drawbacks of microvascular decompression. Microvascular decompression is a procedure in which the patient's head is opened up to reveal the trigeminal nerve near the cerebellum; oftentimes, if the nerve pain is caused by pressure from a proximal blood vessel, a sponge is placed between the nerve and the vessel to distance the sensitive cells from the throbbing vessel. Balloon compression is similar to this treatment in that it also involves accessing the trigeminal nerve through an opening in the skull, but instead of trying to preserve the nerve by separating it from the offending blood vessel, the goal of the procedure is to damage it mechanically so it no longer transmits painful signals.
Thus, this procedure- compared to other surgical options- has a negative connotation because it damages rather than restores the nerve. However, this should not be the primary reason a patient shies away from the procedure; indeed, the procedure is generally successful, can be performed on a variety of patients, and is cost-effective. Of course, as with any surgical procedure, there are side effects- some of which are greater for balloon compression.
But what is the procedure like? As mentioned above, balloon compression is a rhizotomy, which means it is performed to damage the nerve. Specifically, this occurs at the point near the base of the skull where the nerve splits into its three "branches." A benefit of balloon compression is that, considering it is a surgical procedure, the process is relatively non-invasive: while the patient is under general anesthesia, the doctor inserts a hollow needle (a tube called a "cannula") through the cheek. The hollow cannula allows the doctor to thread a soft catheter with a balloon tip towards the nerve at the base of the skull. Once there, the balloon is inflated to press the nerve against the skull and the dura, which covers the brain, mechanically damaging the nerve. The balloon is only inflated for about a minute, then it is removed (with the cannula). The procedure in its entirety takes only about 20 min, so it is generally an outpatient procedure. Although considered non-invasive for a surgery (there are very few side effects associated with the actual procedure or general anesthesia), it is nevertheless a final alternative for patients who have not had success with their medication for trigeminal neuralgia.
Unfortunately, because the nerve is being damaged and not preserved, there are side effects. Balloon compression offers only a small chance of losing sensation permanently, but many patients develop at least temporary weakness (especially in the jaw, for chewing) and facial numbness is more severe with this procedure than with other rhizotomy procedures. In fact, masseter (chewing) muscle weakness is practically guaranteed, although new procedures are being developed which employ a shorter compression time and more monitoring during surgery (Brown and Pilitsis), to help reduce muscle weakness. And unfortunate corollary of this development is that, while it does successfully control pain, in many cases the pain has recurred. Yet, there is no procedure which does guarantee against recurrent pain among trigeminal neuralgia patients, so balloon compression is actually a very viable option, particularly as a non-invasive surgical alternative for patients with recurrent pain after microvascular decompression.
Other positive aspects of balloon compression are its cost-effectiveness and the fact that it works well for patients suffering with other coexisting health conditions. Because it only requires general anesthesia and exposes no other nerves, it has few negative interactions with other treatments. Lastly, if the nerve pain cannot be pinpointed, or if it is caused by something other than pressure from a proximal vessel, stopping the nerve signals with balloon compression would be more helpful than microvascular decompression (particularly if the doctor can find no offending blood vessel during the MVD procedure).
Saturday, June 12, 2010
Tuesday, June 1, 2010
Alternative (herbal) treatments for Neuralgia
Here is a short list of several herbal supplements that people have used to augment treatments for neuralgias. Keep in mind that few (actually, none that I could find) of these herbal remedies have been scientifically proven to aid neuralgia; they are on this list because I have encountered them in the course of researching possible neuralgia treatments. Additionally, all of the alternative treatments are most effective when used in conjunction with other, more conventional treatment courses (typically, a combination of herbal supplements and anticonvulsants or antidepressants).
1) Zanthoxylum clava-herculisis. Also known as "toothache tree," this spiny tree can reduce pain from a toothache because chewing on the bark or leaves numbs the teeth and tongue. It can be helpful for trigeminal neuralgia patients because of its "antispasmodic" properties for the face and mouth.
2) Matricaria recutita, commonly known as German Chamomile, is typically used to treat stomachache and IBS (Irritable Bowel Syndrome), because it is a mild laxative. It is also helpful for sleeping (hence the inclusion of chamomile in many "sleeping" teas), and is anti-inflammatory. Most importantly, in studies with animals the plant has exhibited anti- inflammatory and convulsant properties (as stated above, research is lacking to confirm similar results in humans).
3) Arctium lappa (Burdock) is traditionally used to treat respiratory disorders, joint pain and urinary problems by stimulating cell regeneration. It helps protect against cell damage and abnormal growth, but it is better applied to joint pain and sciatica, rather than neuralgia.
4) Harpagophytum procumbens (Devil's Claw) is also good for treating (chronic) joint pain. It contains harpagoside and beta-sitosterol, which have anti-inflammatory properties, and is good for chronic lower-back pain. Doloteffin is a standardized preparation of Devil's Claw. Unfortunately, Devil's Claw promotes the secretion of stomach acids, so side effects involve gastric complications such as ulcers and stomach discomfort.
5) Asperula odorata (sweet woodruff) also has anti-spasmodic and sedative effects.
Concerning the treatment of neuralgia, these supplements (although not tested in a loarge-scale, scientific setting) are good because they promote general health, and also tend to have minor side effects. Rare side effects include nausea and vomiting, as well as allergic reactions to chamomile (if you are allergic to pollen). Lastly, keep in mind that none of these treatments are specifically promoted as a means to aiding neuralgia- the properties they exhibit for other symptoms can likewise be helpful with certain forms of neuralgia.
Looking to purchase these alternative treatments? They should be available at most native remedy or herbal supplement stores. I looked online and had difficulty finding any "name brand," alternative products for neuralgia, although one product "SciatiGon" contains the first four supplements I mentioned above, and claims to reduce nerve pain, specifically for sciatica.
1) Zanthoxylum clava-herculisis. Also known as "toothache tree," this spiny tree can reduce pain from a toothache because chewing on the bark or leaves numbs the teeth and tongue. It can be helpful for trigeminal neuralgia patients because of its "antispasmodic" properties for the face and mouth.
2) Matricaria recutita, commonly known as German Chamomile, is typically used to treat stomachache and IBS (Irritable Bowel Syndrome), because it is a mild laxative. It is also helpful for sleeping (hence the inclusion of chamomile in many "sleeping" teas), and is anti-inflammatory. Most importantly, in studies with animals the plant has exhibited anti- inflammatory and convulsant properties (as stated above, research is lacking to confirm similar results in humans).
3) Arctium lappa (Burdock) is traditionally used to treat respiratory disorders, joint pain and urinary problems by stimulating cell regeneration. It helps protect against cell damage and abnormal growth, but it is better applied to joint pain and sciatica, rather than neuralgia.
4) Harpagophytum procumbens (Devil's Claw) is also good for treating (chronic) joint pain. It contains harpagoside and beta-sitosterol, which have anti-inflammatory properties, and is good for chronic lower-back pain. Doloteffin is a standardized preparation of Devil's Claw. Unfortunately, Devil's Claw promotes the secretion of stomach acids, so side effects involve gastric complications such as ulcers and stomach discomfort.
5) Asperula odorata (sweet woodruff) also has anti-spasmodic and sedative effects.
Concerning the treatment of neuralgia, these supplements (although not tested in a loarge-scale, scientific setting) are good because they promote general health, and also tend to have minor side effects. Rare side effects include nausea and vomiting, as well as allergic reactions to chamomile (if you are allergic to pollen). Lastly, keep in mind that none of these treatments are specifically promoted as a means to aiding neuralgia- the properties they exhibit for other symptoms can likewise be helpful with certain forms of neuralgia.
Looking to purchase these alternative treatments? They should be available at most native remedy or herbal supplement stores. I looked online and had difficulty finding any "name brand," alternative products for neuralgia, although one product "SciatiGon" contains the first four supplements I mentioned above, and claims to reduce nerve pain, specifically for sciatica.
Monday, May 10, 2010
Transcutaneous Electrical Nerve Stimulation: Too Experimental for PHN?
Transcutaneous electrical nerve stimulation, also known as TENS or TNS, involves placing tiny electrodes over the region experiencing pain. The electrodes deliver electrical impulses to nearby nerve pathways, relieving the pain (Mayo Clinic). Unfortunately, the process is very experimental: it does not work for everyone, and in fact can exacerbate the pain. The exact reason for relief is not known, although it is believed that the new electrical impulses trigger the release of endorphins, a natural painkiller.
On their website, Aetna lists the following as medically necessary for postherpetic neuraglgia (PHN): tricyclic antidepressants, gabapentin, pregabalin, opioids (oral), antivirals (oral), lidocaine patch, and intrathecal corticosteroids. However, it decrees TENS "experimental and investigational because their effectiveness for this indication has not been established" (Aetna clinical policy bulletin number 0725). According to the same site, there have been findings that report positive effects of TENS on some patients with PHN, but no validated, randomized and controlled study has been conducted. Additionally, in 1995 Reeve and Corabian evaluated evidence for clinical success of TENS on acute and chronic pain and found the results inconclusive.
Overall, TENS offers an interesting alternative to many PHN treatments; however, it raises the question, why use a treatment with significantly less conclusive results when you can use a less-questionable treatment? Admittedly, one positive reason to try TENS is its few side effects: it's not invasive, addictive, can be used for indeterminate amounts of time, and does not interfere with oral medications. It should not, however, be used with patients who have pacemakers because the electrical signals of the two devices could interfere with one another. The side effects that have been experienced with TENS include skin irritation from the electrode pads, and burns from extended exposure to stimulation. Yet, even with minor side effects, TENS has not proved to be any more revolutionary or helpful than other established treatments. Also, on a personal note, although I recognize that there are still many things about the body's processes that we do not understand, and this lack of comprehension does not prevent them from being effective, I would nevertheless favor a treatment that works through a known mechanism (particularly if it yields the same results).
But on the other hand, simply because we have not developed the treatment or the studies to their fullest extent does not mean we should dismiss it; there can be ample room for improvement. in an effort to give equal consideration to both sides of the TENS debate, it should be noted that although the treatment may be cumbersome and experimental, it nevertheless requires little effort from the patient and could be very manageable for people who do not need to travel much. And, of course, it would be very worthwhile if it eliminated PHN pain.
TENS can also be used to administer topical steroid medication through the skin to treat acute pain, because the electrical current it generates helps move the steroids into soft tissue, reducing inflammation. The TENS unit is battery-operated portable; it can be worn around the waist and can be turned on or off as needed for pain control. They can cost anywhere from approximately one hundred dollars, all the way up to six hundred dollars from the top manufacturers. The units are purchased or rented with a prescription, and a physical therapist should be consulted on the proper placement of the electrodes. Generally, TENS is used on a trial basis before being recommended as a long-term treatment. Of course, before using a TENS unit, be sure you have spoken to a physical therapist or doctor and know how to work the device and set the electrical signals at appropriate levels.
On their website, Aetna lists the following as medically necessary for postherpetic neuraglgia (PHN): tricyclic antidepressants, gabapentin, pregabalin, opioids (oral), antivirals (oral), lidocaine patch, and intrathecal corticosteroids. However, it decrees TENS "experimental and investigational because their effectiveness for this indication has not been established" (Aetna clinical policy bulletin number 0725). According to the same site, there have been findings that report positive effects of TENS on some patients with PHN, but no validated, randomized and controlled study has been conducted. Additionally, in 1995 Reeve and Corabian evaluated evidence for clinical success of TENS on acute and chronic pain and found the results inconclusive.
Overall, TENS offers an interesting alternative to many PHN treatments; however, it raises the question, why use a treatment with significantly less conclusive results when you can use a less-questionable treatment? Admittedly, one positive reason to try TENS is its few side effects: it's not invasive, addictive, can be used for indeterminate amounts of time, and does not interfere with oral medications. It should not, however, be used with patients who have pacemakers because the electrical signals of the two devices could interfere with one another. The side effects that have been experienced with TENS include skin irritation from the electrode pads, and burns from extended exposure to stimulation. Yet, even with minor side effects, TENS has not proved to be any more revolutionary or helpful than other established treatments. Also, on a personal note, although I recognize that there are still many things about the body's processes that we do not understand, and this lack of comprehension does not prevent them from being effective, I would nevertheless favor a treatment that works through a known mechanism (particularly if it yields the same results).
But on the other hand, simply because we have not developed the treatment or the studies to their fullest extent does not mean we should dismiss it; there can be ample room for improvement. in an effort to give equal consideration to both sides of the TENS debate, it should be noted that although the treatment may be cumbersome and experimental, it nevertheless requires little effort from the patient and could be very manageable for people who do not need to travel much. And, of course, it would be very worthwhile if it eliminated PHN pain.
TENS can also be used to administer topical steroid medication through the skin to treat acute pain, because the electrical current it generates helps move the steroids into soft tissue, reducing inflammation. The TENS unit is battery-operated portable; it can be worn around the waist and can be turned on or off as needed for pain control. They can cost anywhere from approximately one hundred dollars, all the way up to six hundred dollars from the top manufacturers. The units are purchased or rented with a prescription, and a physical therapist should be consulted on the proper placement of the electrodes. Generally, TENS is used on a trial basis before being recommended as a long-term treatment. Of course, before using a TENS unit, be sure you have spoken to a physical therapist or doctor and know how to work the device and set the electrical signals at appropriate levels.
Saturday, May 8, 2010
Lidocaine Patches and PHN
Postherpetic neuralgia is a complication of shingles, which occurs when the virus that causes chicken pox remains in the body, dormant in nerve cells. Shingles manifests as rash and blisters accompanied by pain, but sometimes the pain remains even after the skin condition has disappeared. This is postherpetic neuralgia. Although there are a number of treatments, including steroids, painkillers, and even antidepressants, lidocaine skin patches offer one easy-to-use alternative with (usually) no side effects.
In a 1999 blind study conducted by the Education and Research in Pain Medicine and Palliative Care (Beth Israel Medical Centre, New York), researchers found that 78% of the subjects preferred the lidocaine patch treatment over that of a placebo. Simply put, lidocaine patches are small patches (much like band-aids) that contain lidocaine, which can be applied directly to the skin to numb the areas experiencing pain.
Dermaflex and Lidoderm are two leading providers of lidocaine patches, with Dermaflex offering 2% lidocaine patches and Lidoderm offering 5%. Although PHN can be treated as effectively with pills (taken orally), which are absorbed internally, the patch has the positive feature of not requiring an increase in dosage. Another positive aspect of the patch is that it requires less attention: a patient can wear up to three patches at a time, for twelve hours without interruption (followed by twelve hours without the patch). Additionally, because the patch is not absorbed internally but through the skin, it carries an even smaller risk of interacting negatively with other medications. Side effects are minimal and rare; they include: Mild redness, swelling, burning, blisters, bruising, irritation, change in skin color, or numbness at the application site. Risk of cardiac arrest is increased for those on antiarrhythmic medications. Of course, if you experience any effects more serious than these (confusion, dizziness, allergic reaction), consult your doctor immediately.
On the other hand, the negative aspect of the treatment is that the patch needs to cover the skin where there is pain. If the region of pain is larger than the patch, it can still be effective (assuming size difference is not extreme and the lidocaine is applied to the most painful region), but the patch cannot be worn on the face, and many patients find it inconvenient to use the patch if the affected skin is not under clothing.
Lidocaine works by blocking sodium channels in the neuron (nerve cell) cell membrane. These sodium channels are responsible for nerve signal movement among nerve cells, and when blocked, the sodium cannot move in and out of the cell to amplify the sensory signals as they travel through the body. Thus, the action potential of the nerves is decreased and the lidocaine produces anaesthetic effects. The lidocaine patch, because it focuses the area being treated, can selectively treat postherpetic neuralgia.
In a 1999 blind study conducted by the Education and Research in Pain Medicine and Palliative Care (Beth Israel Medical Centre, New York), researchers found that 78% of the subjects preferred the lidocaine patch treatment over that of a placebo. Simply put, lidocaine patches are small patches (much like band-aids) that contain lidocaine, which can be applied directly to the skin to numb the areas experiencing pain.
Dermaflex and Lidoderm are two leading providers of lidocaine patches, with Dermaflex offering 2% lidocaine patches and Lidoderm offering 5%. Although PHN can be treated as effectively with pills (taken orally), which are absorbed internally, the patch has the positive feature of not requiring an increase in dosage. Another positive aspect of the patch is that it requires less attention: a patient can wear up to three patches at a time, for twelve hours without interruption (followed by twelve hours without the patch). Additionally, because the patch is not absorbed internally but through the skin, it carries an even smaller risk of interacting negatively with other medications. Side effects are minimal and rare; they include: Mild redness, swelling, burning, blisters, bruising, irritation, change in skin color, or numbness at the application site. Risk of cardiac arrest is increased for those on antiarrhythmic medications. Of course, if you experience any effects more serious than these (confusion, dizziness, allergic reaction), consult your doctor immediately.
On the other hand, the negative aspect of the treatment is that the patch needs to cover the skin where there is pain. If the region of pain is larger than the patch, it can still be effective (assuming size difference is not extreme and the lidocaine is applied to the most painful region), but the patch cannot be worn on the face, and many patients find it inconvenient to use the patch if the affected skin is not under clothing.
Lidocaine works by blocking sodium channels in the neuron (nerve cell) cell membrane. These sodium channels are responsible for nerve signal movement among nerve cells, and when blocked, the sodium cannot move in and out of the cell to amplify the sensory signals as they travel through the body. Thus, the action potential of the nerves is decreased and the lidocaine produces anaesthetic effects. The lidocaine patch, because it focuses the area being treated, can selectively treat postherpetic neuralgia.
Thursday, April 29, 2010
Glycerol Injections
Glycerol injections offer a low-risk surgical option to patients suffering from trigeminal neuralgia. Glycerol injections are one example of a rhizotomy; that is, a surgical procedure during which selected nerves are damaged to stop pain. Typically, the outpatient procedure is very straightforward: a needle is inserted through the skin (in the cheek, next to the mouth) into the trigeminal nerve near the base of the skull. This is the place where the three parts of the nerve come together and exits the skull. Doctors use an x-ray to confirm that the needle is in place, then they inject a small amount of glycerol, which damages the nerve and thus blocks the pain signal. Throughout the short process (it takes only a few minutes), the patient is sedated intravenously.
One very positive aspect of glycerol injections is their almost immediate effects; the glycerol acts quickly and stops nerve activity within a matter of hours. In a study published with the Journal of Neurosurgery by Harold Wilkinson, eighteen patients with trigeminal neuralgia were given sixty injections of 10% phenol, and "eighty-seven percent of injections brought marked or total relief initially." The downside to this procedure, however, is that the pain often returns for many patients. About half of the patients who benefit from glycerol injections will have recurrent pain within three or four years; glycerol injections can be performed more than once, but they are less effective over time (or with increasing number of procedures). In Wilkinson's study, relief lasted for an average of nine months and most patients requested a repeat procedure. Also, "Of those injections that provided initial relief, 37% still provided relief after 1 year and 30% after 2 years."
The logistics of the procedure are obviously very straightforward, and because it is so non-invasive, there are relatively few side effects associated with the surgery. Adverse effects to anesthesia are minimal (because the treatment is administered within such a short time), and other major problems include damage to the wrong nerve, or a failure to access the trigeminal nerve, as well as bleeding from the puncture site. The goal of the x-ray, of course, is to help target the correct nerve and prevent administering the glycerol to the incorrect site. More commonly, most patients experience mild facial numbness and/or tingling as a result of the damaged nerve, but this fades over time (unfortunately, numbness can persist for up to six months, which is not much shorter than the time frame for which the injection may be effective).
But how does the procedure really work? According to the National Institute of Neurological Disorders and Stroke, "The glycerol injection bathes the ganglion (the central part of the nerve from which the nerve impulses are transmitted) and damages the insulation of trigeminal nerve fibers." Glycerol and phenol (glycerol more commonly) are used as sympathetic blocks for nerve signals. On one hand, phenol dissolves nerve fibers and kills the nerve tissue prematurely (a process called "necrosis,") during which the dying cells do not signal to the immune system as normally-dying cells would do, leading to a build-up of dead tissue. This is why the injection is only administered in small amounts and to very specific regions of the nerve. Glycerol also prevents the nerve from producing signals by breaking up the nerve fibers. Over time, the pain may return as the nerve repairs and re-myelinates (coats) itself, although studies on rats indicate that examination of phenol- or glycerol- affected nerves can be morphologically distinguished from healthy nerves.
One very positive aspect of glycerol injections is their almost immediate effects; the glycerol acts quickly and stops nerve activity within a matter of hours. In a study published with the Journal of Neurosurgery by Harold Wilkinson, eighteen patients with trigeminal neuralgia were given sixty injections of 10% phenol, and "eighty-seven percent of injections brought marked or total relief initially." The downside to this procedure, however, is that the pain often returns for many patients. About half of the patients who benefit from glycerol injections will have recurrent pain within three or four years; glycerol injections can be performed more than once, but they are less effective over time (or with increasing number of procedures). In Wilkinson's study, relief lasted for an average of nine months and most patients requested a repeat procedure. Also, "Of those injections that provided initial relief, 37% still provided relief after 1 year and 30% after 2 years."
The logistics of the procedure are obviously very straightforward, and because it is so non-invasive, there are relatively few side effects associated with the surgery. Adverse effects to anesthesia are minimal (because the treatment is administered within such a short time), and other major problems include damage to the wrong nerve, or a failure to access the trigeminal nerve, as well as bleeding from the puncture site. The goal of the x-ray, of course, is to help target the correct nerve and prevent administering the glycerol to the incorrect site. More commonly, most patients experience mild facial numbness and/or tingling as a result of the damaged nerve, but this fades over time (unfortunately, numbness can persist for up to six months, which is not much shorter than the time frame for which the injection may be effective).
But how does the procedure really work? According to the National Institute of Neurological Disorders and Stroke, "The glycerol injection bathes the ganglion (the central part of the nerve from which the nerve impulses are transmitted) and damages the insulation of trigeminal nerve fibers." Glycerol and phenol (glycerol more commonly) are used as sympathetic blocks for nerve signals. On one hand, phenol dissolves nerve fibers and kills the nerve tissue prematurely (a process called "necrosis,") during which the dying cells do not signal to the immune system as normally-dying cells would do, leading to a build-up of dead tissue. This is why the injection is only administered in small amounts and to very specific regions of the nerve. Glycerol also prevents the nerve from producing signals by breaking up the nerve fibers. Over time, the pain may return as the nerve repairs and re-myelinates (coats) itself, although studies on rats indicate that examination of phenol- or glycerol- affected nerves can be morphologically distinguished from healthy nerves.
Friday, April 23, 2010
Biofeedback: What Is It?
According to the National Pain Foundation, biofeedback "allows you to train your mind and body to control or normalize the way you respond to pain. It makes you more aware of your body and helps you learn how to relax and relieve pain." For people whose pain is the result of stress or muscle pressure applied to all the wrong places, biofeedback offers one form of holistic, "alternative" treatment.
In August 2008, Massage Magazine published an article about biofeedback and "brain training:" "The New Generation of Mind-Body Therapies." Basically, these techniques are responses to the theory that problems like hypertension and anxiety disorders can be controlled by our minds. Rather than exclusively functioning from the autonomic nervous system (which operates the unconscious activity within the body, such as breathing and heart rate), scientists recognize the role of conscious regulation as well. Biofeedback is similar to the placebo effect- not in the sense that it is a "hoax," but rather that the mind can affect the body's physical responses.
But how exactly does biofeedback work? The University of Maryland Medical Center states, "Researchers aren't exactly sure how or why biofeedback works." As disheartening or even disconcerting as this may sound, there is nothing involved in biofeedback techniques that could pose any threat to the patient's well-being; the worst result one could expect to experience would be a lack of improvement. Unfortunately, this may be the case for many neuralgia sufferers. Although biofeedback is listed as an alternative treatment for neuralgia, no studies have clearly linked biofeedback as a solution to neuralgia. Generally, the technique is most effective for people with stress-related pain, so biofeedback therapy would only be useful to patients whose pain is a result of elevated blood pressure or muscle strain. Nevertheless, it is something to consider.
The actual therapy process involves learning to control (not completely, but to a much greater extent) bodily processes such as heart rate, blood pressure, and muscle tension. Electrodes are attached to the patient's skin so that these processes (typically muscle tension, skin temperature, or brain wave activity) show up on a monitor, either audibly or visually. The therapist leads the patient through mental exercises (usually intended to relax the person or focus their thoughts) until the patient can learn to identify the mental exercises that trigger desired responses. For example, in the case of urinary incontinence, a person can overcome their loss of bladder control by learning what muscles need to be contracted. For pain or stress, the therapist can use the monitor to detect where a patient is tense, and then pinpoint what thoughts or feelings cause tension. Ultimately, the goal of the session is to help the patient become more aware of processes that normally occur unconsciously, so he or she can react to them consciously.
As stated above, one of the best things about biofeedback is that there are no side effects; however, its usefulness for neuralgia patients is yet to be determined (unless your pain is distinctly stress-related). Although sessions range in technique and length depending on the biofeedback specialist, they are typically shorter than an hour. Some patients claim to see results within 8 weeks (one session per week), but treatment generally requires at least ten weekly sessions- and at least twenty for conditions like high blood pressure. The mental exercises, however, are techniques that the patient can use independently, outside the session. Cost for each session can be anywhere from about $35-$85.
From the University of Maryland Medical Center: "Specialists who provide biofeedback training range from psychiatrists and psychologists to nurses, dentists, and physicians. The Association for Applied Psychology and Biofeedback (www.aapb.org) is a good resource for finding qualified biofeedback practitioners in your area."
In August 2008, Massage Magazine published an article about biofeedback and "brain training:" "The New Generation of Mind-Body Therapies." Basically, these techniques are responses to the theory that problems like hypertension and anxiety disorders can be controlled by our minds. Rather than exclusively functioning from the autonomic nervous system (which operates the unconscious activity within the body, such as breathing and heart rate), scientists recognize the role of conscious regulation as well. Biofeedback is similar to the placebo effect- not in the sense that it is a "hoax," but rather that the mind can affect the body's physical responses.
But how exactly does biofeedback work? The University of Maryland Medical Center states, "Researchers aren't exactly sure how or why biofeedback works." As disheartening or even disconcerting as this may sound, there is nothing involved in biofeedback techniques that could pose any threat to the patient's well-being; the worst result one could expect to experience would be a lack of improvement. Unfortunately, this may be the case for many neuralgia sufferers. Although biofeedback is listed as an alternative treatment for neuralgia, no studies have clearly linked biofeedback as a solution to neuralgia. Generally, the technique is most effective for people with stress-related pain, so biofeedback therapy would only be useful to patients whose pain is a result of elevated blood pressure or muscle strain. Nevertheless, it is something to consider.
The actual therapy process involves learning to control (not completely, but to a much greater extent) bodily processes such as heart rate, blood pressure, and muscle tension. Electrodes are attached to the patient's skin so that these processes (typically muscle tension, skin temperature, or brain wave activity) show up on a monitor, either audibly or visually. The therapist leads the patient through mental exercises (usually intended to relax the person or focus their thoughts) until the patient can learn to identify the mental exercises that trigger desired responses. For example, in the case of urinary incontinence, a person can overcome their loss of bladder control by learning what muscles need to be contracted. For pain or stress, the therapist can use the monitor to detect where a patient is tense, and then pinpoint what thoughts or feelings cause tension. Ultimately, the goal of the session is to help the patient become more aware of processes that normally occur unconsciously, so he or she can react to them consciously.
As stated above, one of the best things about biofeedback is that there are no side effects; however, its usefulness for neuralgia patients is yet to be determined (unless your pain is distinctly stress-related). Although sessions range in technique and length depending on the biofeedback specialist, they are typically shorter than an hour. Some patients claim to see results within 8 weeks (one session per week), but treatment generally requires at least ten weekly sessions- and at least twenty for conditions like high blood pressure. The mental exercises, however, are techniques that the patient can use independently, outside the session. Cost for each session can be anywhere from about $35-$85.
From the University of Maryland Medical Center: "Specialists who provide biofeedback training range from psychiatrists and psychologists to nurses, dentists, and physicians. The Association for Applied Psychology and Biofeedback (www.aapb.org) is a good resource for finding qualified biofeedback practitioners in your area."
Sunday, April 18, 2010
TN and the Myth of Upper Cervical Care?
In 1997, author James Tomasi treated his trigeminal neuralgia with upper cervical chiropractic adjustment and was cured of his pain; he subsequently published the book "What Time Tuesday," detailing his experiences with TN, the pain that almost drove him to suicide, and the procedure that cured him.
According to the NUCCA (National Upper Cervical Chiropractic Association), upper cervical care procedures were developed more than forty years ago and, since that time, have gained popularity within the medical community. Generally, upper cervical corrections involve adjusting the large, first vertebrae of the spinal column, called the "atlas." When misaligned- either from everyday activities over time, or trauma to the neck- the atlas can compress the brainstem and cause pressure where previously there was none. The pain of a misaligned atlas can manifest itself in many different ways, and patients with everything from back pain to indigestion have experienced some positive results with upper cervical correction (UCC). Ideally, when a chiropractor corrects the atlas alignment, he (or she) helps straighten the spinal column and removes pressure on any nerves that the misaligned bone may be pressing.
The procedure seems to offer viability for TN patients because it deals with pressure at the base of the brain, near the brain stem, which is the region more invasive techniques- such as microvascular decompression- address (this is where the trigeminal nerve exits the brain). Yet, it is only recently that TN has been treated with UCC. Why? First, there have not been clinical trials that evaluate the connection between TN and upper cervical corrections, and there are no statistics to gauge the success rates of such procedures for TN patients. Second, there is a lot of political tension between the medical and chiropractic community. Seemingly floating between "alternative" treatments and medical procedures, the niche that chiropracticity has carved for itself is very self-contained; because of this, little advertisement is made for chiropractic treatments. Third, not many TN patients seem to have used UCC to treat their pain, so testimonials are few and far between (except, of course, Tomasi's book). Because of all these reasons, it seems difficult to even offer an opinion as to whether the upper cervical correction is worthwhile. Personally, I would tend to avoid such techniques, but I fully recognize that much of that tendency is simply a result of the doctor-vs.-chiropractor bias. There are many cases in which chiropractors are the only viable option (a misaligned spine, for example), but for many people (myself included), the breadth of symptoms that chiropractors can cure makes it seem more "holistic" and less precise.
But that is not fair to the chiropractic field. The spinal column is a central part of the human anatomy, and its involvement with so many physiological roles means that its negative effects can manifest themselves in many places and many ways. Those who have experienced chiropractic treatment- specifically, UCC- can testify that the process is very thorough, with little guesswork involved (assuming the chiropractor is qualified and by-the-book). There are a number of different techniques to re-align the atlas (which can vary from chiropractor to chiropractor), but many involve the use of a "percussion adjusting instrument" which applies a precise, split-second sound vibration to one end of the atlas (just below the ear). This generates a slight pressure (about 3 lbs) that causes the vibration to move through the atlas to realign it. The instrument itself resembles some kind of power tool- an electric drill, perhaps- but the procedure is painless; the patient only feels a slight pressure like a brief tap or massage. The "stylus" on the instrument (the rod that applies the pressure) can be aimed to a particular degree, based off x-rays taken before the procedure.
There are a lot of positive aspects to UCC: it is painless, eases symptoms almost immediately, and there are few side effects. Although the procedure does not involve any cutting or other invasive techniques, however, it is important that your chiropractor be meticulous and well-qualified. The spinal column, for all its strength, is a delicate instrument, and further damage can create even more drastic problems; for example, pressure to a nerve can increase pain, and pressure to a vessel can cut off blood flow, causing a stroke. The negative aspects of UCC- besides its side effects, which result primarily from negligent chiropractors- include the cost of the procedure over time. Ideally, one would only need to have their atlas corrected once (cost for this includes the cost of x-rays, but varies from chiropractor to chiropractor), but the treatment can also entail repeated visits if the patient continually misaligns his/her spine. Luckily, this can often be avoided with basic preventative measures, such as not falling asleep on the couch or with one's head at an awkward angle. Ultimately, in the search for relief from TN, UCC may be included in the list of possible treatments, particularly as a non-invasive alternative with few side effects. With the low risk, UCC may be a reasonable option to try before surgery.
According to the NUCCA (National Upper Cervical Chiropractic Association), upper cervical care procedures were developed more than forty years ago and, since that time, have gained popularity within the medical community. Generally, upper cervical corrections involve adjusting the large, first vertebrae of the spinal column, called the "atlas." When misaligned- either from everyday activities over time, or trauma to the neck- the atlas can compress the brainstem and cause pressure where previously there was none. The pain of a misaligned atlas can manifest itself in many different ways, and patients with everything from back pain to indigestion have experienced some positive results with upper cervical correction (UCC). Ideally, when a chiropractor corrects the atlas alignment, he (or she) helps straighten the spinal column and removes pressure on any nerves that the misaligned bone may be pressing.
The procedure seems to offer viability for TN patients because it deals with pressure at the base of the brain, near the brain stem, which is the region more invasive techniques- such as microvascular decompression- address (this is where the trigeminal nerve exits the brain). Yet, it is only recently that TN has been treated with UCC. Why? First, there have not been clinical trials that evaluate the connection between TN and upper cervical corrections, and there are no statistics to gauge the success rates of such procedures for TN patients. Second, there is a lot of political tension between the medical and chiropractic community. Seemingly floating between "alternative" treatments and medical procedures, the niche that chiropracticity has carved for itself is very self-contained; because of this, little advertisement is made for chiropractic treatments. Third, not many TN patients seem to have used UCC to treat their pain, so testimonials are few and far between (except, of course, Tomasi's book). Because of all these reasons, it seems difficult to even offer an opinion as to whether the upper cervical correction is worthwhile. Personally, I would tend to avoid such techniques, but I fully recognize that much of that tendency is simply a result of the doctor-vs.-chiropractor bias. There are many cases in which chiropractors are the only viable option (a misaligned spine, for example), but for many people (myself included), the breadth of symptoms that chiropractors can cure makes it seem more "holistic" and less precise.
But that is not fair to the chiropractic field. The spinal column is a central part of the human anatomy, and its involvement with so many physiological roles means that its negative effects can manifest themselves in many places and many ways. Those who have experienced chiropractic treatment- specifically, UCC- can testify that the process is very thorough, with little guesswork involved (assuming the chiropractor is qualified and by-the-book). There are a number of different techniques to re-align the atlas (which can vary from chiropractor to chiropractor), but many involve the use of a "percussion adjusting instrument" which applies a precise, split-second sound vibration to one end of the atlas (just below the ear). This generates a slight pressure (about 3 lbs) that causes the vibration to move through the atlas to realign it. The instrument itself resembles some kind of power tool- an electric drill, perhaps- but the procedure is painless; the patient only feels a slight pressure like a brief tap or massage. The "stylus" on the instrument (the rod that applies the pressure) can be aimed to a particular degree, based off x-rays taken before the procedure.
There are a lot of positive aspects to UCC: it is painless, eases symptoms almost immediately, and there are few side effects. Although the procedure does not involve any cutting or other invasive techniques, however, it is important that your chiropractor be meticulous and well-qualified. The spinal column, for all its strength, is a delicate instrument, and further damage can create even more drastic problems; for example, pressure to a nerve can increase pain, and pressure to a vessel can cut off blood flow, causing a stroke. The negative aspects of UCC- besides its side effects, which result primarily from negligent chiropractors- include the cost of the procedure over time. Ideally, one would only need to have their atlas corrected once (cost for this includes the cost of x-rays, but varies from chiropractor to chiropractor), but the treatment can also entail repeated visits if the patient continually misaligns his/her spine. Luckily, this can often be avoided with basic preventative measures, such as not falling asleep on the couch or with one's head at an awkward angle. Ultimately, in the search for relief from TN, UCC may be included in the list of possible treatments, particularly as a non-invasive alternative with few side effects. With the low risk, UCC may be a reasonable option to try before surgery.
Sunday, April 11, 2010
How Microvascular Decompression Works
According to the Mayfield Clinic in Cincinnati, Ohio, microvascular decompression (MVD) is one of the most invasive surgeries to treat Trigeminal Neuralgia, vagoglossopharyngeal neuralgia, and hemifacial spasms, but it may actually preserve facial sensation. MVD is an applicable treatment for neuralgia when the nerve pain is caused by compression from a proximal blood vessel; the pulsing of the vessel and its pressure on the nerve causes the nerve to send "bad" messages, translating to pain. MVD is a specific treatment for cranial nerves that is performed by inserting a tiny sponge between the vessel and the nerve at the base of the brainstem. Specifically, for TN, the sponge is placed between the trigeminal nerve and the superior cerebellar artery or a branch of the petrosal vein. The sponge separates the nerve from the pulsing vessel without creating more pressure.
The Mayfield Clinic indicates that the most viable patients for the procedure are those who desire minimal facial numbness (this can result from treatments like glycerol injections), or who experience recurrent pain after other radiosurgeries.
Generally, the procedure is as follows: the surgeon will make a small incision behind the ear (on the side of the face where pain is located), and then a circular opening (about a inch) in the back of the skull, to expose the trigeminal nerve. The surgeon will separate the nerve from the vessel and place a sponge between the two. If the vein is stuck to the nerve, it is cauterized (burnt with electric current to stop blood flow and remove the vessel). If no vessel is visible near the nerve, the surgeon may just sever the nerve. This does not usually happen, however. Typically, the nerve remains undamaged, which is why few patients have facial numbness. Because the bone opening is small enough, it is usually covered by a titanium plate and the skin is stitched back together. Statistics from the Mayfield Clinic say that this procedure is effective for 95% of patients. The major benefit of MVD is that it causes little or no facial numbness. After MVD, 20% of patients have pain recur within 10 years.
The risks that accompany MVD are those typical for any surgery (bleeding, infection, blood clots, and reactions to anesthesia), but risk is also greater because the surgery involves nerves in the brain. There are small chances of decreased hearing, facial weakness, facial numbness, double vision, paralysis, or even death. Often, surgery is a last resort for patients suffering TN or other nerve pain or facial spasms. Although there are many different surgical options, and the invasiveness of MVD makes it a more extreme choice, it has high effectiveness rates and few side effects. Of course, the few side effects that distinguish MVD from other neuralgia operations are dramatic. Most other surgeries dealing with nerve pain result in decreased sensation, and for those who are interested in not only halting their pain, but also preserving sensation, MVD is an option to consider.
The Mayfield Clinic indicates that the most viable patients for the procedure are those who desire minimal facial numbness (this can result from treatments like glycerol injections), or who experience recurrent pain after other radiosurgeries.
Generally, the procedure is as follows: the surgeon will make a small incision behind the ear (on the side of the face where pain is located), and then a circular opening (about a inch) in the back of the skull, to expose the trigeminal nerve. The surgeon will separate the nerve from the vessel and place a sponge between the two. If the vein is stuck to the nerve, it is cauterized (burnt with electric current to stop blood flow and remove the vessel). If no vessel is visible near the nerve, the surgeon may just sever the nerve. This does not usually happen, however. Typically, the nerve remains undamaged, which is why few patients have facial numbness. Because the bone opening is small enough, it is usually covered by a titanium plate and the skin is stitched back together. Statistics from the Mayfield Clinic say that this procedure is effective for 95% of patients. The major benefit of MVD is that it causes little or no facial numbness. After MVD, 20% of patients have pain recur within 10 years.
The risks that accompany MVD are those typical for any surgery (bleeding, infection, blood clots, and reactions to anesthesia), but risk is also greater because the surgery involves nerves in the brain. There are small chances of decreased hearing, facial weakness, facial numbness, double vision, paralysis, or even death. Often, surgery is a last resort for patients suffering TN or other nerve pain or facial spasms. Although there are many different surgical options, and the invasiveness of MVD makes it a more extreme choice, it has high effectiveness rates and few side effects. Of course, the few side effects that distinguish MVD from other neuralgia operations are dramatic. Most other surgeries dealing with nerve pain result in decreased sensation, and for those who are interested in not only halting their pain, but also preserving sensation, MVD is an option to consider.
Monday, April 5, 2010
Acupuncture as an Alternative Treatment
In March 2008, Peter Valaskatgis published a case study concerning a 72-year old female suffering from post-herpetic neuralgia and atrial fibrillation (AF). Over a period of four months, the woman underwent two series of acupuncture treatments (20 treatments in four months. Although the authors state that "further studies are warranted to explore these observations of a possible effect of acupuncture on both atrial fibrillation and post-herpetic neuralgia" (abstract), they also report that the woman experienced pain levels reduced by 67%.
On their website, the National Pain Foundation has stated, "Little quality research has been done to accurately reflect the benefit of acupuncture for treating TN but it can be effective for some people." Indeed, many patients have experienced positive results with acupuncture for all kinds of pain, including neuralgias. However, it is important to note that, at the very least, most patients continue taking medications- at a reduced dosage- or herbal supplements to complement the acupuncture procedures. Today, the problems between acupuncture and modern medicine are the fundamental understandings of the body that guides each practice. Acupuncture originated in China and involves placing long, thin needles into areas of the body where bad health occurs. To an acupuncturist, these health problems arise from a blocked "channel" within the body, through which energy, or "qi" normally flows.
Typical acupuncture procedures involve the insertion of anywhere between one and twenty needles into the body. The needles may just break the surface, or be inserted into the skin by several inches (obviously, longer needles are inserted into deeper layers of muscle/fat, or along the skin just beneath the surface). The location of the needles is entirely dependent on the pain the patient is experiencing, although there are several established insertion points for patients suffering neuralgia. Usually, the needles are left in the body for 15 to 30 min, but sometimes they are removed after only a few seconds. For a stronger effect, or with patients who have more persistent pain, the needles are warmed or electrically charged—don’t worry, though! This occurs after the needles have been inserted and produces no additional pain.
The NIH has concluded that “adverse side effects of acupuncture are extremely low and often lower than conventional treatments.” For every 10,000 procedures, it is estimated there are 671 cases of adverse effects, including: bleeding, bruising, dizziness, fainting, nausea, and increased pain (all typically minor). Although acupuncture is technically an “invasive” procedure because it involves needles, few patients experience sensations stronger than tingling. The needles are much thinner (and safer) than a typical hypodermic needle because they are not hollow; they also come to a smoother point. In the U.S., needles must be sterilized and can only be used once. Also, there are styles of Japanese acupuncture that never actually penetrate the skin. Generally fees range from $60-120 per session. The initial treatment is usually longer and more comprehensive and usually costs more, and often discount prices are available for “package” treatments. For more price details, see http://www.costhelper.com/cost/health/acupuncture.html
Although there is no data to refute or support the hypothesis (Cheng 2009), it is generally believed that acupuncture works by locally stimulating the affected nerve. Studies with animals have demonstrated increased blood flow in nerves by acupuncture, presumably helping the nerve heal or prevent it from overcompensating for a lack of sensation (Cheng, Neuroanatomical Basis of Acupuncture Treatment for Some Common Illnesses). For muscle pain, studies show that acupuncture needles stimulate nerve fibers in the muscle and cause minor tissue damage that triggers a local healing response, including blood flow (Cheng 2009). Unfortunately, no mechanism has been likewise established for pain that is exclusively associated with a nerve.
Basically, the American Academy of Medical Acupuncture states that at least one study has indicated the success of acupuncture in treating neuralgias. However, the benefits are inherently difficult to test scientifically because there is no easy reconciliation between the concept of "energy levels" that guides acupuncture and the Western understanding of nerve mechanisms. Additionally, it is hard to create tests that are “controlled,” because acupuncture administration is so dependent on the patients’ pain sensation. Regardless, many people have experienced pain relief from acupuncture, over the course of several treatments (some physicians attribute this to the placebo effect, and indeed there is a large association between acupuncture and mental health, but again no link has been substantiated). If you are considering acupuncture, the primary considerations you must remember are: check that your acupuncturist is well-trained, with credentials, and will be using sterile needles. Initially, you would probably not need electrical or heat stimulation, but your acupuncturist’s decision to use either treatment immediately is certainly not indicative of a bad procedure.
On their website, the National Pain Foundation has stated, "Little quality research has been done to accurately reflect the benefit of acupuncture for treating TN but it can be effective for some people." Indeed, many patients have experienced positive results with acupuncture for all kinds of pain, including neuralgias. However, it is important to note that, at the very least, most patients continue taking medications- at a reduced dosage- or herbal supplements to complement the acupuncture procedures. Today, the problems between acupuncture and modern medicine are the fundamental understandings of the body that guides each practice. Acupuncture originated in China and involves placing long, thin needles into areas of the body where bad health occurs. To an acupuncturist, these health problems arise from a blocked "channel" within the body, through which energy, or "qi" normally flows.
Typical acupuncture procedures involve the insertion of anywhere between one and twenty needles into the body. The needles may just break the surface, or be inserted into the skin by several inches (obviously, longer needles are inserted into deeper layers of muscle/fat, or along the skin just beneath the surface). The location of the needles is entirely dependent on the pain the patient is experiencing, although there are several established insertion points for patients suffering neuralgia. Usually, the needles are left in the body for 15 to 30 min, but sometimes they are removed after only a few seconds. For a stronger effect, or with patients who have more persistent pain, the needles are warmed or electrically charged—don’t worry, though! This occurs after the needles have been inserted and produces no additional pain.
The NIH has concluded that “adverse side effects of acupuncture are extremely low and often lower than conventional treatments.” For every 10,000 procedures, it is estimated there are 671 cases of adverse effects, including: bleeding, bruising, dizziness, fainting, nausea, and increased pain (all typically minor). Although acupuncture is technically an “invasive” procedure because it involves needles, few patients experience sensations stronger than tingling. The needles are much thinner (and safer) than a typical hypodermic needle because they are not hollow; they also come to a smoother point. In the U.S., needles must be sterilized and can only be used once. Also, there are styles of Japanese acupuncture that never actually penetrate the skin. Generally fees range from $60-120 per session. The initial treatment is usually longer and more comprehensive and usually costs more, and often discount prices are available for “package” treatments. For more price details, see http://www.costhelper.com/cost/health/acupuncture.html
Although there is no data to refute or support the hypothesis (Cheng 2009), it is generally believed that acupuncture works by locally stimulating the affected nerve. Studies with animals have demonstrated increased blood flow in nerves by acupuncture, presumably helping the nerve heal or prevent it from overcompensating for a lack of sensation (Cheng, Neuroanatomical Basis of Acupuncture Treatment for Some Common Illnesses). For muscle pain, studies show that acupuncture needles stimulate nerve fibers in the muscle and cause minor tissue damage that triggers a local healing response, including blood flow (Cheng 2009). Unfortunately, no mechanism has been likewise established for pain that is exclusively associated with a nerve.
Basically, the American Academy of Medical Acupuncture states that at least one study has indicated the success of acupuncture in treating neuralgias. However, the benefits are inherently difficult to test scientifically because there is no easy reconciliation between the concept of "energy levels" that guides acupuncture and the Western understanding of nerve mechanisms. Additionally, it is hard to create tests that are “controlled,” because acupuncture administration is so dependent on the patients’ pain sensation. Regardless, many people have experienced pain relief from acupuncture, over the course of several treatments (some physicians attribute this to the placebo effect, and indeed there is a large association between acupuncture and mental health, but again no link has been substantiated). If you are considering acupuncture, the primary considerations you must remember are: check that your acupuncturist is well-trained, with credentials, and will be using sterile needles. Initially, you would probably not need electrical or heat stimulation, but your acupuncturist’s decision to use either treatment immediately is certainly not indicative of a bad procedure.
Friday, March 26, 2010
Treatment with Saturated Fats: Lies or Legitimacy?
The pain associated with Trigeminal Neuralgia is so severe that it has been christened "the suicide disease;" because the pain can be triggered by any number of external stimuli (or even nothing at all), patients experience frequent misdiagnosis; treatments can range from noninvasive medication, to alternative acupuncture, to drastic surgeries. Given all these facts about TN, it is difficult to envision a solution as easy as altering the saturated fat in your diet. Personally, I'm not one to buy into "miracle diets," whether they simply lead to magical weight loss or the cure for cancer, and because no formal study has been conducted that links a decreased saturated fat intake to reduced neuralgia pain, I'm equally reluctant to suggest diet change as a legitimate cure for neuralgia.
However, I have to admit that the mystery and diversity of neuralgia cases- including the myriad triggers and variable responses to treatment- has made it nearly impossible to develop a unified and consistent approach to neuralgia anyway. If some patients respond as well to medication as some do to surgery, then wouldn't it be worthwhile to test a treatment that, even if it doesn't cure your condition, will only make you healthier? Reducing the saturated fat in one's diet would be a basic (and easily reversible) step to take for curing neuralgia, and it would certainly yield an enormous ROI for those who experience results.
So, to the debate: what are the effects of saturated fat on patients suffering neuralgia? Again, no direct correlation between saturated fat and nerve pain has been established, but Mayo Clinic doctors have stated that saturated fats can reduce the body's ability to repair damaged nerves. Patients at MD Junction say they can at least control their pain if they keep their intake of saturated fats below 10 grams/day. According to those who have experienced results, the pain does not decrease until 1.5-2 weeks after beginning a low-saturated fats diet.
At the Trigeminal Neuralgia Association's National Conference in 2004, Frank Sherwood (not a doctor) presented a paper on the validity of the low-saturated fat diet for TN. The paper primarily discussed the case-study of an 82-year old TN patient (the presentation can be found at http://www.franksherwood.com/mytalk.htm). The patient was diagnosed with typical TN after a root canal, and controlled the pain for seven years with medication (mainly Tegretol), one successful glycerol injection, and then nearly nine years of varied, unfulfilling treatment options. Finally, in preparation for surgery, the patient followed the American Heart Association diet, which reduces saturated fat to 20%, and her pain was dramatically reduced. Of course, the internet is full of testimonials for "miracle diets," and the one pseudo-study conducted in conjunction with Sherwood's presentation is not very conclusive (50% of 22 patients reported "substantial improvement" in a questionnaire), but even if the diet-as-treatment is not substantiated, the health benefits of consuming less saturated fat are medically supported.
Saturated fat is the main dietary cause of high blood cholesterol, according to the American Heart Association. It is found mostly in foods from animals (red meat, whole milk, cheese, butter) and plants (coconut, coconut oil, tropical oils). Also, unfortunately you would want to minimize your intake of sweets: chocolate, candy, ice cream, cakes, cookies. In general, good foods to eat are: seafood, beans, rice, pasta, vegetables, fruit, and very small amounts of lean poultry (chicken, turkey). The American Heart Association recommends limiting saturated fat intake to less than 7% of total daily calories. For example, a sedentary female age 31-50 (who should be consuming approximately 2000 calories a day) should be consuming less than 16 g saturated fat. Of course, when checking labels for saturated fat content, be sure to note the "serving size." The chocolate bar you are about to polish off could actually constitute two serving sizes, and thus contain twice the saturated fat content listed on the label.
Overall, although still not convinced by testimonials, if suffering from TN I would certainly be willing to experiment with a low-saturated fat diet for a month or two. Counting the grams of fat in my food is a small concession to make if it definitely improves my health and possibly cures my disease.
However, I have to admit that the mystery and diversity of neuralgia cases- including the myriad triggers and variable responses to treatment- has made it nearly impossible to develop a unified and consistent approach to neuralgia anyway. If some patients respond as well to medication as some do to surgery, then wouldn't it be worthwhile to test a treatment that, even if it doesn't cure your condition, will only make you healthier? Reducing the saturated fat in one's diet would be a basic (and easily reversible) step to take for curing neuralgia, and it would certainly yield an enormous ROI for those who experience results.
So, to the debate: what are the effects of saturated fat on patients suffering neuralgia? Again, no direct correlation between saturated fat and nerve pain has been established, but Mayo Clinic doctors have stated that saturated fats can reduce the body's ability to repair damaged nerves. Patients at MD Junction say they can at least control their pain if they keep their intake of saturated fats below 10 grams/day. According to those who have experienced results, the pain does not decrease until 1.5-2 weeks after beginning a low-saturated fats diet.
At the Trigeminal Neuralgia Association's National Conference in 2004, Frank Sherwood (not a doctor) presented a paper on the validity of the low-saturated fat diet for TN. The paper primarily discussed the case-study of an 82-year old TN patient (the presentation can be found at http://www.franksherwood.com/mytalk.htm). The patient was diagnosed with typical TN after a root canal, and controlled the pain for seven years with medication (mainly Tegretol), one successful glycerol injection, and then nearly nine years of varied, unfulfilling treatment options. Finally, in preparation for surgery, the patient followed the American Heart Association diet, which reduces saturated fat to 20%, and her pain was dramatically reduced. Of course, the internet is full of testimonials for "miracle diets," and the one pseudo-study conducted in conjunction with Sherwood's presentation is not very conclusive (50% of 22 patients reported "substantial improvement" in a questionnaire), but even if the diet-as-treatment is not substantiated, the health benefits of consuming less saturated fat are medically supported.
Saturated fat is the main dietary cause of high blood cholesterol, according to the American Heart Association. It is found mostly in foods from animals (red meat, whole milk, cheese, butter) and plants (coconut, coconut oil, tropical oils). Also, unfortunately you would want to minimize your intake of sweets: chocolate, candy, ice cream, cakes, cookies. In general, good foods to eat are: seafood, beans, rice, pasta, vegetables, fruit, and very small amounts of lean poultry (chicken, turkey). The American Heart Association recommends limiting saturated fat intake to less than 7% of total daily calories. For example, a sedentary female age 31-50 (who should be consuming approximately 2000 calories a day) should be consuming less than 16 g saturated fat. Of course, when checking labels for saturated fat content, be sure to note the "serving size." The chocolate bar you are about to polish off could actually constitute two serving sizes, and thus contain twice the saturated fat content listed on the label.
Overall, although still not convinced by testimonials, if suffering from TN I would certainly be willing to experiment with a low-saturated fat diet for a month or two. Counting the grams of fat in my food is a small concession to make if it definitely improves my health and possibly cures my disease.
Friday, March 12, 2010
Gamma Knife Surgrey: The Best (Radical) Option?
In October 2005, ScienceDaily published an article concerning research performed at the Comprehensive Cancer Center at Wake Forest University Baptist Medical. The article, titled "Gamma Knife Effective in Treating Trigeminal Neuralgia," states that Gamma Knife Stereotactic Radiosurgery (GKRS) is a safe, effective alternative treatment for patients suffering from neuralgia. Typical side effects of surgical treatments can include facial numbness, as well as problems with infection or anesthesia because they require incisions. GKR, on the other hand, is a non-invasive procedure that relies on small beams of radiation to target the problematic nerve. ScienceDaily reports that, in the Comprehensive Cancer Center research: "Ninety percent of patients with trigeminal neuralgia had significant pain relief within an average of four weeks. Approximately one-third of these patients did experience some degree of facial numbness, but 80 percent reported a significant improvement in their quality of life since the numbness was much more tolerable than the facial pain."
Gamma-Knife Radiosurgery works by focusing 201 beams of cobalt-60 radiation on a specific region in the brain; for Trigeminal Neuralgia patients, this target area is the trigeminal nerve, at the point where it exits the brain. The treatment does not require general anesthesia, and the patient stays in the hospital for less than five hours. However, because it deals with radiation, risk of radiation injury increases with the amount of tissue receiving treatment. Radiation injury can cause latent swelling, which usually resolves itself but can also be controlled with corticosteroid medications for persistent brain swelling.
One positive aspect of GKR is that most patients are eligible for the surgery; because it is non-invasive, it is a possible treatment for the elderly, as well as patients suffering other medical conditions. However, because the treatment is so recently developed (most cases of TN have been treated within the last five years) that there is not much information on long term effects, although no major complications have been reported to date.
Overall, patients report a drastic reduction of pain (80-90%), with results similar to that of microvascular decompression and radiofrequency lesioning (the advantage to GKR, of course, is the fact that it is a non-invasive, outpatient procedure). The major disadvantage to GKR is its delayed effect: it can take 4-6 weeks for a patient to notice a difference in pain.
Gamma-Knife Radiosurgery works by focusing 201 beams of cobalt-60 radiation on a specific region in the brain; for Trigeminal Neuralgia patients, this target area is the trigeminal nerve, at the point where it exits the brain. The treatment does not require general anesthesia, and the patient stays in the hospital for less than five hours. However, because it deals with radiation, risk of radiation injury increases with the amount of tissue receiving treatment. Radiation injury can cause latent swelling, which usually resolves itself but can also be controlled with corticosteroid medications for persistent brain swelling.
One positive aspect of GKR is that most patients are eligible for the surgery; because it is non-invasive, it is a possible treatment for the elderly, as well as patients suffering other medical conditions. However, because the treatment is so recently developed (most cases of TN have been treated within the last five years) that there is not much information on long term effects, although no major complications have been reported to date.
Overall, patients report a drastic reduction of pain (80-90%), with results similar to that of microvascular decompression and radiofrequency lesioning (the advantage to GKR, of course, is the fact that it is a non-invasive, outpatient procedure). The major disadvantage to GKR is its delayed effect: it can take 4-6 weeks for a patient to notice a difference in pain.
Sunday, March 7, 2010
Anti-convulsants: Primary Treatment for TN
Today, Trigeminal Neuralgia is most frequently and effectively treated with anticonvulsant, also known as antiepileptic, drugs. One proposed cause of trigeminal neuralgia is degeneration or damage to facial nerves, causing them to compensate for "mismatched" signals by becoming hypersensitive. Anticonvulsant medications work by regulating incoming and outgoing signals in the nerves, quieting these "distress" signals and the accompanying pain felt by TN patients. Although prescribed less frequently, anticonvulsants may also be used to treat postherpetic neuralgia.
The greatest obstacle to anticonvulsant drugs as treatment for TN is their side effects; these include dizziness, confusion, drowsiness, double vision, nystagmus (eye twitching) and nausea, as well as dramatic changes in blood levels. Anticonvulsants have also been linked to an increased risk of suicidal tendencies, so if you are taking anticonvulsants (especially for the first time), you should be extra aware of any changes in behavior or thought, and notify your doctor immediately. Carbamazepine, the chief anticonvulsant for treating TN, can also trigger a serious reaction is some people (most commonly those of Asian descent). Normally, initial treatment with anticonvulsants involves only one medication, but many patients end up requiring a combination of drugs, or higher dosage if the medications begin to lose effectiveness.
Carbamazepine is, in most cases, the most effective (and most prescribed) drug for treating TN. It is so effective that relief from pain with carbamazepine is often a good indicator that a patient does indeed have TN. Nearly all patients prescribed carbamazepine- usually in the form of Tegretol- complain of side effects, although these fade as the body adjusts to the medication (which, unfortunately, can last as long as the time it takes to increase dosage). More potentially serious side effects that have been linked with carbamazepine that are not dose-related are memory loss, skin rash, and blood problems (found in 2-6% of carbamazepine users). These blood problems include a drop in the number of white blood cells, hyponatremia (low sodium in the blood), and aplastic anemia (the bone marrow stops making blood cells). Oxycarbamazepine (Trileptal) is a new form of Tegretol that may involve fewer side effects, but must be taken in higher doses. Additionally, Gabapentin has fewer side effects than carbamazepine, but is almost as equally effective.
Other alternative medications for carbamazepine include:
Phenytoin (Dilantin, Phenytek)
Gabapentin (Neurontin)
Lamotrigine (Lamictal)
Levateracitam (Keppra)
Pregabalin (Lyrica)
Topirimate (Topamax)
Valproic acid (Depakote)
Clonazepam (Klonopin,Rivatril)
Generally, the above medications are less effective than carbamazepine, and the differences among them are more arbitrary. However, they do have less severe side effects and can be used in combination with each other to strengthen their pain reduction.
The greatest obstacle to anticonvulsant drugs as treatment for TN is their side effects; these include dizziness, confusion, drowsiness, double vision, nystagmus (eye twitching) and nausea, as well as dramatic changes in blood levels. Anticonvulsants have also been linked to an increased risk of suicidal tendencies, so if you are taking anticonvulsants (especially for the first time), you should be extra aware of any changes in behavior or thought, and notify your doctor immediately. Carbamazepine, the chief anticonvulsant for treating TN, can also trigger a serious reaction is some people (most commonly those of Asian descent). Normally, initial treatment with anticonvulsants involves only one medication, but many patients end up requiring a combination of drugs, or higher dosage if the medications begin to lose effectiveness.
Carbamazepine is, in most cases, the most effective (and most prescribed) drug for treating TN. It is so effective that relief from pain with carbamazepine is often a good indicator that a patient does indeed have TN. Nearly all patients prescribed carbamazepine- usually in the form of Tegretol- complain of side effects, although these fade as the body adjusts to the medication (which, unfortunately, can last as long as the time it takes to increase dosage). More potentially serious side effects that have been linked with carbamazepine that are not dose-related are memory loss, skin rash, and blood problems (found in 2-6% of carbamazepine users). These blood problems include a drop in the number of white blood cells, hyponatremia (low sodium in the blood), and aplastic anemia (the bone marrow stops making blood cells). Oxycarbamazepine (Trileptal) is a new form of Tegretol that may involve fewer side effects, but must be taken in higher doses. Additionally, Gabapentin has fewer side effects than carbamazepine, but is almost as equally effective.
Other alternative medications for carbamazepine include:
Phenytoin (Dilantin, Phenytek)
Gabapentin (Neurontin)
Lamotrigine (Lamictal)
Levateracitam (Keppra)
Pregabalin (Lyrica)
Topirimate (Topamax)
Valproic acid (Depakote)
Clonazepam (Klonopin,Rivatril)
Generally, the above medications are less effective than carbamazepine, and the differences among them are more arbitrary. However, they do have less severe side effects and can be used in combination with each other to strengthen their pain reduction.
Sunday, February 28, 2010
PHN Treatment: Antidepressants
To treat neuralgia, specifically trigeminal and postherpetic neuralgia, physicians typically begin by prescribing antidepressants, anti-convulsants, or anti-spasticity drugs. Normally, antidepressants function by regulating levels of serotonin, dopamine, and norepinephrine in the brain to increase the sensitivity of nerve cells to glutamate, which is a non-essential amino acid linked to anxiety and depression, as well as the way one's body interprets pain; however, these medications are usually prescribed in smaller doses for neuralgia patients. Specifically, tricyclic antidepressants (which also affect nervous sodium channels) are usually prescribed to patients suffering from postherpetic neuralgia (PHN), rather than trigeminal or glossopharyngeal neuralgia.
These antidepressants should ease nerve pain within a few days, although they can also take up to several weeks to begin working fully, and are less effective in patients with burning pain or pain triggered by external stimuli. They are more effective when started within the first year after symptoms occur. Patients usually become dissatisfied with medication therapy, because it only moderates the pain and nerve pain can re-emerge unless dosage is increased over time (this is actually a phenomenon that has developed among patients suffering depression; no scientific correlation to neuralgia patients has been established). Side effects for tricyclic antidepressants include: dry mouth, constipation, bladder problems (especially in men with enlarged prostrate conditions), impaired sexual function, dizziness, drowsiness, blurred vision, increased heart rate, and weight gain. Unfortunately, side effects are more severe in the elderly- who are more at risk for neuralgia.
Nortriptyline (Pamelor, Aventyl), amitriptyline (Elavil, Endep), and desipramine (Norpramin) are standard drugs, but desipramine and nortriptyline have fewer side effects than amitriptyline and are preferred for older patients. In a study published in 2005 by the UCSF Pain Clinical Research Center, Michael Rowbotham treated postherpetic neuralgia patients with desipramine, amitriptyline, and fluoxetine. He concluded that: "Desipramine produced the greatest reduction in pain intensity (47%), followed by amitriptyline (38%) and fluoxetine" (Journal of Pain, Vol. 6, Issue 11). Additionally, he found that fluoxetine exhibited the most severe side effects: "The fluoxetine group had the highest noncompletion rate, with 1 subject hospitalized for hyponatremia. Although the magnitude of pain reduction and the category pain relief rating was not significantly different among the 3 drugs, the tricyclics desipramine and amitriptyline were well tolerated and provided clinically meaningful pain relief in 53% to 80% of subjects."
Antidepressants for neuralgia include:
- Amitriptyline: Elavil, Amitril, Emitrip, Endep, Etrafon, Levate, Limbitrol, Novotriptyn, Triavil. This is the most commonly used antidepressant for neuralgia treatment, and in most cases it does NOT demonstrate a loss of affectivity over time.
- Protriptyline: Vivactil
- Nortriptyline: Aventyl, Pamelor
- Desipramine: Norpramin
- Duloxetine: Cymbalta
- Fluoxetine: Prozac (US), Seronil, Fontex (Europe). The use of fluoxetine to treat neuralgia is more experimental, and often used only as an alternative to oter antidepressants, due to its higher cost.
These antidepressants should ease nerve pain within a few days, although they can also take up to several weeks to begin working fully, and are less effective in patients with burning pain or pain triggered by external stimuli. They are more effective when started within the first year after symptoms occur. Patients usually become dissatisfied with medication therapy, because it only moderates the pain and nerve pain can re-emerge unless dosage is increased over time (this is actually a phenomenon that has developed among patients suffering depression; no scientific correlation to neuralgia patients has been established). Side effects for tricyclic antidepressants include: dry mouth, constipation, bladder problems (especially in men with enlarged prostrate conditions), impaired sexual function, dizziness, drowsiness, blurred vision, increased heart rate, and weight gain. Unfortunately, side effects are more severe in the elderly- who are more at risk for neuralgia.
Nortriptyline (Pamelor, Aventyl), amitriptyline (Elavil, Endep), and desipramine (Norpramin) are standard drugs, but desipramine and nortriptyline have fewer side effects than amitriptyline and are preferred for older patients. In a study published in 2005 by the UCSF Pain Clinical Research Center, Michael Rowbotham treated postherpetic neuralgia patients with desipramine, amitriptyline, and fluoxetine. He concluded that: "Desipramine produced the greatest reduction in pain intensity (47%), followed by amitriptyline (38%) and fluoxetine" (Journal of Pain, Vol. 6, Issue 11). Additionally, he found that fluoxetine exhibited the most severe side effects: "The fluoxetine group had the highest noncompletion rate, with 1 subject hospitalized for hyponatremia. Although the magnitude of pain reduction and the category pain relief rating was not significantly different among the 3 drugs, the tricyclics desipramine and amitriptyline were well tolerated and provided clinically meaningful pain relief in 53% to 80% of subjects."
Antidepressants for neuralgia include:
- Amitriptyline: Elavil, Amitril, Emitrip, Endep, Etrafon, Levate, Limbitrol, Novotriptyn, Triavil. This is the most commonly used antidepressant for neuralgia treatment, and in most cases it does NOT demonstrate a loss of affectivity over time.
- Protriptyline: Vivactil
- Nortriptyline: Aventyl, Pamelor
- Desipramine: Norpramin
- Duloxetine: Cymbalta
- Fluoxetine: Prozac (US), Seronil, Fontex (Europe). The use of fluoxetine to treat neuralgia is more experimental, and often used only as an alternative to oter antidepressants, due to its higher cost.
Sunday, February 21, 2010
Diagnosing Neuralgia
Neuralgia presents a conundrum to both doctors and patients, because of the difficulty inherent in diagnosing it. Although there are common symptoms for neuralgia, such as a constant, burning pain or a short, stabbing pain (both in localized areas), these are also symptoms which accompany a variety of other disorders. For example, people with trigeminal neuralgia are often diagnosed with having toothaches or even damage to the jawbone. This can be further complicated by the irregularity of the pain attacks; remission can last for months and typically there is no lasting paralysis, although episodes are sometimes precluded by a more lasting, throbbing sensation. In extremely rare cases, localized numbness and muscle spasms accompany the pain, which can be severe enough to also disrupt regular heartbeat rhythms.
Also involved in diagnosing neuralgia is pinpointing the nerve from which the pain is originating; unfortunately, this is difficult to do, and oftentimes the origin of the pain remains unknown. The mechanisms in the nervous system that are often actually attributed to neuralgia include: overly-sensitive neural receptors, malfunctions in the ion-transfer process along neural pathways, cross-signaling between large and small fibers, or damage in the central nervous system that "misreads" peripheral signals.
Also involved in diagnosing neuralgia is pinpointing the nerve from which the pain is originating; unfortunately, this is difficult to do, and oftentimes the origin of the pain remains unknown. The mechanisms in the nervous system that are often actually attributed to neuralgia include: overly-sensitive neural receptors, malfunctions in the ion-transfer process along neural pathways, cross-signaling between large and small fibers, or damage in the central nervous system that "misreads" peripheral signals.
Introduction to Neuralgia
Neuralgia is characterized by a burning or stabbing pain that follows the path of a nerve. Because it usually occurs in conjunction with nerve damage or degeneration, it is most common in people over the age of 50 (and is more often diagnosed in women than men). Typically, it is classified by the type of nerve involved, the most common diagnosis being "trigeminal neuralgia," which involves intense pain on one side of the face. Although it can be a result of nerve damage or inflammation, the most common cause of trigeminal neuralgia is nerve compression (pressure- in this case from facial blood vessels- that inhibits normal neural pathways). Neuralgia can be a difficult condition to live with, not only due to the debilitating pain, but also because it can be triggered by the slightest external stimuli: such actions as brushing one's teeth or walking in a cool breeze can prompt intermittent bouts of stabbing pain that lasts anywhere from a few seconds to a few minutes at a time; sometimes, such episodes can be precluded by a prolonged throbbing sensation.
The easiest form of neuralgia to diagnose is postherpetic neuralgia, which exists in regions of shingles outbreak. Shingles (herpes zoster) arises when dormant chickenpox virus in nerve cells reactivates, causing pain, rash, and blisters. Although the skin usually heals within a month, sometimes pain persists and this is postherpetic neuralgia.
Two other recognized forms of neuralgia include occipital neuralgia and glossopharyngeal neuralgia. The first is pain in the neck, back of the head, or behind the ears resulting from damage, inflammation, or compression to the occipital nerves in the head. The latter, most rare form of neuralgia, is actually more common in men, and involves pain in the tonsils, tongue, or the back of the throat. Similar to the other cases of neuralgia, it is assumed that the pain results from compression of, or damage to, the glossopharyngeal nerve, although the exact cause is unknown.
The easiest form of neuralgia to diagnose is postherpetic neuralgia, which exists in regions of shingles outbreak. Shingles (herpes zoster) arises when dormant chickenpox virus in nerve cells reactivates, causing pain, rash, and blisters. Although the skin usually heals within a month, sometimes pain persists and this is postherpetic neuralgia.
Two other recognized forms of neuralgia include occipital neuralgia and glossopharyngeal neuralgia. The first is pain in the neck, back of the head, or behind the ears resulting from damage, inflammation, or compression to the occipital nerves in the head. The latter, most rare form of neuralgia, is actually more common in men, and involves pain in the tonsils, tongue, or the back of the throat. Similar to the other cases of neuralgia, it is assumed that the pain results from compression of, or damage to, the glossopharyngeal nerve, although the exact cause is unknown.
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