Nerves that zing: back pain and neuropathy

In this Clinical Connections, an unusual internal medicine physician talks about back pain that doesn't show up on imaging, and the neuropathy that drives many people half crazy in later life.

We’ve featured posts by Mary Braun Bates, MD before. She’s an internal medicine physician in New Hampshire who writes on Substack as Doctoring Unpacked. She’s also board certified in palliative care and hospice, and there’s nothing like those two specialties to humble anyone in healthcare about what we thought we knew: she doesn’t get confused about the difference between medicine and real life.

Her writings are fictionalized composites of real patients with real problems; readers get to see common symptoms she sees in her practice, how she’s thinking, the interactions between Dr. Bates and the patient…and how it all works out. Here she deals with two problems that more than a few of us have experienced, whether it’s in ourselves or our aging parents.

When you take care of everyone—who takes care of you?

Click for this story about persistent back pain without a known physical cause in a woman who is everything to everyone else. A quote from Dr. Bates I really like: “There are a number of conditions that Western medicine is notoriously bad at treating. They are all at the boundary of mind and body, not like mental illness, but more like you’ve gotten something tangled up in your emotional/spiritual insides, and it’s caught up a part of your body in the tangle.”

Stress and backpain are indeed related in a way Western medicine hasn’t identified, but studies suggests that chronic stress can lead to chronic pain and vice versa. For many people, this involves back pain. The key, of course, is whether those of us trained to Western medicine are willing to handle a cause that can’t be seen on an x-ray.

I particularly love this story from Dr. Bates because it ends with her referring ‘Jane’ to Teri Leigh, a mindfulness and stress management coach. There is a concept, shoshin, from Zen Buddhism, meaning ‘beginner's mind.’ It refers to having an attitude of openness, a lack of preconceptions like the rigidity that can come with expertise. Let me tell you how hard that is for healthcare providers to overcome when we are hit with problems for which Western medicine has no solution. Kudos to Dr. Bates for looking elsewhere. It’s been so much easier—particularly with problems like Jane’s, to just say it’s in our minds and our problem. Stories about women’s healthcare are ripe with that.

Mysteries of neuropathy (and off-label prescriptions)

Click for this story about the nightmare of neuropathy. At a minimum, 20 million Americans have neuropathy, and there are likely tens of millions more who have it and don’t know what it is. If you have aging parents, I’d be surprised if they don’t have it, and if they’re diabetic, either type 1 or 2, it’s almost certain they either have it now or will. And there is nothing like neuropathy to absolutely ruin sleep. It’s frustrating, and the reason there are hundreds of ‘natural’ and ‘alternative’ aids on Amazon and elsewhere all over the internet. As America ages, this is becoming a huge issue—and one that is understudied in Western medicine as the opportunities for ROI are low—and it’s a fact of life that pharmaceutical companies invest in R&D in anticipation of future profits.

Three things I love in this ‘amalgam’ of a peripheral neuropathy patient:

• The warning blinking in the back of her head about something was missing in Bill’s story—and that he later felt comfortable with her to finally confess it. We all have secret fears that we hold back from providers. Sometimes hiding it costs significant anxiety, effort, and money.

• She has by far the best explanation I’ve ever seen of off-label use of a medication.

• Note her comment about B12 deficiency. As we age, we become deficient in B12, but Western medicine has paid so little attention to the role of nutrition and vitamins in health that a simple addition like B12 is often overlooked. B12 plays a crucial role in neuropathy in the synthesis of myelin, which insulates and protects the axons (nerve fibers) of neurons, the cells that transmit electrical signals throughout the body. B12 is also a vital coenzyme in the synthesis of neurotransmitters. Peripheral neuropathy may be the most common sign of vitamin B12 deficiency. And deficiencies in B12 and other B vitamins are now increasingly implicated in research on depression and other mental health issues.

  • Here’s more about why many providers recommend routine supplementation after age 60; some researchers suggest even younger depending on symptoms. (My opinion—free FWIW, and I’m not a doctor—is that our blood test “normal” parameters have likely not kept up with the role of B12 in aging and disease. Add that to problematic nutrition in the US.)

  • Keep in mind B12 is inexpensive, available over the counter, and it’s water-soluble, meaning what you don’t need is excreted in urine—overdosing does not appear to be an issue. The most bioavailable form of B12 is naturally-occurring methylcobalamin. Cyanocobalamin, a synthetic form of vitamin B12 that is not naturally produced in the body, is even cheaper, so it’s often found in multivitamins. The name "cyanocobalamin" directly refers to the presence of a cyanide group attached to the central cobalt atom.

  • Read more about supplements that may aid neuropathy.