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Neuropathy: Causes and Treatments
Michael Stubblefield, M.D.
August 8, 2018

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Michael Stubblefield, M.D. is medical director of cancer rehabilitation at the Kessler Institute for Rehabilitation in New Jersey and the national medical director for Select Medical’s ReVital Cancer Rehabilitation program. He is known around the world for his expertise in the identification, evaluation, and rehabilitation of pain and functional disorders caused by cancer and cancer treatments, particularly problems caused by radiation and chemotherapy. Dr. Stubblefield is an accomplished researcher and has published extensively on medical rehabilitation, oncology, pain management, palliative care, and neurophysiology.

Listen to the podcast to hear Dr. Stubblefield explain:

  • what neuropathy is, how it happens, and the treatments that can cause it
  • how to explain neuropathy to friends and family
  • risk factors for neuropathy
  • treatments for neuropathy
  • the three things that anyone diagnosed with neuropathy should know

Running time: 31:32

Show Full Transcript

Jamie DePolo: Hello, everyone. I’m Jamie DePolo, senior editor at Welcome to this edition of the podcast. Dr. Michael Stubblefield is medical director of cancer rehabilitation at the Kessler Institute for Rehabilitation in New Jersey and the national medical director for Select Medical’s ReVital Cancer Rehabilitation program. He is known around the world for his expertise in the identification, evaluation, and rehabilitation of pain and functional disorders caused by cancer and cancer treatments -- particularly problems caused by radiation and chemotherapy.

Named one of America’s Top Doctors, America’s Top Doctors for Cancer, and the New York Metro Area’s Top Doctors by Castle Connolly for many years, Dr. Stubblefield is an accomplished researcher and has published extensively on medical rehabilitation, oncology, pain management, palliative care, and neurophysiology. He serves on the editorial board of the journal Muscle and Nerve and is a peer reviewer for more than 30 journals. He also is the editor of Cancer Rehabilitation: Principles and Practice -- the only comprehensive textbook in the field -- and has also authored numerous review articles and book chapters in the field of cancer rehabilitation.

He joins us today to talk about neuropathy and ways to manage it. Dr. Stubblefield, welcome to the podcast.

Dr. Michael Stubblefield: Thank you so much, Jamie. It’s a pleasure to be here.

Jamie DePolo: To start, we have a lot of discussion on our social media pages and also in our discussion boards on our website about neuropathy. So, I would like to talk about the basics. Can you explain to us what neuropathy is, how it happens, where it can happen, and some of the treatments that can cause it?

Dr. Michael Stubblefield: Yeah, absolutely. So, probably to understand neuropathy, it’s best to understand a little bit about the body’s nervous system in general. We all know we have a brain. The brain connects to a spinal cord, and nerve roots -- that literally look like roots of a tree -- come out of the spinal cord. They have these complicated interconnections called plexuses -- you have a brachial plexus in your arm, a cervical plexus in your neck, and a lumbosacral plexus in your pelvis. And then nerves, individual large-named nerves, come off of that plexus.

So, when we’re talking about peripheral neuropathy, we’re really talking about damage or malfunctioning of the peripheral nerve -- which is everything including that nerve root, the plexus, and most specifically, the peripheral nerve outside of it. So, for instance, your big finger would have... any sensation that you feel there or your ability to move it would start in the brain and go down the spinal cord, out through these nerve roots, out through the plexus, and then to, say, your median nerve, which is a large-named nerve that would go to your index finger. So that’s the basics of peripheral neuropathy, is damage to the nervous system outside of the brain and spinal cord.

How can it happen? There’s a number of ways, and it depends on where you are. Believe it or not, one of the most common neuropathies in the world is leprosy, which is caused by an infection. It used to be much more common before we had good treatments of it. Here in the United States, probably the most common cause of neuropathy is diabetes, which has a number of ways of damaging the peripheral nervous system. In the cancer setting, the most common cause of neuropathy is chemotherapies. So, particularly, things like the vinca alkaloid, vincristine; the taxanes, like paclitaxel, or Taxol; and the platinum compounds, like cisplatin, carboplatin, oxaliplatin.

Jamie DePolo: When you’re talking about the damage and peripheral neuropathy -- now, is it just in the hands and feet that’s considered peripheral neuropathy, or can it happen like from your hips down -- is that still considered peripheral neuropathy? Is it, you know, all your limbs, or is it just your hands and feet, your extremities?

Dr. Michael Stubblefield: Yeah, so the answer is, it’s most commonly distal, meaning out in your fingers and toes. More severe neuropathies tend to come more proximally up your thighs and can even affect truncal instability. There’s three major components to neuropathy: One is the sensory problems, and that’s usually pain or the loss of ability to feel. Sometimes it’s just numbness and tingling or tingling, which we call paresthesia. But there’s also the motor component -- the ability to work the muscle. So weakness, and the weakness, again, is usually distally out in the hands or out in the feet.

There’s also the autonomic nervous system, which is part of the peripheral nervous system, which is your ability to digest. Your ability to maintain your blood pressure. For men, the ability to get an erection. All of those can be damaged if the peripheral nervous system is damaged. Different causes of neuropathy may damage different components of the peripheral nervous system differently. So, for instance, the platinum drugs, which I talked about, primarily damage the sensory nervous system -- so you may have pain, and you may have loss of knowing where your joints are in space, but your muscles actually remain strong.

So, really it very much depends, but neuropathy can just be numbness in the toes, or it can be so severe that you actually can’t move. And there’s neuropathies that are so severe -- like Guillain-Barre syndrome, where patients are literally paralyzed, even to the point where they need mechanical ventilation because of the neuropathy -- but that is still very much a peripheral neuropathy, just an extremely severe one.

Jamie DePolo: People have talked about losing their balance as being part of peripheral neuropathy. And, people -- or I shouldn’t say “people” -- but that’s not discussed very much. It’s usually when people think of neuropathy, they think of the pain and the tingling and the numbness, but as you said, there’s the muscle weakness and then there’s a lack of balance, which can be a really big issue.

Dr. Michael Stubblefield: Absolutely, and loss of balance can have components of both the motor, the sensory, and the autonomic. So, the autonomic is when you lose your blood pressure, so that you’re not perfusing your brain. You can feel dizzy, because you stand up and your blood pressure -- which is normally running 120/60, say -- now drops to 70/30, you can’t even palpate it. And if that happens, you don’t get enough oxygen to your brain, and you feel dizzy until your blood pressure comes up -- that’s one component.

Then you need the sensory nervous system to be able to tell where your joints are in space. So, if you’re standing around moving your arm out -- moving your arm around with your [eyes] closed or in a dark room -- you have a pretty good idea of where your arm is relative to your body because of what are called proprioceptors, which are little nerves in the joints and other tissues that are responsible for relaying that information to your brain.

If those go out, then your ability to know where your body is relative to your legs malfunctions and you can fall, lose your balance as a result of that. And then, of course, the motor system. If you’re simply not strong enough, or you can’t correct imbalance quickly enough, then you can have a fall as a result of the neuropathy.

Jamie DePolo: Now, are neuropathy symptoms ever confused with another condition? I guess I’m wondering if it’s difficult for somebody to be diagnosed with neuropathy, or is it kind of a trial-and-error thing?

Dr. Michael Stubblefield: No. It’s fairly easy to diagnose, right? So, if you’re a cancer patient and you received chemotherapy, and you've got the typical neuropathy in the setting of that chemotherapy, we’re not going to do any additional workup for it. We’re going to assume that your neuropathy is due to that chemotherapy. That being said, yes, there are a number of things that can mimic peripheral neuropathy, or more specifically, chemotherapy-induced neuropathy.

So, for instance, if you have bad arthritis in your back, or a disk herniation in your back, it can pinch the nerves coming out of your spine that are going to your legs, and it can look -- for the world, to the untrained eye -- like a peripheral neuropathy. You have numbness and tingling in your feet and your toes, you have loss of balance, you have loss of proprioception, your feet are weak, you have trouble -- what we call “dorsiflexing,” lifting your foot up at your ankle -- that is very common. And if you have something like -- we call that a “radiculopathy,” because it’s the nerve roots, the radicals if you will, that are damaged -- so the radiculopathy can look very much like a peripheral neuropathy to the untrained eye.

Similarly, carpal tunnel syndrome. I’ve had a number of patients referred to me for “neuropathy,” when what they really had was carpal tunnel syndrome, which can cause numbness and tingling in the hands, usually in the thumb, index, and middle finger. But the oncologist, even if they’re the best oncologist in the world at treating cancer, may not be as good at neuromuscular medicine, just because it’s not their specialty and they can confuse it. So, absolutely, you can have mimics of peripheral neuropathy.

Also, a very important point is you can have both together. So, it’s very common for patients to have a little bit of carpal tunnel they didn’t even know they had, to have a little bit of pinched nerves in their back that they didn’t really even know they had. And then when we challenge them with the chemotherapy, and we damage those nerves further, then they get symptomatic. And a good clinician who does neuromuscular medicine should be able to sort out if you have one thing or both things together.

Jamie DePolo: And I realize -- I want to back up -- I realize I forgot to ask: So, you said chemotherapy is the most common cause of neuropathy. Now, how exactly does the chemotherapy damage the nerves?

Dr. Michael Stubblefield: Yeah, well, chemotherapy in the cancer setting. You know, outside of the cancer setting, it’s diabetes, it’s stuff you’ve probably never heard of, like CIDP, et cetera. So, each chemotherapy has a different way of damaging the nerves, which is also very useful for making the diagnosis for clinicians who know how to look for it. So, things like vincristine, the vinca alkaloids; and the taxanes: paclitaxel, docetaxel, those types -- they are what we call tubulin inhibitors.

So, if you think about a motor nerve -- or I guess you probably don’t think about a motor nerve! You know… I’m very tall -- you wouldn’t know that, but I’m like 6’ 5”. So, I’m sitting here, and my nerve goes from my spine all the way down to the tip of my toes. It’s one long nerve supplying sensation to the tip of my toe, or the muscles that lift my toe up. In my case, that nerve might be 3 feet long.

So, all of the stuff in that nerve is made in the cell body, which is up in my pelvis. It’s either in my spinal cord, for the motor nerve, or just outside the spinal cord, in something called the dorsal root ganglion, for the sensory nerve. And your body has to get whatever it needs, right, from the cell body all the way down that three-foot-long microscopic neuron to the end of my foot. And it uses tubulin, which is almost like a little pulley system -- they’re these little proteins that clump together and pull things along the nerve.

So, what the taxanes and the vinca alkaloids do is they poison your body’s ability to make that tubulin. And what that does for a cancer cell is cancer cells divide -- you also use tubulin to pull cells apart during the dividing process -- so it inhibits that, and then the cell doesn’t know what to do, so it dies. Which is a good thing if it’s a cancer cell. That’s also why it damages other things, like people get diarrhea because the fast-dividing cells in your GI tract are sensitive to that, and the nerves are sensitive to it.

So, as a result of that process, you get a length-dependent -- meaning the longer the nerve is, the bigger hit it takes -- motor nerves and sensory nerves are equally affected. And again, it’s a polyneuropathy, meaning most are affected, and it’s symmetrical -- it’s the same on both sides. So, we call that a “length-dependent motor and sensory axonal,” because it’s damaging the axon polyneuropathy -- and that’s kind of medical speak for what I described. It’s a big word but it rolls off the tongue if you say it enough!

The platinum drugs are very different. So, the platinum drugs don’t damage the cancer cells or kill cancer cells in the same way. What they do is they get into the DNA of the cell, and they start screwing up the metabolism of the cell. So, the cell is still located near the center of the body. It can’t get into the motor nerves -- because it has to go across something called the blood-brain barrier, and it can’t get in -- but it does get in the sensory nerves. And they just damage the sensory nerves and not the motor nerves.

So, you get a very mean, painful neuropathy very often. Loss of sensation, you may have trouble walking -- not because you’re weak, but because of the proprioceptor problems, you don’t know where you are in space. But they look very differently to the trained eye. They’re very different types of neuropathy, the tubulin inhibitors versus the platinum drugs.

Jamie DePolo: Thank you, that was very helpful. Now, one other thing, a lot of our visitors have said that neuropathy is hard for them to explain to their co-workers, to their family, to their loved ones, because people just don’t seem to understand what they’re going through. Do you have kind of a -- I almost want to call it an elevator description -- of what neuropathy is that people could use to explain it?

Dr. Michael Stubblefield: Yeah. I guess the simplest thing is just to say, "My nerves don’t work properly as a result of my cancer treatment." But that means different things to different people, because they may experience their neuropathy differently. So, it may be that you have this gait unsteadiness, or weakness, or it may be that you have severe pain, or that you have such bad sensation loss that you have trouble buttoning and doing little things that other people take for granted. You know, the problem with neuropathy is other people can’t see it. They can see you struggling to do tasks that you normally could do, but they can’t see that you have neuropathy.

Jamie DePolo: Now, are there risk factors for neuropathy? Are some people just more likely to get it because of certain factors in their body, or some other kind of medical history, or is it strictly the chemotherapy treatment? In the cancer setting, I’m specifically talking about.

Dr. Michael Stubblefield: Yeah, a great question. So, the answer is yes. So, diabetes, which I mentioned earlier. So, if you already have bad diabetes -- or even mild or moderate diabetes -- and you have some nerve injury from the diabetes, it stands to reason that that is going to get worse when we challenge you with a nerve-damaging chemotherapeutic agent.

And there is a number of other types of neuropathy. Like I mentioned, CIDP -- another big word: chronic idiopathic demyelinating polyradiculoneuropathy. That’s a mouthful. But, it’s actually not as common as its really ugly name -- or as rare, I should say -- as its very long name would imply. It’s actually a fairly common type of neuropathy in older people, and if you have that, you’re more likely to have nerve dysfunction if you get challenged with the chemotherapy, and I could go on.

There’s B12 deficiency. There’s hereditary neuropathies that have been well-shown to get worse with chemotherapy, et cetera. Also, if you have a carpal tunnel syndrome, or pinched nerves in your back, as I described earlier, I think you’re more likely to become symptomatic -- not necessarily to develop a full-on, chemotherapy-induced peripheral neuropathy, but to cause any symptoms you had from your pinched nerves in your back or your neck or your carpal tunnel to get worse. 

So, absolutely, those will predispose you to getting additional symptoms when you get challenged with the chemotherapy.

Jamie DePolo: Now the counterpoint to that is, is it possible to reduce the risk of chemotherapy-induced neuropathy? You know, people use cold caps in an attempt to keep their hair when they go through chemotherapy. I know some people have iced their hands and their feet in hopes of reducing the risk of neuropathy. But this icing of the hands and feet doesn’t seem to be discussed as much at chemotherapy centers, and I know some people have gone through chemotherapy and said, “Oh, I wish I knew that. I would have tried it, because now I have neuropathy.”

Dr. Michael Stubblefield: Yeah, another great question. So, the short answer is up until recently, nothing that has been studied has really affected the development of neuropathy in any meaningful way for patients treated with chemotherapy. The cold cap started coming on... I don’t honestly know when. I probably started hearing about them 4 or 5 years ago, where people would use iced gloves and stockings to help prevent the neuropathy. And I would look -- and I actually looked just before this phone conversation -- to see what had been done.

I had seen a presentation at ASCO, American Society of Clinical Oncology, in June on neuropathy. And a slide was presented. And it turns out that just this year, what I believe is likely the first well-done article on this came out showing that, in fact, it does seem like wearing cold gloves and cold stockings will help prevent the symptoms of neuropathy. That said, this is one study, at least that I’m aware of so far, it’s published just this year. There are some flaws with it that need to be looked at in larger studies. But it is absolutely promising that maybe this is one way -- not to completely eliminate the risk of neuropathy -- potentially to decrease the risk of neuropathy. And it was only looked at for paclitaxel -- so, that’s one of the tubulin inhibitors, one of the taxanes. That is not necessarily generalizable to other types of neuropathy from, like, the platinum drugs or other types of neurotoxic chemotherapies we haven’t even discussed yet.

So, there’s a little bit of data there. I’m sure we’re going to get more data. I would say that anybody who’s getting paclitaxel chemotherapy, I think the risk is very low of doing this. There is nothing reported in this trial as a risk. We don’t believe that it decreases the efficacy of the chemotherapy, but more research is needed to be done there.

Jamie DePolo: Okay. Yeah, that was actually going to be my next question. If somebody did want to try it, if they were going to be on a taxane chemotherapy -- are there any side effects? But it doesn’t sound like there are.

Dr. Michael Stubblefield: So, it’s kind of an abstract here that people were able to tolerate the cold, which was nice. One of the concerns I would have was, is this so cold people just can’t do it -- and apparently, that’s not an issue.

Jamie DePolo: But people would pretty much be on their own with doing this. I mean, with the cold caps now there are a couple companies that you can rent the caps, buy the caps, and they come with instructions. Or are there actually systems that people can rent, purchase, that are available at the chemotherapy centers that they could use, or do they have to do it all on their own?

Dr. Michael Stubblefield: That’s a great question. I’ll admit I don’t honestly know. Right, clearly you can buy this stuff online and bring it with you. My sense is the oncology centers and oncologists, like anybody, they’re very evidence-driven, there hasn’t been a lot of evidence for this. Everything so far has been anecdotal until this one study -- that’s just one study, which isn’t enough to make a definitive argument. So, I would have a sense that some oncology practices are going to give this as a matter of course to their patients and others it may be something that you want to ask or suggest.

Jamie DePolo: So, if somebody didn’t have that option, you know, went through chemotherapy, say, 2, 3, 4, 5 years ago and is now dealing with neuropathy -- are there ways to manage it, or is it always permanent? Can it be made better?

Dr. Michael Stubblefield: Yeah. Another great question. So, the answer is yes. Neuropathy can sometimes be permanent. Probably 5% of patients, depending on which group you’re looking at, will have neuropathic symptoms that last for a very long period of time. But that’s not everybody. Can they get better over time? Yes, absolutely. The natural history of most neuropathy is to get better over time with a couple of exceptions.

So, the taxane drugs that we talked about -- paclitaxel, docetaxel, the tubulin inhibitors; vincristine is the other one in another class -- you get the neuropathy with those effectively immediately. And then once you’ve stopped getting the chemotherapy, the neuropathy usually gets better. And it can get better over a series of weeks to months. In some situations, it may not completely go away, and some patients may be left with weakness, with pain, with numbness, with gait dysfunction -- whatever constellation of issues they have.

The platinum drugs are a little bit different. Remember, I talked about how they get inside the DNA? So, you may not start getting the neuropathy from a platinum drug until -- you know, if you’re doing six cycles, you might get it on your fourth cycle, might get a little worse on the fifth cycle, you finish it your sixth cycle -- and then the neuropathy continues to get worse for 6 to 9 months after the chemotherapy is stopped. That’s called the coasting effect. Actually, I had a patient on Monday who had coasting from a platinum chemotherapy. Even those drugs, though, once the coasting stops, the natural history is usually to get better. But you still have a group of patients where they will have issues from the neuropathy indefinitely.

Jamie DePolo: What would be a treatment? Are there medicines? Are there complementary therapies like acupuncture or something? What can someone do?

Dr. Michael Stubblefield: Yeah, so the answer depends on what you have. So, if you’re dealing with numbness, unfortunately nothing really works for the numbness that is caused by neuropathy. The inability to feel does not go back, because that happens to be the nerve being dead, and it will either get better on its own or it won’t get better on its own. None of the supplements, physical therapy doesn’t really help -- nothing really helps that.

Pain is a different story. Pain is caused by the nerve, not being dead, but going off and sending false signals -- a sick nerve sending false signals into the spinal cord and brain being perceived as pain. Those will very often respond to medications. The medications, the one that is best studied, is something called Cymbalta -- or is the trade name; duloxetine is the generic name -- was actually studied a couple of years ago in the New England Journal of Medicine, which showed that it actually helped with the symptoms, the pain symptoms, of chemotherapy-induced neuropathy.

Other medications we use for the pain are things like gabapentin and pregabalin. So, gabapentin’s generic name is Neurontin -- or the trade name’s Neurontin -- and the pregabalin, the trade name is Lyrica. Those have a different mechanism from the duloxetine. My experience has been that they can be very effective for the pain of neuropathy.

There’s other drugs, older drugs, like the tricyclic anti-depressants, nortriptyline and amitriptyline. Those can be very helpful. And just because a patient doesn’t respond to one doesn’t mean they won’t respond to another. We’re all wired a little differently and respond a little differently.

If those don’t work, then sometimes we do have to go to opioid-type medications to treat the pain, which usually are effective --although you certainly have some patients who either can’t tolerate the opioid, for whatever reason, or it just doesn’t work for them. And if they don’t respond to one, sometimes they will respond to another, again, because of the way we’re wired.

We use topical medications for the pain sometimes. So, we may use lidocaine patches. We may use topical creams that are compounded by pharmacies. Technically, they have no reason in the world to work, because they’re not really absorbed and they don’t get into the central nervous system, but some patients swear by them.

Acupuncture and other complementary medicines work for some patients. Those are still kind of iffy in the big trials. My personal sense is if you think acupuncture is going to work for you, acupuncture is likely to work for you. If you don’t think acupuncture is going to work for you, then you’re more likely to be a non-responder But, patients who volunteer that they want a complementary treatment like that, I absolutely will refer them and cross my fingers that it helps, because it’s a fairly safe thing to do.

Then we’re left with the problems with gait, the weakness, the problems with dressing yourself from the loss of sensation. Those can be helped by therapy -- so, physical therapy, a physical therapist specialized in the treatment of balance and gait dysfunction can be very useful at making patients more mobile, less likely to fall. For patients with severe motor damage, sometimes we have to use things like AFOs -- those are ankle-foot orthoses, which are little foot braces that hold the foot up if you have a dropped foot.

Occupational therapists can be very useful for trying to help strengthen your upper extremities and improve your dexterity and give you tricks to help you do things more easily. So, yeah, there’s treatments for most of the components. There’s not necessarily a cure, but almost everybody we can make more functional and more comfortable.

Jamie DePolo: That’s very good to know. I’m also wondering, does diet play a role at all? You know, changing how you eat, what you eat? Is there any research on that? I’m just curious.

Dr. Michael Stubblefield: Eating well is always a good thing. Keeping your weight down is always a good thing. But unless you have a specific nutritional deficiency -- like, you’re B12 deficient, which can cause neuropathy -- then supplementing you is not going to make you better. So, giving you B12, which is kind of a common thing people get for neuropathy, is only effective if you’re B12-deficient, and it can be curative in those patients. For chemotherapy-induced neuropathy, it’s not.

There have been a number of big NCI, National Cancer Institute-sponsored studies. So, this is a big national organization that tries to identify and fund high-quality research, looking at various supplements in the treatment specifically of chemotherapy neuropathy. There’s, like, a dozen of them looking at things like glutamate and acetyl-L-carnitine and other things. And unfortunately, none of them have been positive studies. In fact, one of them -- I forget which -- made the neuropathy worse. Which, anecdotally, I guess I should remember that! So, the study was actually halted early because their assessment of it is, those patients who are getting the supplement were doing worse than other patients. 

So, for most of them, there’s probably little downside actually in taking them, but there’s no real evidence that they work.

Jamie DePolo: Do you know of any studies, I’m curious, about medical marijuana -- either the CBD oil or, you know, an edible or something like that as more states are legalizing that? Is there any reason to think that that could be helpful for neuropathy?

Dr. Michael Stubblefield: Yeah. Another great question. So, this has been, in my clinic -- I’m getting this literally every clinic, somebody is bringing up -- it’s the latest craze. And Sanjay Gupta coming on CNN and saying that it’s effectively the cure to everything is probably at least partially responsible for that. The problem is, because it has not been legal at the national level, there’s very little high-quality research on the use of any of these marijuana products to treat really anything.

There’s been a couple of meta-analyses of some of the issues -- and they’ve been slightly positive in some things -- but for the treatment, specifically, of chemotherapy-induced neuropathy, there’s really not very much out there. Nothing that I’m aware of that would convince me that it is a great treatment. I look at it very much like I look at acupuncture, although acupuncture actually has probably has quite a bit more data.

Unless you’re smoking it, and you’re getting the complications of the smoking, there’s probably little risk to judicious use of these. And if, anecdotally for you, as an individual, they’re helping you, then I think that’s fine. But I personally don’t have enough information on it to really advocate for it. I’m not telling my patients to go out and do this at this point, because there isn’t enough information. That being said, if they tell me they’re doing it, and that it’s helpful, I am grateful for that, because in the final analysis, all I want is for the patients to be better.

Jamie DePolo: We’ve talked about a lot of things, and I’m wondering, to wrap up, if there were three main points about neuropathy -- someone’s been diagnosed with it, they’re suffering from it because they’ve had chemotherapy to treat breast cancer. What three things would you want that person to know?

Dr. Michael Stubblefield: So, the first one is that if you have neuropathy, you want to make sure that it is just neuropathy and not something else -- meaning the carpal tunnel, or the pinched nerves in your back -- because if you have carpal tunnel, the treatment’s very different and can be very effective. For instance, injections, therapy, sometimes even surgery, may make that go away. So, having the right diagnosis is useful in this situation, particularly for, like, neuropathies that come on way after the chemotherapy -- outside of the timeline for coasting -- you really have to consider other disorders.

The other one is: there are treatments for neuropathy. So, depending on what you have, physical and occupational therapy can be extremely useful for improving your function and your quality of life. Decreasing pain, making you walk better, less prone to fall, easier for you to dress. And then: there are pain medications that, in most instances, can at least help a little bit. Not necessarily cure your neuropathy or make you completely comfortable, but can certainly make you much better -- and in some cases, make you considerably better.

So, I just want people to know, one: get the right diagnosis; two: seek physical and occupational therapy; and three: seek pharmacologic management of the pain if that’s your big issue.

Jamie DePolo: Thank you so much. This has been very informative. I’m sure our visitors will be grateful for your information.

Dr. Michael Stubblefield: My pleasure, Jamie. Thank you so much for inviting me on the podcast.

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