Friday, September 16, 2016

Approach to Neurologic Problems - Neuropathies

There is a local and perhaps nationwide shortage of neurologists, so what this means is that it takes a long time to get an appointment to see one. What that means is that primary care doctors are sometimes doing what they can to initially evaluate and sometimes manage neurologic problems. There are anyway a number of neurologic conditions that are quite common, things like headaches, neuropathy (or neuropathic symptoms), and weakness, as well as particular sorts of pain syndromes. I would also add that not all of these patients need to see a neurologist, mainly because there is little to do and management is often quite simple.

Let's start out in this series with the category of neuropathies, then focus on diabetic polyneuropathy. I would often see patients referred for electromyography (EMG) before they had seen a neurologist. A basic thing one could say about an EMG for neuropathy is that if you didn't know what was going on when you sent the patient for it, the test is unlikely to hand you the diagnosis on a platter. Given that situation, let's step back from this and go back to the patient.

Neuropathic symptoms
The two main functions of peripheral nerves are for sensation and movement, in particular muscular strength. Loss of sensory function would cause numbness or loss of feeling in the skin, but there are other kinds of sensation which for example have to do with feedback from joints to inform about arm, leg, and body position, and also feedback from muscles which allow for a sense of how much effort is being made, as well as the results of that effort.

Sensory nerve functions can be divided into two categories related to nerve fiber size. Very small and unmyelinated nerves carry signals related to pain and temperature. With loss of these functions, patients may say they injure themselves and don't realize it until they see they've cut themselves, or they have a hard time judging the temperature of bath water, especially with their feet. Myelinated nerve fibers carry signals related to some aspects of pain, but mainly light touch, vibration, and position sense. Loss in these areas may reduce fine motor manipulation such as is required for buttoning, or trying to pick out a particular object in a pocket based on feel. Loss of position sense impairs balance or coordinated activities, especially in the dark.

There is another kind of sensory nerve symptom which we can think of as either a nerve signal that gets messed up, so that normal stimulation is perceived as strange, maybe painful (called dysesthesias), or where there is a nerve sensation in the absence of stimulation, like pain or tingling (paresthesias).

Sensory nerve symptoms are quite common. We all have had at least brief episodes of tingling or numbness, maybe related to pressing on a nerve somewhere for too long.

Loss of motor function leads to loss of strength, or early on may mainly cause reduced stamina. Almost universally, patients will not see the difference. Strength has to do with the maximal force that can be generated from a group of muscles. Stamina has to do with how long you can apply that strength. There is another confounding issue which is important to consider, and this is sudden weakness which relates to pain from activity or effort.

Diabetic neuropathy as an example
This is probably the most common neuropathy most doctors will see. Diabetic patients are certainly aware of it, and at times I have had a hard time getting a patient to describe symptoms, since I keep getting responses like "I have [diabetic] neuropathy". What are your symptoms? "Neuropathy." Considering that diabetics can certainly have other kinds of neuropathy, this is important information. Start with the basic categories of location, kind of symptom, whether it occurs (mostly) at some time of day, any causative factors, any alleviating maneuvers.

It actually turns out that there are several different kinds of neuropathy. The most common is the symmetrical, distal neuropathy, where there is a progressive loss of nerve fibers, especially the small, unmyelinated fibers, so as expected there is loss of pain sensation, temperature sensation, and in some but not all there can be pain mostly or especially in the feet. Typically a burning character is described or acknowledged. I try to get patients to offer their own words for their descriptions before I suggest burning, sharp, dull, electric or some other type. There is a predilection for the burning to be worse or maybe only occur at night or bedtime. Often it is said to be especially bad after being on the feet or walking a lot during the day. Severe diabetic neuropathy may cause weakness, but much more often there is none or only loss of stamina.

Diabetics may also have focal neuropathies, often related to pressure. I consider diabetes a condition that sensitizes nerves to pressure, so you may see neuropathies at the elbow or knee (foot drop) more often in diabetics. Another much less common neuropathy is called diabetic amyotrophy. Although the name suggests only that there is muscle atrophy, it was shown some years ago that it is pathologically a kind of proximal nerve ischemia which produces most commonly proximal leg weakness, without prominent sensory symptoms. One of the happy days I had in practice was being able to "undiagnose" ALS (Lou Gehrig's disease) in a patient who actually had diabetic amyotrophy. At least in some cases, improving blood sugar control can result in much recovery.

The exam features that are important to document would be condition of the skin (evidence of trauma/ulcers), signs of muscular atrophy in some particular distribution, including the intrinsic foot and hand muscles. We're not expecting to see focal or asymmetric features in typical diabetic polyneuropathy. Much is made of loss of reflexes, though areflexia tends to be a weak element. With the sensory exam, you want to evaluate a mix of large fiber and small fiber functions. The former would be tested with light touch with some light stimulus (I used an aesthesiometer in practice, though in diabetics this can be difficult to interpret), and also proprioception -- how do you test that?

Proprioception involves in part the sense of where joints are or whether they have moved. The simple way to test is to hold a limb steady with one hand, then very slightly move a particular joint while the patient looks away. Do a series of repeated small motions, asking for a response of "up" or "down" with each movement. If you don't watch the movement yourself, you can compare your own sense and direction of movement as your benchmark. There is a learning curve for the patient, so expect to throw out initial errors as the process is demonstrated. Start with distal joints in fingers or toes, then as needed (if there are a lot of errors) work up to proximal joints of digits, then maybe even wrists or ankles (most of the time you won't get that far). Without labelling it as malingering, there is a certain instance of factitious reporting. Severe loss of proprioception (as high as the wrists or ankles) should impair function. This is the purpose of the Romberg test, where you have a patient stand with feet together, first with eyes open, then eyes closed. Impaired ankle proprioception will result in a positive Romberg with eyes closed (falling over with eyes open is something else completely). If you also have them hold their arms out, you watch for arms or hands drifting in unusual ways (drifting down and pronating the forearms only is a subtle sign of weakness, typically of CNS origin).

What about vibration? Yes you can test this, but here is a confession: I stopped assessing vibratory sense with regularity many years ago. Why? The biggest problem was that so many people have gradual loss of vibration sense as they get older, and the second biggest problem was that if that is the only thing on exam, it's almost worthless diagnostically. The standard way I was taught is also I think flawed. This was to smack the tuning fork on something, then hold the bottom end on a joint and have the patient tell you when the vibration goes away. There are uncertainties here. The first is that you know that by the time the patient indicates absence of vibration, some brief delay occurs from when the sensation stopped to when they spoke. Secondly, with a continuous vibration, you are likely to have persistence of perception at various levels in the nerve pathway. Here is a better method: on, off. Smack the tuning fork, then use an on, off technique asking the patient to indicate each time if they feel the vibration. As the vibration naturally decays you get a sense of amplitude from your own hand to compare. Don't forget the null stimulus -- some patients will say yes in the absence of vibration!

Small fiber function is mainly tested with sense of pin prick. The best instrument for this is a straight pin, and you only need to lightly touch the skin; no need to make a hole in it. Start distally and work your way up the arm or leg, perhaps 2 or 3 times to verify some level at which the pin becomes sharp, and in some way document that level for future reference. Even when it is felt sharp distally, there still may be a gradient of feeling as you come up the leg in particular. Some patients are hypersensitive distally. You can also test temperature sense, though I tend not to be too religious about this when the pin sense findings are sensible (sic).

The point of the motor exam, muscle strength testing, is to combine some measure of amount of strength with the overall distribution of any weakness. Years ago I used to see examiners referring to strength somewhere being "50%", but what does that mean? There is a tried and true method, the MRC scale, in which strength is assigned a number from 0 to 5, 0 being no ability to even tighten a muscle, 5 being normal strength. 3 means that the muscle can operate with full range of motion against gravity, so for the quadriceps/knee extension evaluation would be tested with patient seated. Any small addition of resistance by the examiner does not allow full range of motion. 4 means that some resistance can be overcome, but strength is less than normal, and 2 means there is some motion against gravity, but less than full range. Grade 1 is some tightening of the muscle without motion. Typically you want to see if there is a mainly proximal distribution of weakness, or distal, and furthermore, when weakness is distal, it tends to be worse in the ankles than wrists in neuropathies. A proximal pattern of weakness suggests something other than diabetic polyneuropathy, and is a hallmark of the various demyelinating neuropathies. There are patients who will not give a steady strong effort, or will suddenly give away. This cannot be graded, though sometimes a brief strong effort is long enough to use for reasonably good grading of strength.

Something worth saying about this exam is that you get better at it the more times you do it. To develop and maintain a sense of what is normal for different ages, you should do parts of this in patients without neuropathy symptoms.

In summary of the history and exam features of diabetic polyneuropathy, if you see a diabetic patient with loss of pain sense and perhaps painfulness at nighttime, associated with some loss of pin sensation on exam, and preservation of light touch, proprioception (position sense), and little or no weakness, they have diabetic polyneuropathy. An EMG is not going to add anything, and typically for my own patients fitting this picture I don't even order an EMG.

Curiously, there are nondiabetics who also have this same picture. Some of them will develop diabetes later, but others never do. The approach is no different.

Management and some curious features
A newly diagnosed diabetic of course needs that managed as appropriate. Curiously, there doesn't seem to be any good correlation between the severity or duration of the diabetes and the severity of the associated neuropathy. There is not always a correlation between degree of control of sugars and the likelihood or severity of the neuropathy. One paradoxical thing I have seen is a worsening of neuropathic symptoms with better control of sugars. This is typically temporary and occurs when sugars have been severely out of control. I think this is because severe hyperglycemia has some anesthetic effect on nerve function. Even though there is this discrepancy of severity of diabetes and severity of neuropathy, I still believe that for the individual patient, they will do better with better sugar control, not the least because of the other various complications of diabetes.

I'm not going to discuss management of painful neuropathy, but save this for the next post. One thing to say in summary so far is that for the typical diabetic, there isn't such a great need for a neurologist, at least to make the diagnosis. One can save time and money by not getting EMGs routinely on these patients.

Wednesday, September 07, 2016

A Reminiscence

For some reason this memoir from a long time ago in a galaxy far away just occurred to me.

I grew up in a small town in Ohio, so small my graduating class was 25 persons. There was a special moment I had, back there in the pre-computer, pre-social media days. Our math teacher set up some advanced math classes for a few of us, maybe 6 people out of my senior class (or was it junior?), and we got exposed to things like different bases for numbers (our decimal system is "base 10", binary "base 2", but you can have whatever you want), some precalculus, some plane and spherical geometry. We just worked our way through the material, wherever it went.

In the latter part of the school year we took a test run by the GTCTM, the Greater Toledo Council of Teachers of Mathematics. I came in second out of that whole area. I never knew how many students took the test, but keep in mind this was advanced math, nerdville.

So I went to Toledo, received my recognition and a prize of a slide rule, a very fancy one (made by Keuffel & Esser as I recall). I had no idea what it was for, but when I went to college in those precalculator days had plenty of use for it later. I still have it somewhere.

I felt the honor of this, but it seems like it should have been a bigger deal to me, this small town guy besting out a lot of math students in the Toledo area (except one). At that time I suppose that there just wasn't such an interest in math (and maybe there still isn't).

A sad addendum
I found my slide rule, but it became immediately apparent that the case had gotten wet, since inside parts were rusted, and in particular, the slide with the hairline had become detached, and as far as I can tell can't be restored. 

Tuesday, September 06, 2016


It's an interesting and at times rather confusing process, this retiring from practice. I speak in my case of someone working for a health care corporation, so I didn't have to shut the practice down, just my own part of it.

As things went along, there was little in the way of spontaneous information coming my way, so I had to ask questions about my health insurance, my liability insurance, and so on. I found out quickly that everything stops at midnight on your last day. Since I'm over 65, I wasn't eligible for COBRA (except for dental care).

I already had Medicare Part A, since you must sign up for that, but struggled a bit to understand Part B. I registered on the Social Security website, but it takes a lot of fishing around to try to understand the process. I finally called the local SS office and received forms for my employer to fill out. This ensures I don't pay extra for signing up for Part B late.

One thing that working in rehab has taught me is that you need to have supplement insurance. You don't want a Medicare replacement policy, just a supplement. If you get a replacement policy, you hand over all the decision-making to these private companies. Here, our experience has been that Anthem and Humana can be a bit flaky with approvals, so I decided to go with a UnitedHealthcare supplement through AARP, which seems to behave pretty well. But you're not done yet, since there are standard Plan types that each company must offer. I chose Plan C, which has some additional bells and whistles like travel insurance. At this point you can sign up online, and there are links from the Social Security website for that.

I wasn't, and still am not, absolutely certain I won't go back and practice in some way, though an eye opener was learning that to pay for my current malpractice insurance would cost me $13,000 per year(!). There are some alternatives that might be more like $8-9,000, still a chunk of money, meaning I'd have to work that much just to break even. For now I just have a "volunteer" policy (costing $100), which says I can see patients as long as I don't charge them.

So now I have my coupon booklet for making my supplement premium payments, and Medicare tells me they will bill me for 3 months at a time. Once I sign up for Social Security, I understand they will take the premium for Part B out of that payment automatically.

The Social Security website is a pretty good one for finding out a lot of details, but still this was piecemeal work I had to do myself to fully understand what I needed to do when.

On to retirement!

Saturday, July 02, 2016

The neurology of fireflies

Last year and this one, I've have a chance to sit out in the summer evenings in our sunroom and watch the day turn to dusk, then to dark. And then out come the fireflies this time of year.

What I've noticed is an interesting phenomenon, interesting to me anyway. We know that the male firefly is flashing its light to attract the female, but there is something in particular I've noticed about this. In the vast majority of cases, the firefly is on an upward flight while it flashes, and many times very close to a straight vertical flight. When you can see the firefly after the light goes out, there is an immediate downturn in the flight trajectory when the light goes off.

I suppose we might hypothesize that, well of course, the firefly "wants" to increase the likelihood of some female seeing him, and how better to do that than to fly upward? Or maybe flying upward is a sign of "male robustness" and therefore of a fitter male. Seems dubious to me, as if we're assigning a lot of cognitive activity to a firefly, or invoking Darwinism to explain this.

What I wonder about is whether there might be some more simple neural connection here. For example, does the neural activation of the lighting mechanism (release of the chemical) cause a spillover of neural activity that increases wing flapping and therefore upward flight? Or perhaps increasing wing activity is a necessary precursor to this. I know from experience of catching and putting fireflies in a bottle as a kid that they can light their lights without flying, but maybe when flying and lighting happen at the same time there is some neural synchrony...

I tried googling this, but not surprisingly this seems to be quite unmentioned or unnoticed.

This also reminds me of a former patient of mine who had ALS, and a very colorful man he was. One visit he told me he was sitting in his backyard one evening, and wondered if he should grab fireflies and eat them to try to counteract the disease. We laughed about it, but then a few days later he mailed me a copy of a newspaper report indicating that scientists were using fireflies in order to try to understand some things about the human nervous system.

Tuesday, June 21, 2016

The time has come, the walrus said...

As I was saying a couple of years ago, I was contemplating retirement, and now I've decided. It will be this year, a few months from now.

It wasn't exactly a difficult decision when I finally came to it. The main thing was that I was enjoying medical practice less and less, finding the relief of the weekends too short, and the dread of the coming week on a Sunday more and more.

For the short term, I'll have plenty to do, with various things around the house to catch up on. In the longer term, there is some uncertainty, but I look forward to being away from set schedules, all the various messages demanding answers, and so on.

People ask me if we'll be traveling a lot, but we've traveled quite a bit over the years, so nothing out of the ordinary is planned. Occasionally I have seen something about some trip that might last a couple of weeks that formerly I would never have considered, so maybe that will change.

Perhaps I'll find more time for this blog.

Saturday, February 14, 2015

eReadings 20 -- World War I

No, I didn't stop reading since the last eReadings post. I've actually read a LOT of things since then. Of course, I'm talking about on my Kindle, not other reading, of which I do a lot also.

What I fell or drifted into in the last year or so was a series of books about World War I, written at the time. What follows is a somewhat ordered list of what I have read so far.

My Four Years in Germany
James W Gerard

Mr. Gerard was appointed the US ambassador to Germany in 2013, before there was any inkling of war breaking out. To be sure, there was a lot of militarism in the world, especially in Germany.

This is a personal account of his time there, which of course ended when the US declared war on Germany. He describes in great detail the structure and operation of the Kaiser's court, and of Germany in general. Once war was finally underway, he became the representative for Britain and several other countries.

This was very interesting to get this insider's view of the prelude and beginning of the war.

From October to Brest-Letovsk
Leon Trotsky

This is Trotsky's account of the Russian revolution, going on of course as Russia was involved in World War I. As the communists come to power, they have more pressing things to do, and sue the Germans for peace.

What I found interesting was how rapidly Lenin and his followers adopted totalitarianism, control of the press, and created a ruling group. There was never any plan to give any real power to the proletariat, who were supposedly those for whom the revolution was carried out. An interesting item in the negotiations with Germany was that both sides formally agreed there would be no independent Ukraine.

What is Coming? A Forecast of Things After the War
H. G. Wells
Wells describes himself as a futurist, and aside from the various novels we are more commonly aware of, he also published works describing things as they were and trying to predict where they were going. This book was written as WWI was being waged, and as such contains some interesting insights.

He anticipated that Germany would lose the war, though how confident he was at the time is hard to gauge. He nonetheless expected that Germany would not be seriously damaged by this war, and would be able to wage war again, and thus felt an important outcome should be removing the Kaiser from power. He was a strong advocate of a world government and saw that England needed to reach out to learn more about other important countries. At a time before the Russian revolution, he was suggesting that England should become closer to Russia, even teaching Russian in English schools.

There is therefore a lot of his predictions which were quite off base, but considering they were written in 1914, very interesting in that context.

Mille et un jours en prison à Berlin
Henri Severin Beland
Ok, showing off a bit. This book is in French (1001 Days in Prison in Berlin). I've spent some time with my Kindle working on my French (e.g., simultaneously going through Candide by Voltaire in French along with its English translation), and a couple of years ago translated a French book on Scribus to English at the site. Somehow I was able to read this book pretty comfortably (with the occasional help from Google Translate), perhaps because this is a chronicle rather than a novel.

This is the story of a French Canadian physician, who was travelling through Belgium as WWI broke out. Initially he offered his services to a local hospital as it began to treat war casualties. As conditions worsened with the German occupation he tried to be allowed to travel to Holland so that he could go back home. The Germans initially sounded like they might acquiesce, but eventually higher ups had him sent to detention in Berlin, in a former prison, which by then had a number of people from various countries.

Repeated petitions for release to return home were ignored, though he did manage to get some privileges due to the fact that he assisted the prison's physician in taking care not only of the other prisoners, but also the German soldiers who worked there.

Mr. Britling Sees It Through
H.G. Wells
When I started this one, I had no idea that it would have anything to do with the war. After some preliminary chapters describing Mr. Britling as an essayist, perhaps something like Wells was himself, suddenly the war is upon Britain.

Mr. Britling was too old to fight in this war himself, but there are close friends and his son who do get involved.

Much of the book purports to be his ruminations about the possibility of war, the onset of war, and its conduct plus the effect on British society. As such, his ruminations seem entirely too wordy to be believable even for someone of high intellect.

Aside from this, it offers an interesting glimpse of wartime in England from the perspective of those not directly involved with it, yet having to deal with a variety of the war's effects and side effects.

Thursday, May 08, 2014

Exit Strategy

It wasn't that long ago that I honestly told people that I had no idea when I might retire.

Somehow things have changed. In some future posts I would like to explain this a bit, but let's just for the time being say that I'm in the process of finding a way to stop doing what I'm doing as a physician.

My "Uncle Doc", my grandmother's brother, some years ago told me that he "retired too soon." This coming from a man who retired from family practice at 84yo. But what he meant was that he had no exit strategy. He didn't take the time, take the bother to develop some outside interests, some idea of what he was going to do when he retired. So when he retired, he spent his days, first of all stopping by the office where he used to practice to chat to his former staff, then he'd swing over to the hospital he used to attend at and sit in the doctors lounge and chat with colleagues.

I can't see myself doing that. Sure, I may stop and visit at times, but that's not going to define my days, and from his experience it's just as well.  He died not long after that visit I had with him.

I don't find medicine as envigorating as it once was. Yes, I enjoy my time in the hospital, facing some unknown issue, getting a history, doing an exam, putting together some hypothesis about what's going on, what to do about it. But I am more bothered by episodic interruptions, by getting the names of new consultations in the mornings. Not that I see things I don't know what to do. I've seen so much it all just happens now, the differential diagnosis, testing, empiric and other treatments. And it's not boring.

But still this dread of having to go in every day, not knowing when the next new thing is coming. I think it's time to look for the exit from this.

Getting back to my uncle, what's next? I have a lot of interests. Many of them involve computers. I have this blog, but the time since my last post says a lot about how invested I am in this. I help with the development of Scribus, an open source software program. My job is mostly documentation.

I'm thinking I need to carve something else out. Maybe something I haven't done before, or maybe only dabbled in. I have some interest in, but not necessarily a lot of faith in the various things you find out there for "preventing dementia." Do these things work or just identify people who were low risk in the first place?

But I like learning new things anyway, so this will probably be part of my strategy. I like to travel, and no doubt will continue that to some degree, but I also know that travel is irritating in various ways, so I don't see spending a lot of time on that. Maybe I can now take some trip that might last a couple of weeks or more, something I haven't ever considered in the past. You take two weeks off work and the mountain that piled up while you were gone is amazing.

There are any one of a number of charitable things I could do in some way related to medicine, but right now I just don't see these as options. Maybe I just need some time away to see their appeal.

So here I am, still at the beginning or the middle of this. The reason I'm blogging about it is that I think it's true that one of the ways of working through a dilemma is to write down your thoughts about it. The process of turning a lot of competing, well- and ill-formed ideas into something you can understand yourself begins with making some coherent piece that lays it all out so you can create and reread it later.