Why do my feet tingle?

Peripheral neuropathy is a common condition, affecting some 6% of adults 45 or older.

What is it, what causes it and what can you do about it?

Our nervous system consists of the central nervous system (CNS) – the brain and spinal cord – and the nerves that carry sensation to and commands back from the CNS. These nerves are the peripheral nervous system.

The peripheral nerves can be thought of as the body’s wiring system. There are sensory nerves that bring sensations of touch, temperature and pain to the CNS, motor nerves that carry commands from the CNS to our muscles, and autonomic nerves, that regulate bodily functions not usually under conscious control such as heart rate, breathing and gastrointestinal function.

Many things can damage nerves, some of which happen no matter what we do while others are under our control.

If sensory nerves are damaged, we may be unable to feel hot or cold or where our feet are, or we may feel numbness or tingling, or we may feel pain for no reason.

If motor nerves are involved, you will notice muscle weakness.

Autonomic neuropathy can have many effects, including drop in blood pressure when you stand up.

Because the nerves to the feet are the longest peripheral nerves, they are most susceptible to damage and usually the first to suffer. Hence, we usually notice abnormal sensation in the feet rather than higher up. The fingers may be next.

What causes peripheral neuropathy? The commonest known cause is diabetes; the longer and more poorly controlled is the diabetes, the more likely to result in neuropathy. Another common cause is excess alcohol. Vitamin deficiency, particularly of B12 and other B vitamins, is a very treatable cause. (Oddly enough, excess B6 can also cause neuropathy!) Chemotherapy often results in neuropathy.

There are numerous diseases, too many to list, that have peripheral neuropathy as one of their symptoms.

Finally, there is that great wastebasket of “we do not know.” One of the commoner causes of peripheral neuropathy is simply aging, with no specific disease found after thorough testing.

What can you do? If you notice any of the symptoms listed above, bring it to your doctor’s attention. Verifying the presence of neuropathy is usually easily done by physical exam. If it appears likely, you should probably see a neurologist for a more thorough exam and testing.

To minimize the likelihood of developing neuropathy, eat a healthy diet with lots of fruits and veggies to get your B vitamins and minimize your alcohol intake. If you have diabetes, work with your doctors and nurses to keep it under good control.

Do not dismiss it (or let your doctor dismiss it) as simply aging. Only after treatable causes are excluded is this an acceptable conclusion.


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Are you taking a daily aspirin?

Should you be taking a daily aspirin?

First, a little bit of (easy) basic science: we cut ourselves all the time, and nature has given us protection against bleeding to death every time this happens.

The first line of defense is our platelets, small blood particles that go to the site of disrupted blood vessels and plug any small holes, like the little Dutch boy at the dike.

The second and more permanent way bleeding is stopped is that proteins in our blood form clots.

These protective forces can cause harm. Platelets attracted not to a hole in an artery but to an irregular surface such as a cholesterol plaque can block off the artery, causing a heart attack or stroke.

(Unneeded clots can also cause problems – we will discuss that another day.)

Aspirin works to prevent platelets from clumping together. This effect is rapid and effective: a single dose of 81 or 162 mg (“low dose”) aspirin paralyzes all the circulating platelets. Platelets turn over rapidly; you get an entirely new set every 7 days, so a single dose will be effective for a few days only.

Many decades ago, it was shown that daily low dose aspirin started within 24 hours of a heart attack dramatically reduced the risk of another heart attack and stroke. This effect is called “secondary prevention:” preventing a recurrence, and nothing has changed this benefit. If you have coronary disease, you should be on aspirin unless you are at very high bleeding risk.

The problem comes when the prescription of aspirin moves from this valid use to broader use. It seems logical that if aspirin taken after a heart attack prevents another one, taking aspirin before a heart attack should prevent a first one, so-called “primary prevention.”

Aspirin taken this way DOES decrease a first heart attack or stroke, but only by a very small amount. This benefit is typically outweighed by the increased risk of bleeding that comes with aspirin use.

The higher your risk of heart attack or stroke and the lower your risk of bleeding, the more the evidence says to take aspirin. If you have multiple risk factors such as hypertension, high cholesterol, smoke and have a positive family history, and particularly if you have a high coronary calcium score, the more likely you would benefit from daily low dose aspirin.

If your coronary risk is only moderate and if you have had a bleeding ulcer or other serious bleeding, you are better avoiding aspirin.

In between? The old fallback: talk to your doctor!

No known major coronary risk? The risks almost certainly outweigh the benefits.


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How much water do you need?

It depends!

Water truly is life – we can go without eating for weeks and survive but get very sick if we do not get adequate water for a few days.

You are doubtless familiar with “rules” such as the need to drink 8 glasses of water a day. The problem with relying on such simple rules is that the real answer truly is “it depends.”

A man who is 6’5” and weighs 205 lbs. needs more water than a woman who is 5’4” and weighs 110.

It is currently sunny and pushing 90 degrees F. Walking up to get the mail left me sweating. We clearly need more water under these conditions than we do when it is 65 and shady.

People doing physical work outdoors in the heat need more water than those sitting at desks in air-conditioned offices.

“Water” includes most other liquids such as herbal tea and fruit juice – but not caffeinated drinks or alcohol, which tend to pull water out of the body.

Finally, and perhaps less obvious, we do not get water only by drinking. Many foods, particularly fruits and vegetables, contain significant amounts of water. Our habitual diet will change the amount of water we need.

Then how do you know how much water to drink? A simple reliable way to assess this is to look at your urine. If your urine is dilute – clear to pale yellow in color – you are adequately hydrated. If your urine is closer to apple juice than lemonade in color, you are dehydrated and need to drink more.

If your urine is very dark, you ought to seek medical attention, as you may need intravenous fluids.

Do not depend on thirst as your sole indicator. If you are thirsty, you are probably somewhat dehydrated, but lack of thirst is not as reliable as the color of your urine.

So: drink up!


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A shot in the knee?

A lot of us develop osteoarthritis (“wear and tear arthritis” – though the process is not that simple) as we age.

If it is truly disabling, surgery may be the only way to reduce pain and increase mobility, but there are many less invasive options. Do any of them work?

Let’s get one myth out of the way first. Many people see an orthopedic surgeon and are told “your knee(s) are bone-on-bone, and nothing will work but surgery.” This is very often an exaggeration. There may be complete loss of cartilage in a portion of the knee, but rarely does this involve the whole knee. If it is on one edge, a brace may give great relief. The decision to have surgery should almost never be based on an X-ray.

The most time-tested non-surgical approach is an injection of a cortisone-type product into the knee, usually accompanied by a local anesthetic. This injection generally starts working in 2 days, and the effect may last 3-4 months. I had patients who got these shots 3-4 times a year for several years with good relief.

Like any treatment, cortisone shots do not work for everyone, and there is a worry that the drug may hasten deterioration of cartilage. The treatment is universally covered by Medicare and commercial insurance plans.

Hyaluronic acid is a lubricant that mimics the body’s natural joint fluid and injecting it into the knee is another “standard” procedure that is covered by insurance. Since most of the product leaks out of the joint within a few days, it is unclear how it works, and recent studies have suggested that it has largely a placebo effect.

Newer treatments are available that are considered experimental and typically NOT covered by insurance.

One is injection of platelet-rich plasma (PRP), drawn from your own blood, centrifuged to separate the PRP from the rest of the blood and injected into the knee. These seem to work by reducing inflammation and may provide relief for as long as a year. Be prepared to pay several thousand dollars out of pocket if you go this route.

Widely advertised is the use of stem cell injections, which can theoretically grow new cartilage. The jury is still out on this, but most studies show benefit lasting only 3-4 months. The cost, in the thousands, will almost certainly not be covered by insurance.

The newest kid on the block is radiofrequency ablation (RFA) of the pain nerves in the knee. This treatment has been shown to give pain relief for up to six months. It is minimally invasive and has few side effects, but is often not covered by insurance, at least not without prior approval from your insurance company.

Knee replacement surgery is generally, but far from always, successful. If you opt for this surgery, know that you must be committed to doing a lot of physical therapy for many months to get the best result.

Do not forget weight loss! Whether through use of the newer drugs or old-fashioned diet, significant weight loss will usually help your knees.


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Do you feel safe at home?

Domestic violence has been a plague throughout human history, but only in recent decades has it come to the forefront of medical and legal concerns.

Domestic violence or "intimate partner violence", is a pattern of behavior in any relationship that is used to gain or maintain power and control over an intimate partner. Abuse can be physical, sexual, emotional, or psychological.

While domestic violence most commonly involves a male against a female, the victim can be of any gender or age.

How common is domestic violence? Nearly 3 in 10 women (29%) and 1 in 10 men (10%) in the US have experienced rape, physical violence, and/or stalking by a partner and reported it having an impact on their functioning. In the United States, more than 10 million adults experience domestic violence annually.

Since the abuser is a spouse or companion, and often repeatedly apologizes and promises to stop, the victim is often reluctant to call the police, and the pattern continues.

If there are children, the victim may be even more reluctant to separate, and the children become emotionally (if not physically) traumatized.

Once thought of as a problem among lower socioeconomic classes, we now know that domestic violence is prevalent in every community, and can affect anyone regardless of age, socioeconomic status, sexual orientation, gender, race, religion, or nationality.

If you are the victim, or you know someone who is a victim, what can you do? First, know that it is NOT your fault. Disagreements among spouses or other domestic partners are normal and common, but never justify violence.

If you feel you are in immediate danger, call 911 and get help getting away from your abuser.

Find someone you can trust and seek their help. This may be your physician, pastor, or a close friend or relative. You almost certainly cannot solve the problem yourself.

For anonymous, confidential help, 24/7, call the National Domestic Violence Hotline at 1-800-799-7233 (SAFE) or 1-800-787-3224 (TTY). Almost every state has 24/7 hotlines and most offer immediate help with shelter and legal resources.

If you suspect a friend or relative may be a victim, you can help. Be aware of clues such as bruising, cut lip or emotional withdrawal. Listen – let them know you want to help – but do not offer concrete advice until asked. Believe them – you may find it hard to believe but know how common the problem is.

Reassure them that you believe them, that it is NOT their fault and that they do NOT “deserve” what is happening. Help the victim create a safety plan that can be put into action if violence occurs again or if they decide to leave the situation.

This should include a safe place to go in an emergency, or if they decide to leave, a way to let family or friends know what is happening and an "escape bag" with cash, important documents (birth certificates, social security cards, etc.), keys, toiletries, and a change of clothes that can be easily accessed in a crisis.

Domestic violence will probably never disappear, but you do not have to accept it.


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We are having a heat wave...

The U.S. and most of the world experienced unprecedented heat waves last summer, and this summer promises more of the same. The Northeast is set to experience it’s first official heat wave as I write. Extreme heat can cause serious health issues, including death, so prepare – prevention is much better than treatment.

The body is generally quite good at maintaining a normal internal (or “core”) temperature. We get rid of excess heat by increasing blood flow to the skin, where it can be removed by air flowing over us, and by increasing sweating, which dissipates heat as it evaporates.

In extreme heat conditions, these mechanisms may be inadequate, and our core body temperature rises. The heart feels the stress – it works much harder trying push more blood through dilated blood vessels.

The first sign of heat beyond the body’s ability to cope are cramps and “heat exhaustion:” dizziness, weakness, nausea, headache, and an unsteady gait. If the sufferer is moved to a cool environment, these symptoms will usually pass.

If the core body temperature exceeds 104 (40C), you may go on to experience “heat stroke.” This life-threatening condition begins with confusion and can go on to seizures, delirium, coma, and death if untreated.

While everyone can experience these heat-related emergencies, certain people are at higher risk: children and the elderly, those doing physical work outdoors and those taking medications that impair the body’s response to heat (such as diuretics – fluid pills - many psychiatric drugs and anticholinergics, used for some urinary and bowel problems).

How can you prevent heat-related illness? The most obvious is the most important: stay cool! Keep blinds down to lessen indoor heat; use your air conditioner, and if only 1 or 2 rooms have AC, stay in those rooms. If you do not have AC, use public places that do, such as the library or official cooling sites.

Avoid doing physical work in the heat of the day; if you MUST run or cycle, do it in the early morning. Hydrate! You are going to lose water by increased sweating, so push the water and electrolyte drinks.

If you are experiencing any of the symptoms noted above, stop physical activities and get to somewhere cool. If you do not improve, call 911. An emergency home remedy is to get in a cold tub or to put ice bags under the armpits, behind the neck and in the groin.

Check on any neighbors who may be at risk. Since an early sign of heat-related illness is confusion, they may not react properly.


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Symptoms and cancer

Most cancers eventually cause symptoms, but usually only when the cancer has been there a long time, and often when the optimal time for treatment has passed. This has led to the recommendation behind many “screening tests,” tests done in people with no symptoms.

Colonoscopy, Pap smears (often combined with HPV virus testing), mammograms and low-dose chest CT are among the recommended tests done routinely in people with no relevant symptoms.

Do symptoms have any role in cancer detection? Yes, in both directions.

Let’s start with men. Many men worry they may have prostate cancer when they begin noting urinary urgency and frequency, and feel that if they have no urinary symptoms cancer is unlikely. In fact, urinary symptoms reflect growth of the central part of the prostate, which surrounds the urinary passage out of the bladder, while most cancers begin in the outer part of the gland. So, counting on symptoms to prompt a search for prostate cancer is unwise.

Whether screening for prostate cancer saves lives remains controversial, but if you want to find it early, get tested regardless of any symptoms.

For both men and women, both kidney and bladder cancers are usually heralded by blood in the urine, though this may be small enough to only be seen when the urine is checked by a lab. Since a small amount of blood in the urine is common, and most often due to something else (infection and stones lead the list), there is tendency to overlook it. Don’t.

If your patient portal shows you that you have any amount of blood in your urine, be sure your doctor stays on top of it. At a minimum, get this rechecked. If it is still there, the next test is usually an ultrasound – both safe and harmless, so not to be feared.

Uterine cancer is becoming more common, for reasons not entirely clear. This cancer almost always announces itself early, with abnormal bleeding. If caught early, uterine cancer should be nearly 100% curable, but diagnosis is too often delayed because the bleeding is attributed to something else. Don’t accept a diagnosis of fibroids or endometriosis or hormone imbalance without at least discussing having a sampling biopsy. If you have been through menopause and then bleed, demand a biopsy.

Finally, for women, is ovarian cancer. This, like pancreatic cancer, is often found only after it has spread. It has been taught that early ovarian cancers do not cause symptoms, but a recent study found that 72% of women with early-stage cancer had one or more symptoms. The leading symptoms were abdominal and/or pelvic pain, fullness or bloating and urinary frequency. Most often these symptoms are not due to ovarian cancer, but do not ignore them. You know your body, and if these symptoms are new, persist and do not have another explanation, push your doctor to check for ovarian cancer, typically with a pelvic ultrasound. Catching it early may save your life.


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