We will cover many different treatment options on this website. To avoid feeling overwhelmed by the information, we feel that the best way to think about treatment approaches and options for diabetic peripheral neuropathy or polyneuropathy is by dividing the treatments into groups. It is then easier to understand the goal of each treatment. Some treatments have multiple goals. For example, Tai Chi helps motor symptoms (through improving balance, strengthening) and mood (through relaxation, meditation). Cymbalta helps with sensory symptoms (pain, numbness, tingling) as well as mood (has anti-depressant effects). We are confident that you will find this method of looking at the various treatment options very helpful. To read about the details of each treatment, please go to the article/post on that particular treatment.

1. Treatments to control blood sugar: This is the first and most important step that you can take to control neuropathy. In has been proven that better blood glucose control results in better control of neuropathy symptoms (less numbness, tingling, pain, weakness, etc).

• Medications for blood glucose control
• Special diets for diabetics
• Exercise treatments
• Relaxation and meditation

2. Treatments for sensory symptoms (numbness, tingling, pain)

• Oral Medications for numbness, tingling and nerve pain: Modern medications used in the medical field and considered to be effective specifically for  numbness, tingling and nerve pain symptoms associated with neuropathy are Gabapentin (brand name is Neurontin), Nortriptyline (amitriptyline is similar but with slightly more side-effects), Pregabalin (brand name is Lyrica), Duloxetine (brand name is Cymbalta). There are many other medications, from acetaminophen, ibuprofen and naproxen to narcotics. More details can be found in the articles about these medications.
• Topical creams, ointments, lotions and patches for numbness, tingling and nerve pain: Capsaicin, Lidoderm patch.
• Supplements and herbal treatment
• Desensitization:
• Acupuncture
• Sympathetic nerve blocks:
• Spinal cord stimulator

3. Treatments for motor symptoms (weakness, clumsiness, loss of position sense or ‘proprioception’)

• Self-exercise programs: Tai-chi
• Physical therapy
• Occupational therapy

4. Treatments for effects on neuropathy on mood (depression, anxiety)

• Qi-gong
• Lifestyle change
• Meditation
• Psychotherapy and counseling
• Medications for depression
• Medications for anxiety

Introduction
Although there are many different treatment options available to help control nerve pain (neuropathy) due to diabetes or other causes, for some people these usual treatments provide inadequate or unsatisfactory pain relief. We are all aware that uncontrolled pain can make life quite miserable and no one deserves to be in that situation. For those of us in this unfortunate situation, there is another resort. Spinal cord stimulation has been becoming an increasingly popular treatment. The technology has actually been available for decades and is a medical treatment covered by Medicare, medicaid and most other health insurance providers, but there seems to be a lack of awareness about this treatment method.

What is the spinal cord stimulator?
The spinal cord stimulator is a device to help control nerve pain (neuropathy) from diabetes or other causes of injury to nerves. It is an electrical device that uses tiny electrical signals to stimulate nerves in the spinal cord and replace painful sensations with a different sensation that can be pleasant, which overrides  the pain. Some people hear the words “electrical device” and think that the spinal cord stimulator is similar to a TENS unit (go to this link to read about TENS unit), however the effect is extremely different from the TENS unit.

How does it work?
All sensations like touch, temperature and pain are transmitted from the feet and legs as electric-like signals that are carried by nerves to the spinal cord, and through the spinal cord to the brain which senses these feelings. In diabetic neuropathy or other conditions that damage nerves, abnormal pain sensation signals are carried through these nerves to the spinal cord and ultimately the brain, instead of normal sensations. The spinal cord stimulator involves insertion of 1 or 2 (sometimes 3) thin and soft wires called ‘leads’ or electrodes into the space surrounding the spinal cord (‘epidural space’) with the help of X-ray guidance. These leads or electrodes are connected to a tiny battery about the size of a cell phone battery. The battery is controlled by a handheld remote control which is about the size of a cell phone. With the remote control, the battery can be made to send small electrical signals to the leads, which in turn stimulate the spinal cord to send signals to the brain. So instead of sending the signals for painful sensations from the feet and/or legs, the spinal cord now sends the non-painful signals from the spinal cord stimulator to the brain. In this way, the spinal cord stimulator blocks painful signals from reaching the brain.

Will it be covered by my health insurance?
The spinal cord stimulator treatment is approved by almost all health insurance companies as well as Medicare and Medicaid. The medical provider who is usually an interventional pain management specialist will obtain pre-authorization or pre approval from your health insurance company before proceeding with the spinal cord stimulator treatment for your pain. Most health insurance companies including Medicare require a psychological screening to be done before the spinal cord stimulator  trial. Many people who suffer from severe pain do also suffer from depression related to being in constant pain, and therefore depression or other mental health issues are usually not a problem in getting approval. The psychological screening is usually a just a prerequisite to make sure that the person does not have such severe mental health problem that is would interfere with their ability to use or operate the spinal cord stimulator.

Is spinal cord stimulation safe? What are the advantages and disadvantages?
Spinal cord stimulator treatment is backed by many years of research. It is a medically approved treatment by the Food and Drug Administration (FDA) since the 1980s. In addition to painful neuropathy from diabetes or other causes, it is also approved for certain other painful conditions that do not respond to usual treatments, such as ‘failed back surgery syndrome’, radiculopathy (severe pain in the arm or leg related to problems in the neck or low back), peripheral vascular disease (leg pain due to poor blood circulation),  complex regional pain syndrome (CRPS) which is also know as reflex sympathetic dystrophy (RSD). Many people have described spinal cord stimulation as a “life changing” treatment for their pain.

Although the spinal cord stimulator is considered a safe treatment, it should be obvious that whenever a device is placed in the body, there are is always the possibility of complications and certain risks. The chance of serious complications like infection, bleeding, paralysis are quite rare when performed by experienced interventional pain management physicians or certain spine surgeons experienced with spinal cord stimulator insertion. This procedure is performed under sterile conditions just as if a surgery were being performed. The chance of being allergic to the leads is also quite rare, but is a possibility that could require removal of the leads. Headache is a possible complication from the procedure. If you had a fall or some other occurrence that caused the leads to move, then this is called lead migration. This can often be corrected without having to actually reposition the leads in the spine area, by just re-programming the way the electrical signals flow from the leads. But sometimes if the leads have migrated or moved significantly, then the physician may have to reposition the leads which would have to be done as a procedure under X-ray guidance. In the long term, the battery may need to be replaced after some years of use. There are also some people who feel that the beneficial effects of the spinal cord stimulator decrease after several years of use.

Which specialist should I work with for spinal cord stimulator treatment?
The specialists who usually have the most experience with spinal cord stimulators are called ‘Interventional pain management physicians’. They usually work in pain clinics. In some areas, spine surgeons perform both the trial as well as the permanent implant of spinal cord stimulator.

How do I know if the spinal cord stimulator will work for me? What is the spinal cord stimulator ‘trial’?
You get to try out the spinal cord stimulator before a permanent implantation of the spinal cord stimulator. This ‘trial’ of the spinal cord stimulator involves the pain management physician inserting one to three leads through a needle (usually no incision or surgery involved for the trial) with the help of X-ray to position the leads outside the spinal cord. The needle is then removed, and the lead/s come out of the skin from the back, and are covered with a dressing. The lead/s are attached to the battery which is worn on your belt or kept in your pocket for the duration of the trial. (Keep in mind that if you do end up having the permanent spinal cord stimulator, these leads and the battery are also under the skin, and nothing is outside the body other than the remote control which you may carry in your pocket of bag). You then get to try out the spinal cord stimulator for 5-7 days. You then return to the clinic to discuss the results of the trial with your doctor. The leads inserted for the ‘trial’ will be removed at the end of the trial period. If you felt the spinal cord stimulator helped greatly in decreasing your pain during the trial period, then you can go ahead with a permanent stimulator. On the other hand, if you feel that during the trial period the spinal cord stimulator did not really help much, then there would not be any point in going ahead with the permanent implant.

What are the steps to receive a spinal cord stimulator?
1. You are already taking the first step by educating yourself about the spinal cord stimulator treatment by reading this article.

2. Make a list of questions for your pain management physician or talk to your primary care provider about getting a referral to a pain management physician who is experienced with spinal cord stimulation. The specialists who usually have the most experience with spinal cord stimulators called called ‘Interventional pain management physicians’. They usually work in pain clinics. In some areas, spine surgeons perform both the trial as well as the permanent implant of spinal cord stimulator. The interventional pain physician will perform an evaluation to assess if you a candidate for a trial of spinal cord stimulation.

3. You will be referred for a psychological screening which is a requirement by almost all health insurance companies before they will pre-approve or authorize coverage for the spinal cord stimulator trial. You will not be denied the treatment if you suffer from depression or any other psychological disorder. Many people who suffer from severe pain also suffer from depression due to being in constant pain, and therefore depression or other mental health issues are usually not a problem in getting approval. The psychological screening is usually just a prerequisite to make sure that the person does not have such severe mental health problems that it would interfere with their ability to use or operate the spinal cord stimulator.

4. Once authorization or prior approval has been obtained from your health insurance company that they will cover the spinal cord stimulator treatment for you, you will receive the trial of spinal cord stimulator, followed by the permanent implant if you feel the trial was very helpful in controlling your pain.

Conclusion
We hope this article provided you with all the necessary information about this rather complicated topic of spinal cord stimulation in an easy to understand manner. We encourage you to ask questions. We can answer any questions that you may have about this topic through the ‘comments’ section of this website. Please remember that this is information and any information on this website cannot and should not substitute the advice you get from a medical provider that is specific to your situation. Thanks for reading.