Tips from an occupational therapist
I am an occupational therapist. In my line of work, I see many clients with neuropathic pain stemming from diabetes. I have never experienced neuropathy myself, but I know from working with my clients that it is often an unrelenting, terrible kind of pain. The burning, the pins and needles, the stabbing sensations, the numbness — peripheral neuropathy is hard to live with and can also be hard to treat.
The causes of peripheral neuropathy (neuropathy affecting the legs, feet, arms or hands) are not well understood, although it is clear that the condition can have a number of triggers, including physical trauma, infections and toxins. In people with diabetes, neuropathy is usually the result of elevated blood glucose levels, which in many cases leads to permanent nerve damage. However, many people with diabetes find that improving their blood glucose control — especially if their blood glucose far exceeds recommended levels — can lead to a reduction or even elimination of neuropathy symptoms.
In part because of the unknowns surrounding the physical mechanisms of neuropathy pain, conventional drug treatments can be hit or miss when it comes to getting relief. You may have to be zonked out on pain medicine to get any substantial effect, and even then you may still feel pain. It can be hard to find the balance between pain relief and quality of life. However, we therapists have a few techniques up our sleeves for “tricking” the nervous system into perceiving less pain.
As a disclaimer, everyone responds differently to each of these techniques. You may have to try several approaches before you find one that works for you. The word “works” also carries some ambiguity, since none of these approaches is a cure-all for neuropathic pain. However, one or more of them may help you get your pain to a more manageable level, so you can go about your daily routine and spend more time living again.
The good news: None of these techniques will make your pain any worse — at least not in a lasting way — so what do you have to lose?
What is type 1 diabetes?
Type 1 diabetes is an autoimmune disorder in which the immune system attacks and destroys the insulin-producing beta cells in the pancreas. As a result, the pancreas produces little or no insulin. Type 1 diabetes is also characterized by the presence of certain autoantibodies against insulin or other components of the insulin-producing system such as glutamic acid decarboxylase (GAD), tyrosine phosphatase, and/or islet cells.
When the body does not have enough insulin to use the glucose that is in the bloodstream for fuel, it begins breaking down fat reserves for energy. However, the breakdown of fat creates acidic by-products called ketones, which accumulate in the blood. If enough ketones accumulate in the blood, they can cause a potentially life-threatening chemical imbalance known as ketoacidosis.
Type 1 diabetes often develops in children, although it can occur at any age. Symptoms include unusual thirst, a need to urinate frequently, unexplained weight loss, blurry vision, and a feeling of being tired constantly. Such symptoms tend to be acute.
Diabetes is diagnosed in one of three ways – a fasting plasma glucose test, an oral glucose tolerance test, or a random plasma glucose test – all of which involve drawing blood to measure the amount of glucose in it.
Most people find warmth soothing. When is the last time you didn’t feel relaxed in a warm bath or while lying in the sun? Warmth provides the body with a pleasant, comfortable sensation that might just be enough to provide some relief from neuropathic pain. The body only has so many sensory nerve receptors, so why not give some of them something nice to do for a change?
Heat can be applied in a number of ways. You can purchase a plug-in heating pad in almost any pharmacy; many pads have temperature controls to make them adjustable to your needs. Place the heating pad on the body part that needs soothing, taking care to place a layer or two of fabric (such as folded dish towel) between yourself and the heat source. Leave the heat on the affected area for a maximum of 10 minutes; remove it earlier if it becomes uncomfortable. (For more on applying treatments safely, see “Tips for Using Heat and Ice.”)
If you want to experience a spa-like treatment at home, you can purchase a paraffin wax warmer, which is also available at many pharmacies. This device is slightly messier and hotter than a heating pad, but using it can feel nice for your hands. If you use one, be sure to follow the package instructions and to check the temperature of the wax before putting your hand in it. Use a candy thermometer to ensure the wax temperature is no higher than 100°F, and continue to monitor it as you use the bath. Temperatures over 120°F can cause serious burns.
Another option — and the least expensive — is simply to use warm water. Again, make sure the temperature of the water is no higher than 100°F. Run your hands under the faucet, submerge your hands or feet in a basin of warm water for several minutes, or soak towels in warm water and wrap them around the affected area. Add some scented oil or shower gel to the water for an even more pleasant sensory experience.
In general, ice is not as soothing as heat. However, it does have the advantage of being an analgesic: It can provide a mild numbing effect, which can relieve pain. Ice is also anti-inflammatory, meaning it helps reduce swelling. This can be useful if your hands or feet are prone to edema (fluid buildup), which can increase sensations of pain. Ice may also be the key for someone whose pain does not respond to heat.
Using ice is as simple as going to your freezer: Fill a large freezer bag about halfway with ice cubes and seal it. Place a doubled-up towel over the area you are treating, then mold the bag of ice to the area and keep it in place for no more than 10 minutes. Some people prefer using bags of frozen vegetables such as peas, which are easy to shape to various body parts and can simply be thrown back into the freezer when done to reuse later. Just be sure to label your “cold pack” so that no one cooks it for dinner. You can also buy different sizes of reusable cold packs — filled with gel or pellets — at a drugstore and keep them in your freezer; having options can be helpful if you use ice frequently or for more than one area of your body.
Contrast baths are a little messy, but they may offer some relief from both pain and swelling in the hands or feet. Start with two basins: one filled with ice water, the other with warm water. Starting with the ice water, submerge your hand or foot for 30 seconds — if you can tolerate it — and then immediately switch to the warm water for 2 minutes. Repeat the process about five times. If you can’t tolerate the entire 30 seconds of cold, you can cut the time for each bath in half.
Contrast baths are nice for people who get good results from ice but cannot tolerate using it for long periods of time. Like ice, contrast baths can keep edema under control. If you decide to try this method, be sure to keep several towels handy — no matter how careful you are, water tends to get everywhere.
Have you ever had a headache or some other kind of pain, then forgotten about it? Later you might realize the headache or pain has gone away or is less bothersome somehow. Sometimes you only notice the pain again when you remember that you felt it before. Did your pain actually go away and then come back? Probably not; more likely, you were just distracted.
Distraction works under the principle that pain is all in your head. It’s not that you are imagining your pain; it’s that your brain — where feelings of pain are processed — only has so much attention to give. The more it focuses on pain, the less likely it is to notice much else. The flipside, however, is that if you can direct some of that attention elsewhere, your brain will have to turn down the “noise” caused by the pain.
Anything can be grounds for distraction: music, a good book, television, calling up a friend to chat. Whatever you enjoy and can focus on, do it. Distraction can be especially helpful when your pain is holding you back from a task that needs to be done. This applies most often to physical tasks such as exercise or mundane housework — although if a mental task does not demand all of your focus, it may benefit from distraction, too.
Sometimes the pain caused by peripheral neuropathy gets worse with overuse of the affected area. Just as your body would ache after a heavy workout, your hands may ache when you demand too much of them. But how to avoid this? Can you name a household activity that doesn’t use your hands? Most likely, you have a daily routine that includes holding, lifting and carrying objects. If you can find a way to make those tasks easier, it might lessen the burden on your hands and spare you some pain. There are two ways to approach reducing the physical burden of tasks: joint protection and work simplification.
Joint protection means performing daily tasks in ways that lessen the load on your joints, particularly those in your hands and wrists. Joint protection is all about physics: using larger-handled objects, for example, or replacing knobs with levers, which require less force to operate. There are joint-protecting tools for just about any task or hobby, from eating to gardening. (See “Sources of Aids for Daily Living.”)
Work simplification also involves making tasks easier. Rather than focus on reducing the stress on joints, however, work simplification aims to eliminate some of the steps or effort required in routine tasks. Some examples of this strategy include switching to wrinkle-free clothing, using automatic cleaning devices (such as those for showers and toilet bowls, or a robotic vacuum cleaner) and choosing pre-chopped vegetables for cooking.
Both of these strategies may require some monetary investment — after all, new gardening equipment and a new wardrobe generally don’t come cheap. But if a purchase helps you get back to a hobby that you love, or even if it makes your daily routine a bit less strenuous, it’s probably worth it.
Pain has a tendency to make people feel grumpy and edgy — meaning that the frustration caused by neuropathic pain can be about far more than the pain itself. Holding this frustration inside is almost always a bad idea, and it can be enormously therapeutic just to vent. One excellent way to do this — even though it may sound a bit hokey — is to write about your feelings.
A major advantage of using a journal over, say, a good friend to vent is that the journal never gets tired of listening to you gripe. It never judges you. You can use the strongest language you want, and no one ever has to hear it. A journal is a safe place to write anything you need to get out of your system — just be sure to keep your journal locked or hidden away if you want to keep your thoughts private. After you have vented in your writing, you can then call a friend and talk about something more pleasant.
Another advantage of journaling is that you can track your pain. By noting what you are doing when your pain gets worse (or better), including what time of day it is and details such as what you’ve been eating, you may discover patterns that you might not otherwise notice.
Relaxation is a powerful pain-fighting tool. Think about it: When you’re in pain, do you feel relaxed or tense? Are your muscles at rest, or clamped up? Is your nervous system calm, or do you feel anxious and edgy? By consciously working to control these reactions to pain, you can sometimes reduce your perception of the pain itself. To use an analogy, the fire alarm may be disturbing you as much as the fire — and you’ll feel better if you manage to turn it off.
Naturally, different people find different activities relaxing. If you have a tried-and-true method of relaxation, that activity may be a good remedy when your pain starts to act up. If you don’t have an activity in mind, though, here are a few ideas.
Go to a gentle yoga class. Yes, you will be moving, and moving hurts. But in yoga, you focus on the breath (distraction!) and slowly relax the muscles and the mind. You finish by lying down and simply breathing. Be sure to choose a class for beginners (avoid any class with the word “power” in the title) and to inform the teacher of your condition beforehand. He may help you modify a few poses to increase your comfort.
Don’t have time for a whole yoga class? Turn on some peaceful music. Use headphones if you can, to help block out the rest of the world. You can also look for a CD or a free podcast that provides guided imagery, in which you slowly let go of all of your tension while imagining you are somewhere peaceful and safe. Using guided imagery — or any other form of guided relaxation — at home may be an attractive alternative to a public class.
You may be skeptical of exercise as a remedy for neuropathic pain — and such skepticism would be justified, since some exercise can make pain worse. But exercise can also help; you just have to do it the right way. This means, above all, exercising gently — no grunting, heavy lifting or sweating bullets.
People with peripheral neuropathy may experience more than just nerve pain; they can also have motor nerve damage, which affects how the muscles function. Exercise won’t repair damaged motor nerves, but it can help your muscles compensate for any damage. Specialized strengthening exercises can help you reclaim muscle function and thereby lessen the burden of day-to-day tasks.
If you are new to exercise or if you haven’t exercised in a while, it is a good idea to consult an experienced occupational or physical therapist before embarking on any program. Unlike a personal trainer, therapists have specialized education in treating a wide range of health conditions. A therapist knows how muscles and nerves function, and what can interfere with their performance. By seeing a therapist, you can get an exercise program that is tailored to your particular needs.
Neuropathic pain can range from annoying to practically debilitating, and sometimes the available remedies may seem troublesome or inadequate. But many people find at least partial relief from one or more of the treatments and strategies described in this article. If one attempt to soothe your pain doesn’t work, it is important to keep trying. Whether through heat or cold therapy, relaxation, exercise or adaptations to your daily routine, you may find a reduction in pain — and greater peace of mind — somewhere you didn’t expect to find it.