Introduction

Peripheral neuropathy is any damage or dysfunction of the nerves outside the spinal cord and brain. It can occur anywhere in the body - it can be localized or widespread.

Please see conventional, complementary, and alternative medical treatments for important background information regarding the different types of medical treatments discussed on this page. Naturopathic, Complementary, and Alternative treatments that may be considered include:

Pathophysiology

Peripheral Neuropathy is generally classified as either widespread or local, as discussed below.

Widespread Peripheral Neuropathy

Widespread peripheral neuropathy is usually due to some systemic problem, for example:

  • Diabetes, porphyria, uremia, or other systemic metabolic disease
  • Drug, alcohol, or toxin side effects
  • Too much or too little of the various B vitamins (or an imbalance)
  • Autoimmune diseases such as multiple sclerosis
  • Guillain-Barr

Local Peripheral Neuropathy

Local peripheral neuropathy is usually due to trauma, for example:

  • Local trauma, e.g. crush injuries
  • Spinal column subluxations, fixations, or degenerative disc disease that results in compression of nerve roots exiting segments of the spine
  • Brachial, lumbar or sacral nerve plexus damage
  • Repetitive strain injuries
  • Foot drop (peroneal nerve)
  • Wrist drop (radial nerve)
  • Tumors
  • Bell's palsy
  • Trigeminal neuralgia

Diagnosis

Peripheral neuropathy can cause many symptoms, including:

  • Pain or tingling
  • Muscle twitching
  • Loss of sense of touch (numbness)
  • Loss of muscle or organ function.
  • Autonomic nervous system disruption:
    • ED
    • Cardiac arrhythmias
    • Gastrointestinal problems (gastroparesis)
    • Bladder problems

Management

Sometimes treatment can at least partially cure, but often treatment can only slow or stop the progression of the disease process. The sooner treatment is begun, the better the prognosis.

In general, treatment is based on identifying and treating the cause:

  • Correct spinal problems
  • Correct metabolic problems (e.g. blood sugar)
  • Correct nutritional imbalances and deficiencies
  • Avoid toxic medications and environmental toxins
  • Control blood pressure
  • Ensure proper blood flow and lymphatic drainage

Conventional Treatments

In the following paragraphs, NNT is the Number of patients Needed to Treat in order to get a 30-50% (moderate) reduction in pain; NNH is the Number of Patients needed to treat in order to cause Harm sufficient for the patient to discontinue treatment. The first number represents the effectiveness of the treatment and the second number represents the safety/tolerability.

A recent meta-analysis [Finnerup2015  🕮 ] identified the following palliative drugs as being first-line, second line, or third line based on effectiveness and safety profile:

First Line

  • Amitriptyline (Tricyclic) 25-150mg/day; NNT = 3.6, NNH = 13.4
  • Gabapentin (Anti-epileptic) 1200-3600mg/day in divided doses; NNT = 6.3, NNT = 25.6
  • Duloxetine (SNRI) 150-225mg/day; NNT = 6.4, NNH = 11.8
  • Venlafaxine (SNRI) 25-150mg/day; NNT = 6.4, NNH = 11.8
  • Pregabalin/Lyrica (Anti-epileptic); NNT = 7.7
  • Gabapentin ER/Enacarbil (Anti-epileptic) NNT = 8.3, NNH = 31.9

Second Line

  • Lidocaine patch
  • Capsaicin 8% patch; NNT = 10.6
  • Tramadol ER (Opioid+SNRI) 400mg/day; NNT = 4.7, NNH = 12.6

Third Line

  • Morphine (Opiate) 90-240mg/day; NNT = 4.3, NNH = 11.7 (concern for abuse)
  • Botox-A; NNT = 1.9

Insufficient Data

  • Tapentadol/Nucynta (Opioid+SNRI)
  • Sativex (Cannabinoid) (concern for abuse)

Ineffective

  • Topiramate/Topamax (Anti-epileptic); NNH = 5.1
  • Zonisamide (Anti-epileptic); NNH = 2.0
  • oxcarbazepine/carbamazepine (Anti-epileptic); NNH = 5.5
  • Topical Clonidine
  • SSRI
  • NMDA-antagonists

Harmful

  • Valproate (Anti-epileptic)
  • Levetiracetam/Keppra
  • Mexiletine

Naturopathic, Complementary, and Alternative Treatments

Low Dose Naltrexone (LDN)

[LdnResearchTrust_conditions] reports that peripheral neuropathy is a condition that LDN could help. [Brown2023  🕮 ] reports a case series of 70 pain patients having various diagnoses which showed a positive response in 64% of the cases. 51% of the responders had a diagnosis of neuropathic pain or CRPS. This suggests a NNT less than 2, which outperforms the response rate of all the pharmaceuticals evaluated above under the topic of Conventional Treatment.

[Hutchinson2008  🕮 ] suggests that this effect may be mediated by the action of LDN on Toll-like receptor 4. Dr. Weyrich has been trained to use Low Dose Naltrexone (LDN). However, Dr. Weyrich has not treated any cases of peripheral neuropathy with LDN.

Please see What is Low Dose Naltrexone? for more information.

Nutritional Medicine

The most important intervention is controlling the underlying disease process. For diabetic neuropathy, this includes normalizing blood glucose levels and treating microvascular diseases.

The following nutritional interventions should be considered in treating neuropathy:

  • Acetyl L-carnitine 1,000mg/day [Gaby2011, pg 550] [Rogers2001, pp 329 ff]
  • Thiamine (consider 10-30mg/day) [Gaby2011, pg 550]
  • Vitamin B6 [Gaby2011, pg 550]
  • Vitamins B12 and B9 [Gaby2011, pg 550]
  • Vitamin B5 [Gaby2011, pg 550]
  • Vitamin B3 (niacin or niacinamide) [Gaby2011, pg 550]
  • Magnesium - needed for thiamine function [Gaby2011, pg 550]
  • Alpha-Lipoic Acid (300mg TID) [Gaby2011, pg 550] [Javed2015] [Rogers2001, pp 329 ff]
  • Full spectrum Vitamin E [Gaby2011, pg 550] [Rogers2001, pp 329 ff]
  • Stop smoking (damages microcirculation)
  • Gluten-free diet - [Gaby2011, pg 550] reports peripheral neuropathy and cerebellar ataxia are associated with gluten-sensitivity.
  • Low-glutamate diet - [Gaby2011, pg 550] reports a case of peripheral neuropathy associated with MSG consumption.
  • Benfotiamine (a fat-soluble analogue of thiamine/vitamin B1) [Javed2015]
  • Phosphatidyl Choline [Rogers2001, pp 329 ff]
  • EPA and DHA [Rogers2001, pp 329 ff]
  • IP-6 [Rogers2001, pp 329 ff]
  • Micronutrients such as chromium and vanadium [Rogers2001, pp 329 ff]

Other

  • Spinal manipulation
  • Acupuncture
  • SCENAR
  • Diathermy
  • Ultrasound
  • Herbs

References