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Treatment

Several treatment modalities are available within the field of neuropathic pain and neuropathy.

Palmitoylethanolamide, PEA: key items presented

In the following sequence of presentations we bring to you the essence of knowledge around the body-own compound and supplement palmitoylethanolamide! We start with the general introduction, an overview of palmitoylethanolamide, an endogenous cellular protectant in plants, invertebrates, vertebrates and humans, tested extensively since 1970 and widely available as food supplement. Its main action is […]

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Topiramate to treat neuropathic pain

Topiramate is a drug we should not forget in treating patients suffering from neuropathic pain.  Especially not for patients with refractory neuropathic pain, that is if other drugs do not help.

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Thalamus pain, mast cells and PEA: a new treatment hypothesis

Thalamic pain after stroke is one of the most difficult to treat central painsyndromes. New therapeutic inroads are clearly needed, as the classical anti-neuropathic analgesics are not effective. In the future times we will need anti-gliopathic analgesics, as we pointed out elswere in our website.

The thalamus is a part of the brain were many mast cells reside. Mast cells play an important role in neuropathic pain. Palmitoylethanolamide (PEA) is a body-own fatty acid, synthetized in all our membranes, with mast cell stabilizing properties. PEA is registered in the catagory of medical food in Europe, and especially due to absence of side effects might be a promising new therapy for central thalamic pain. 

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Welcome to our Institute and Website!

neuron.jpgWelcome to our Institute for neuropathy and neuropathic pain, and our Website. We gathered here for you many articles in the field of neuropathy and neuropathic pain. In our centre we are specialised in treating patients suffering from neuropathic pain and neuropathy following an Integrated Medicine concept. Part of our activities are within the field of consultation. We assist pharmaceutical companies in R&D strategies related to finding new drugs to treat neuropathic pain and neuropathy. 

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Mast cells, gingivitis and palmitoylethanolamide

Gingivitis is not nice. Redness and pain of the gums and bad breath. The cause of gingivitis is an inflammation of the gingiva, or of the gums. It is found in well over 60% (!) of adults over age 45 or even nearly 100%, according to some dentists. Inflammation of the gums is usually the result of poor dental hygiene. Sadly enough it creates a second, more serious problem, periodontal disease. Unless corrected this usually poses a real thread for both tooth and jawbone. Mast cells can be found in normal gingivae as well as in acute necrotizing gingivitis, chronic marginal gingivitis,andand pregnancy gingivitis, and these cels have been identified already more than half a century ago.

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Nitrates in neuropathic pain

The Indian group of Agrawal and collegues (2007) explored the analgesic effects of glyceryl trinitrate spray in neuropathic pain. They suggested that impaired nitric oxide (NO) synthesis may play an important role in the pathogenesis of painful diabetic neuropathy. Some studies demonstrated impaired neuronal nitric oxide generation in diabetic rats induces hyperalgesia and in other studies a decreased nitric oxide production was seen to to a reduction in endoneural blood flow in type 2 diabetic patients with neuropathy. Both iso-sorbide dinitrate as well as glyceryl trinitrate may act as potent nitric oxide donor and have similar pharmacological activity compared to endothelial derived relaxing factor, a nitric oxide dependent enzyme with vasodilator capacity. In our institute we have now gathered quite some experience using isosorbide dinitrate cream in neuropathic pain, with good results.

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Multimodal pain management, and the role of palmitoylethanolamide

As yet, no “gold standard” has emerged for multimodal pain management for neuropathic pain. The various multimodal pain protocols that have been developed, however, share similar objectives, to reduce side effects, to reduce dose and to avoid and even to eliminate narcotics leading to troublesome side-effects while reducing the quality of life. Because pain involves multiple mechanisms that rely  on different receptor systems, it is beneficial to utilize  a multimodal approach to achieve pain relief in complex pain states such as neuropathic pain. 

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Vitamin E protection for neuropathy due to chemotherapy

Vitamin E protects against nerve damage from chemotherapy, showed by French researchers, in a study of more than 100 patients, a study published in 2010.

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Pain with hernia and treatment with palmitoylethalonamide (Normast, PeaPure)

Heavy neuralgia radiating to the leg is also called sciatica or lumbosacral radiculopathy. Doctors have called this neuritis or neuritis of the sciatic nerve, the Nervus Ischiadicus, for a long time. This old concept has now been given a complete new turn.

Sciatica is caused by mechanic pressure by an intervertebral disc on the beginning of the sciatic nerve, the so-called nerve root within or just outside the vertebral column. Because of that pressure the nerve becomes inflamed and then the pain starts usually quite sudden. Then an inflammation that is maintained by the pressure on that nerve, the hernia, starts. 

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Amitriptyline as good as pregabalin for painful diabetic Neuropathy

Amitriptyline as good as pregabalin for painful diabetic neuropathy says a review ariticle on Diabetes in control.com, dated March 23, 2010. This is based on the results of a head to head comparison of both drugs in a group of 41 patients. The study had some methodological flaws, but the results are in line with our expectations and experiences. Both drugs have similar efficacy, but amitriptyline, if dosed higher up (>25 mg an) has more side- effects.

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Palmitoylethanolamide (PEA) combined with pregabalin in neuropathic pain

Palmitoylethanolamin (Normast®;PeaPure®) is a endogenous lipid with analgesic and anti-inflammatory properties. In a study were 30 patients were entered, suffering from diabetic neuropathic pain and post-herpetic pain, palmitoylethanolamide was combined with pregabalin in the treatment of neuropathic pain.

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Cannabis as treatment for intractable abdominal pain syndrome

Treatment resistent abdominal pain, with unknown etiology can sometimes be treated succesfully by Cannabis. It might be that this chronic pain syndrome has something to do with small fiber neuropathy in the innervation network around the gut. But, whatever its etiology, it is merely a hypothesis and very difficult to substantiate. However, having said that, there are patients suffering from for instance diabetic neuropthy, with severe gasterointestinal complaits, and we feel these pains and complaints can be due to small fiber neuropthy. As Cannabis appeared to be a useful drug for treating treatment resistant neuropathic pain, we sometimes prescribe Cannabis to patients suffering from treatment resistent abdominal pain, and we follow the so called ex juvantibus approach. This means we give the patient the befifit of the doubt, that the pain might be caused by an internal neuropathy, and if so, whether the patients responds favourable on a treatment regime withn Cannabis, orally taken.  

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vitamin D and chronic pain

Vitamin D could save the country about €37.5 billion in health care costs, according to a new review  of professor A. Zittermann.

Vitamin D
receptors are expressed in many other tissues beyond
the musculoskeletal system, and vitamin D plays protective
physiologic roles against several chronic diseases such
as cancer, osteoarthritis, diabetes, and cardiovascular
conditions. There is clear evidence for an association
between low vitamin D status and pain in the general
population. The chronic pain syndromes included chronic back
pain, chronic musculoskeletal pain or widespread pain, and polymyalgia and in all these cases vitamin D was suggested as the cause of such nonspecific pain.

Vitamin D through its receptor modulates neuronal differentiation as well as neuronal growth and function. In rats, the production of nerve growth factor which is required for the development and survival of both sympathetic and sensory neurons decreases in the presence of vitamin D deficiency. In fact, in vitamin D deficient diabetic animals correction of vitamin D deficiency resulted in an improvement in nerve growth factor production. Decrease in neurotrophins and defective calcium homeostasis leaves the nerve vulnerable to toxins including hyperglycemia. As a result, a deficiency of vitamin D impairs nociceptor function, worsens nerve damage, and lowers the pain threshold.

And: 

In another study vitamin D levels were not only inversely proportional to a neuropathy symptoms score but also showed a statistically significant (OR 3.47 95% CI 1.04–11.56 P = 0.04) association with slower nerve conduction velocities after correction for duration of diabetes and levels of HbA1c, LDL, and urinary albumin

Two qoutes from a recent report were a patient suffering from severe neuropathic diabetic pain, refractory to analgesics, experienced cler pain relief after the correction of the vitamine D deficiency. 

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Regional analgesia, nerve block, in painful neuropathy

Until recently, regional anesthesia provided for the patient with a preexisting neuropathy has received scant attention. A review of major reference works dedicated to regional anesthesia spanning 87 years, and more than 4,700 total pages, found only 5 pages wherein the issue of central neuraxial anesthesia or PNB was discussed in the context of neuropathy. 

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Dolori dell’ernia e trattamento con palmitoiletanolamide

pea_in_normast_peapure_pelvilen.png

Normast e PeaPure: informazioni palmitoilethanolamide:PEA è disponibile come PeaPure, Normast, Pelvilen e attraverso gli altri nomi commerciali. Normast in Italia attraverso la farmacia e ottenere PeaPure è realizzato nei Paesi Bassi e in tutto il mondo come un supplemento inviato.

I neutraceutici PeaPure® e Normast®, sia palmitoiletanolamide antidolorifico naturale (PEA) contengono, aprendo la strada a un nuovo metodo naturale di trattamento del dolore cronico. Entrambi i prodotti sono realizzati secondo i più alti standard (GMP). Perché PEA nei Paesi Bassi solo dal 2010, e abbiamo anche molte domande per telefono, ecco un elenco di domande e risposte. Anche domande e commenti da parte di persone su Fori di discussione su PEA parlare, abbiamo elaborato.

Fine anno del 2012 nei Paesi Bassi, sono decine di migliaia di pazienti trattati con PEA. Non ci sono effetti collaterali significativi segnalati. PEA può essere senza problemi, oltre a prendere altri farmaci e medicinali.

Nel 2012 un preparato palmitoiletanolamide nuovo introdotto. PeaPure contiene il più alto contenuto di PEA (vedi tabella). Solo PeaPure un certificato di analisi disponibili su Internet.

 

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Acupuncture recommended by anesthesiologists

In April 2010 a new guideline was issued on the treatment of chronic pain: Practice Guidelines for Chronic Pain Management: An Updated Report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. 

In this guideline anesthesiologists of name and fame gathered and analysed all approaches to chronic pain. For acupuncture their assessment was:  

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Pharmacologic Treatment of Central Post-Stroke Pain

Pharmacologic Treatment of Central Post-Stroke Pain By:  A. Frese, I.W. Husstedt, E.B. Ringelstein, and S. Evers:  ClinJ Pain 2006;22:252–260: 

Treatment Recommendation for CPSP Based on Evidence Level

Short term pain control:
Lidocaine IV 5 mg/kg over 5 minutes

Propofol IV (Gaba-ergic) 0.3 mg/kg per hour  

Oral treatment:
Drugs of first choice(based on controlled trials):  

amitriptyline(anti-depressant) at least 75 mg per day

lamotrigine(glutamatergic) (at least 200mg per day

Drugs of second choice(based on open studies and experts’ opinion):

Mexiletineupto10 mg/kg per day

Fluvoxamin up to 125mg per day

Gabapentinat least 1200mg per day

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Natalizumab in chronic inflammatory demyelinating polyneuropathy (CIDP)

Natalizumab, a humanized monoclonal antibody against the 4 integrin did not help in treating a patient suffering from chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Although experimental evidence in an animal model pointed out that targeting 4 integrins in the inflamed peripheral nervous system may have clinical relevant effects, this was not the case in a patient.

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Occipital Neuralgia Responding to Palmitoylethanolamide

Under the titel ’Occipital Neuralgia Responding to Palmitoylethanolamide’ Rocco Salvatore Calabrò and Placido Bramanti reported a case in ‘Headache’, a female patient affected by occiptal-treatment-refractory-neuralgia that greatly improved after oral intake of palmitoylethanolamide (PEA).

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PRECISION TM Spinal Cord Stimulator (SCS) System

PRECISION TM Spinal Cord Stimulator (SCS) System : clinical studies forming the base of the registration of this device. Here a summary of the various studies supporting the registration of the precision spinal stimulator.

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PEA influences PPAR

One of the recent insights regarding the workingmechanism of PEA (palmitoylethanolamide) is that this molecule influences PPAR-alpha. PPAR-apha is a receptor located in the nucleus of the cel with a long name: peroxisome proliferator-activatedreceptor alpha. PEA is available in its purest form as PeaPure. PeaPure contains PEA only. Normast contains PEA too, but around 60%; Pevliven contains between 60-40% PEA.

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Trigeminus neuralgia treated with Gamma Knife surgery

Trigeminus neuralgia is difficult to treat. For those patients were medication such as carbamazepin is not helpful, the neurosurgeon can treat with the so called Gamma Knife…. 

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Normast and PeaPure: questions and answers

What exactly is Normast  and PeaPure?

In this page many clinical and patient driven questions will be discussed. This page is under construction. A website has been created for palmitoylethanolamide related science only.

Normast and PeaPure are brandnames for supplements containing a body own molecule, palmitoylethanolamide, against pain and inflammation.  

Normast however contains magnesium stearate, a alien fat for our body, undigestable and an excipient doctors recommend to avoid.

All scientific information is discussed in this review.

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Motor cortex stimulation (MCS) for neuropathic pain

In the European Journal of Pain Supplements, 19 juli 2010 Garcia–Larrea discussed the value of Motor cortex stimulation (MCS), a relatively recent neurosurgical technique for pain control, in the treatment fo neuropathic pain. This is an abstract of a talk he gave at the  Third International Congress on Neuropathic Pain in Athens earlier this year. We were there and would like to make some commets, as this talk was discussed in great detail by a MD from the UK. She stated that there has not been conducted one methodological acceptable clinical trial analysing the safety and efficacy of this technique.

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Cervico-thoracic or lumbar sympathectomy for neuropathic pain and complex regional pain syndrome

Complex regional pain syndrome (CRPS) is a chronic pain condition most often affecting one of the limbs (arms, legs, hands, or feet), usually after an injury or trauma to that limb. Surgical sympathectomy has long been seen as a realistic option to treat CRPS. The use of this operation that destroys some of the nerves however has always remain controversial. In a recent Cochrane analysis no evidence could be found. The conclusion was:

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Combination of analgesics in neuropathic pain

Treating neuropathic pain has to follow a multimodel painrelief approach. here we quote some lines from an FDA document concering pain treatment. An approach to improving pain control that addresses concerns with adverse events is to make use of a combination of different analgesics. By combining drugs lower doses can of each individual analgesics can be prescribed. In addition to the potential safety benefits of combination therapy, other potential advantages to use of a combination of analgesic drugs include the potential to overcome tolerance, improve efficacy, and decrease time- to-onset limitations of monotherapy.

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Carpal tunnel syndrome treated with PEA

median_nerve_in_ct.gifCarpal Tunnel Syndrome (CTS) is the most common compression neuropathy. It is the reason for pain and functional impairment. On the picture we see in yellow the median nerve, being compressed under a ligament in the wrist. This gives rise to chronic pain. Pain normally can be reduced with oral neuropathic analgesics. However, the side effects of most of the NSAIDS limit its use.  

Palmitoylethanolamide (PEA), a fatty acid occuring naturally in our body, has also neuropathic pain reducing properties. Furthermore, it stabilizes mast cells, present in the carpal tunnel. Besides the pain reducing effect, PEA has also neuroprotective properties. To evaluate the clinical effects of PEA in CTS, Italian researchers randomised 28 diabetic patients with CTS, in two groups: one group received PEA twice daily 600mg and the other group received placebo.

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Neuropathic low blood pressure: Droxidopa

Patients suffering from small fibre neuropathy sometimes also suffer from difficult to treat low bloodpressure. In the Orient there is a registered drug for this dindication: L-DOPS (L-threo-dihydroxyphenylserine; Droxidopa; SM-5688). Droxidopa is a synthetic amino acid precursor which acts as a prodrug to the neurotransmitters norepinephrine (noradrenaline) and epinephrine (adrenaline). Unlike norepinephrine and epinephrine themselves, L-DOPS is capable of crossing the protective blood-brain barrier (BBB).

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Evidence based medicine, patient centered medicine and the place of PEA

ebm.jpg Why the supplement PEA (Normast, PeaPure) in chronic painstates? Is Evidence-Based Medicine Patient-Centered and Is Patient-Centered Care Evidence-Based? The patient should be the ultimate judge. Therfore Dr Painless points out that treating patients suffering chronic pain with the non-prescription drug Normast makes sense. Evidence-based medicine is a rather young concept that entered the scientific literature in the early 1990s.

It has basically a positivistic, biomedical perspective. Its focus is on offering clinicians the best available evidence about the most adequate treatment for their patients, considering medicine merely as a cognitive-rational enterprise. In this approach the uniqueness of patients, their individual needs and preferences, and their emotional status are easily neglected as relevant factors in decision-making. 

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Cannabis cookies for neuropathic pain

Cannabis treatment for meuropathic pain using low dose cannabis during prolonged periods of time due to slow resorption from butter rich cannabis cookies: a better way to administer cannabis than the classical joint or marihuana tea.

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