The Functional Medicine Approach to Peripheral Neuropathies

By: Robert Kornfeld, DPM

I have been in private practice as a podiatrist since 1982. During my years in practice, I have seen a tremendous increase in the number of patients suffering from peripheral neuropathy. This condition, which has many causes, results in any combination of intense pain, tingling, burning, hypersensitivity, numbness, structural collapse of the foot, instability, and non-healing wounds. It is a source of profound suffering for so many patients and many of them go from doctor to doctor searching for relief. Conventional Approach

Relief is what traditional medicine attempts to accomplish. Once it is established that the symptoms are neuropathic in nature, most patients are told that the only source of relief comes from medications.

Most neuropathy patients are given prescriptions for medications including:

• Opioid (narcotic) analgesics like Vicodin (Hydrocodone) or OxyContin (Oxycodone);
• Lyrica (Pregabalin) which was originally approved as an anti-convulsant but it also can affect the chemicals (neurotransmitters) that help to transmit a pain impulse into the brain and diminish the perception of pain;
• Cymbalta (Duloxetine) which is a selective serotonin and norepinephrine reuptake inhibitor that was originally approved as an anti-depressant/anti-anxiety medication but has also been found to diminish the perception of pain;
• Ativan (Lorazepam) which is a benzodiazepine originally approved for the treatment of anxiety which has been used to treat chronic pain and neuropathy at low doses as it also can scramble the pain message sent to the brain; and
• Other medications that have similar effects on the brain via direct suppression of pain through the brain or an alteration in neurotransmitters. ?

Unfortunately, all these medications come with side-effects and most patients suffer with “break-through” pain despite being medicated. Many patients find this approach unsatisfactory and often equally disabling.

Causes of Neuropathy

There are many causes of neuropathy. Some of the most common are:

• Diabetes resulting in microangiopathy or the clogging of microscopic blood vessels that bring blood to nerve cells;
• Peripheral arterial disease – clogged large arteries resulting in decreased blood flow to the nerve cells in the lower extremity;
• Raynaud’s Disease, which causes severe microscopic capillary vasoconstriction decreasing blood flow to the nerve cells as well;
• Sympathetic nervous system disorders such as reflex sympathetic dystrophy (now known as CRPS – chronic regional pain syndrome) which occurs with or without major nerve injury causing overstimulation of pain nerve fibers;
• CSS (central sensitization syndrome) which is a disorder in the central nervous system and occurs when the brain over-reacts to stimuli and results in an exaggerated response to stimuli. In both CRPS and CSS, a sensory stimulus like touch or pressure can result in a pain response. This can happen with a simple touch of the foot since the brain evaluates the sensory stimuli as pain. Most will have constant pain even when resting.

Functional Medicine Approach to Peripheral Neuropathy

In functional medicine, which is a different paradigm than traditional allopathic medicine, we do not treat symptoms until we identify and address the underlying causes of the presenting pathology. As I explained above, several medications used result in some relief because they target neurotransmitters to alter the perception of pain. These medications are anti-anxiety and antidepressant medications.

In functional medicine, when we evaluate a patient, we must consider all the contributors to the condition. In other words, why does THIS patient have this condition at this time? I find it fascinating that these intense pain syndromes are managed by medications that are used to treat anxiety and depression. If that’s the case, wouldn’t it make so much more sense to start our evaluation of these patients by looking at anything that could alter the normal, healthy functioning of the human body, such as adrenal hormones and neurotransmitters? And wouldn’t evaluating anything that can burden the immune system make sense, since healing and repair are mediated by the immune system?

Based on a history of the condition, the patient’s medical and family history, a review of all the systems in their body and an understanding of the patient’s emotional state, we can determine a path to uncover these underlying mechanisms.

For instance, with diabetic patients, an assessment of their usual diet is critical. Blood tests do not tell us what is really happening. If we look at an evaluation of Hemoglobin AIC, which gives an average of blood sugar over the course of three months, we may miss all the spikes that occurred from consumption of refined carbs (where vascular damage occurs) and the lows caused by medication adjustments. It is in a diet journal that we get the best information. This holds true for everyone. A poor diet will always give rise to heath challenges. In addition, inadequate hydration is often contributory because it decreases blood volume.

It is also interesting that most diabetics suffer with anxiety and depression. And why would this be? We all have a primitive survival mechanism in the body. You know it as the fight, flight, and fright response to danger. It starts with the release of an adrenal hormone called cortisol. The job of cortisol is to signal the liver and the cells of the body to dump sugar and ATP (the energy molecule made from glucose) into the bloodstream for a rapid increase in available energy to fight the beast that wants to consume you or to run away from the danger. This rapid rise in sugar also occurs in people who consume refined carbohydrates. Since these refined sugars are single molecules in a pre-digested form, the rapid rise in blood sugar tricks the brain into thinking you are in a survival challenge and it responds with helpful excitatory neurotransmitters to facilitate survival.

Neurotransmitters such as epinephrine (which increases heart rate to circulate blood faster), glutamate, histamine, dopamine and others, when constantly stimulated to effect protective changes, can lead to chronic anxiety and depression. Many times, it results in a decrease of inhibitory neurotransmitters which are designed to keep us calm, tranquil, relaxed, and facilitate sleep so the body can take care of its needs.

CRPS and CSS are also often treated with medications to address anxiety and depression. ?So a complete assessment of adrenal hormones and neurotransmitters is performed on ALL of these patients in my office. In almost every case, we find abnormalities which can be treated with natural supplements, dietary changes and stress management. There are, of course, other tests that may also be needed to assess these patients. Some of the more common ones are hormones, oxidative stress tests, food sensitivity tests (food is the largest antigenic challenge we face and any foods that sensitize the immune system create burdens, inflammations and immune overload), Copper: Zinc ratios (which can be one issue in an inefficient immune system), Vitamin D3 and Magnesium levels, Fatty Acid levels, and DNA evaluation for genetic mutations that are associated with high incidence of chronic pain syndromes. Whatever we discover is addressed. The goal is to optimize the health of the patient.

The exception is CSS (Central Sensitization Syndrome). This syndrome requires all the above but also must involve a rewiring of the brain and its association with the pain. Pain therapy becomes critically important for these patients. One of the more common approaches is CBT (cognitive behavioral therapy) or DBT (dialectical behavioral therapy which is a modification of CBT). Another type of psychotherapy specifically created to address chronic pain and CSS is pain reprocessing therapy.

I also employ vascular therapy (MicroVas?) in my office via high voltage electrical stimulation therapy that forces a higher rate of blood perfusion into the foot. When performed consistently, it can increase nutrition to the peripheral nerve cells and help them to heal.

Case History

A 56-year-old male with chief complaint of pain, tingling, numbness and burning in both feet. Patient has been a Type 2 diabetic for 17 years. He admits that he “doesn’t take care of himself”, but now he’s scared because his last A1C was 11.3 just 2 weeks prior to this appointment. A normal AIC level is below 5.7. Exam reveals an obese male (he admits to being about 300 pounds and had gained about 100 pounds in the past year). Medical history is positive for high blood pressure – Chlorthalidone 100 mg once daily; high cholesterol – Pravastatin 40 mg once daily; Type II diabetes – Metformin 1000 mg BID. He also admits to depression but doesn’t take any meds because he says, “Beer works better”. I asked him about his daily consumption of beer, and he laughed but would not give me any more information.

Review of symptoms revealed chronic indigestion, reflux, body aches and shortness of breath when he walks up stairs. He said he takes a lot of Tums and on bad days, Advil for his body aches. Although he admitted to sleeping poorly, he told me that he was given a prescription for a sleep aid (didn’t remember what it was), but he stopped taking it because it made him feel disoriented and didn’t help him sleep.

There are many tests I could have run from the “get go”, but here we obviously have a patient who is his own worst enemy. There would be no point in attempting analysis of mechanisms until we get a handle on his diet and his drinking. I sat with this man and asked him how he wants to die.

He looked at me right in the eye and said “fast”. I then said, “Well that’s not going to happen. First, you will lose a leg. Then maybe another one. You will then develop advanced stages of heart disease, kidney disease and will likely go blind”. He then looked at me and said “Well, you’re full of good news”. I explained how no doctor could help him until he decided to help himself. I was quite honest with him. I told him that I cannot even attempt to treat him until he goes to AA and gets off the beer. His face turned red and he said, “Doc, you’re killing me”. To which I said, “No. You’re killing yourself and I personally don’t want to be a part of that”.

He agreed to go to AA and returned 3 months later with his 3 month coin of sobriety from AA. Not surprisingly, his A1C dropped to 8.9 (he was obviously drinking a ton of beer). Suffice it to say, his diet was beyond horrible. Tons of refined carbs and fast food. No water. Just sodas. At this visit, we spoke about diet, food quality, food choices, food combining, proper hydration and I spent a significant amount of time talking to him about the effects of refined carbohydrates. I explained to him that it was his heroin. It was another addiction he needed to conquer.

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At this point we had to tackle his diet, which was horrible. I had him eliminate all refined carbohydrates and gave him ideas about complex carbohydrate replacements. I also told him to begin drinking water only – no sodas. I told him, “You may not care about yourself, but I do”. His eyes welled up with tears.

With a patient like this we need to be equal parts doctor and coach. I texted him at least 3 times a week to see how he was doing and if he had any questions. He always answered that it was “hard”. I told him it’s harder to die without legs and eyesight. I told him “Just do the right things. Don’t look for results. When you do the right things, the right result always comes. We just don’t know when”.

All this while, I had not directly addressed his neuropathy. He returned to the office after 8 weeks of no refined carbs. He had lost about 22 pounds (you couldn’t tell because he was such a large man) but he was encouraged. He also told me that he was up to 5 glasses of water a day.

The next step in my plan was to introduce him to moving his body. I couldn’t ask him to start walking because his feet were still extremely uncomfortable. However, I convinced him to purchase an exercise bike. I told him to ride it EXACTLY 1 minute a day and not a second more for 2 weeks.?I then instructed him to add 1 minute to his ride every week after that. I told him I wanted him to return when he was up to 10 minutes. He returned about 3 months later. He told me he was up to 12 minutes and was very proud of himself. He had lost another 8 pounds (still couldn’t tell) but his doctor was very happy. His A1C was down to 7.8. At this point, 10 months after meeting him, I felt we were ready to analyze underlying mechanisms. In view of the history of depression, a great starting point would be an adrenal/neurotransmitter analysis.

When his tests came back, he came in for a review. His glucocorticoids, diurnal cortisol and cortisone were elevated, his DHEA was low. He had low serotonin, high normal glutamate, elevated dopamine and 3 of 4 inflammatory markers were elevated. This is indicative of adrenal stress and an excitatory neurotransmitter dominance which can further diminish blood flow to the feet. He was placed on a protocol to address all of this.

Admittedly, I had a long way to go with this patient, but we weren’t far away from more aggressive therapies. It had been 11 months since we first met. I told him to return in 6 weeks. **An important point is you can’t always move quickly if you want to succeed. When we are calculated and patient, lives change.

He returned a little more than a year after we met, he had lost a total of 41 pounds and I could finally see it. He admitted to sleeping better, although his feet were still an issue. More importantly, his at home glucose levels had improved significantly. His digestion was vastly improved. He was doing fine with the supplements, continued on the diet as best he could (he admitted to not being perfect) and was now riding his bike 30 minutes daily.

?It was now time to foster better perfusion in his feet and we spoke about MicroVas therapy.

Three months into MicroVas therapy, he stated that there was a great decrease in the pain and burning. He still had some numbness and tingling, but it wasn’t driving him crazy and he was sleeping much better. We continued for 2 more months. At that time, he still had numbness and but no more tingling. But he was very happy! It was 18 months since we met. All the while, he continued to work hard at improving his health. His A1C was now down to 5.9. He had lost 75 pounds.

At my urging, he had joined a gym so he could stay active and exercise. He got into weight lifting and shockingly, started taking yoga classes. This man had truly transformed his life!

This is how functional medicine works. As we work to improve the overall health of the patient, get them to change bad habits into good habits and educate them about their bodies, there is an amazing transformation that takes place. As long as we have a committed patient who understands that this is not a magic bullet approach (as there is none for neuropathy), the investment in time can create years of improved health and enjoyment of life.

?Conclusion

Treating peripheral neuropathies is complex and requires a comprehensive assessment of each patient’s unique physiology, epigenetics and genetics. It is not “one size fits all” by any means. I have had great success with those patients who remain committed to the process and do not give up. Healing these conditions is slow and laborious but it can be accomplished successfully.

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Dr. Kornfeld has been in practice for over 41 years. He has offices in New York City and Port Washington, Long Island (https://drrobertkornfeld.com) In 1987 he adopted a functional medicine paradigm into his practice. This is a mechanistic approach to understanding the origins and mechanisms of pathology that must be diagnosed and addressed. He has been published numerous times, has been on radio and TV and hosted his own interactive radio program. His approach in practice is an intensive focus on treating chronic foot and ankle pain through a functional medicine model. Dr. Kornfeld founded?The Institute For Functional Podiatric Medicine?which provides a platform to train and mentor podiatrists in the paradigm of integrative/functional medicine for foot and ankle pathology.

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