[MUSIC PLAYING]
JOHN WHYTE: Hello.
I'm Dr. John Whyte, the Chief
Medical Officer at WebMD.
Today, I want to spend some time
discussing myasthenia gravis,
a complex neuromuscular
condition that affects over
50,000 Americans.
While the cause remains
a mystery, and a cure is still
out of reach,
with some new advancements
in treatment, we're able to help
patients live fulfilling lives.
I'm joined by two experts
today, to discuss how physicians
and patients can work together
to get the best treatment.
Dr. Richard Nowak.
He's Director of the Yale
Myasthenia Gravis Clinic,
and Associate Professor
of Neurology at Yale School
of Medicine.
And Dr. John Bach, Professor
of Neurology,
and Professor of Physical
Medicine and Rehabilitation
at Rutgers University, New
Jersey Medical School.
Doctors, thanks for joining me.
JOHN BACH: Pleasure to be
here, John.
RICHARD NOWAK: Great to be here
as well, John.
JOHN WHYTE: Effective
communication is always
key with a patient.
And sometimes doctors aren't
always the best communicators.
How do you communicate
with patients
about their condition
and their expectations?
RICHARD NOWAK: That's
a great question.
I think it's so critical as part
of caring for individuals
with myasthenia gravis,
or any other health issue,
is that there be
an open dialogue with patients,
and that patients are
comfortable in expressing where
they're coming from,
and what they're feeling.
I view this as a partnership
in care with my patients.
JOHN WHYTE: Sometimes
in neurology, say, in headaches,
they want you to take a journal,
write down symptoms.
With myasthenia, do we do any
of that?
Or how do you assess symptoms?
RICHARD NOWAK: I most certainly
ask patients
about their symptoms.
And I find it extremely valuable
that patients express
and communicate their symptoms,
and how their symptoms might
change from one week
to the next, or from one day
to the next.
Because this condition
can fluctuate,
and there can be variability
of symptoms,
depending on the activity
that an individual is engaged
in, such as work or exercise,
et cetera.
JOHN WHYTE: So it's
important for patients
to be very forthright about how
they're feeling
and their symptoms.
Dr. Bach, you're a professor
of neurology
and physical
medicine, rehabilitation.
What are some
of those other aspects
that patients need to
think about
beyond the
pharmacologic treatment?
JOHN BACH: Well, first of all,
every aspect of what myasthenia
can cause,
there are team members that
address them.
So, for example, there can be
difficulty swallowing.
There can be
difficulty speaking.
There are speech language
pathologists who specialize
specifically in helping people
articulate better,
and helping people
swallow better.
Compensatory actions that you
could do to make
swallowing safer.
For example, very often, it's
more difficult to swallow
thin liquids.
So we have something called
thicket, which can make
the liquids thicker,
to make them easier to swallow,
and so on.
Muscle weakness.
In general, any muscle that has
greater than antigravity
strength can be made stronger
by exercise.
But you also must rest
those muscles so that they're
not sore 2 days later
from overdoing it.
Because you can overdo exercise.
And we have physical therapists
that do that.
We also have
occupational therapists who have
many, many appliances that can
help people open jars, and reach
for objects,
and all sorts of things.
So every aspect of the problems
that can occur
with any neuromuscular
condition, there
are team members
in our neuromuscular clinic
that we can send them to,
to address them and help them
compensate for them,
to maximize their function
within the impairment
that they may have.
RICHARD NOWAK: What I would add
to that
is that physical deconditioning,
or muscle deconditioning,
can occur
with any chronic illness,
including myasthenia gravis.
And that's part of the treatment
plan, is to address any
physical/muscle conditioning
after the autoimmune "attack,"
quote, unquote, is squashed
or addressed to get patients
stronger and better.
JOHN WHYTE: So, clearly,
the questions have to be more
than "How are you feeling?
How are you doing?" which
sometimes in primary care we do.
But I also wanted to ask you,
what do you think patients
should be asking you?
Because we've talked
at a previous time about,
how do they know a treatment
is working?
What's their expectation?
So the question should go
both ways.
And we always like to give
viewers, empower them
with information.
What should they ask you, Dr.
Novak, at a visit?
RICHARD NOWAK: Absolutely.
I think what I would ask
my patients that I see
is to be engaged,
to be involved,
and to be curious about--
JOHN WHYTE: How do they do that?
Practically speaking.
RICHARD NOWAK: Absolutely.
So there's a lot of resources.
Most certainly, the internet
provides that opportunity.
But patient advocacy groups,
for instance, are a great source
of information.
JOHN WHYTE: And there are
many in myasthenia.
RICHARD NOWAK: Right.
It's important to not just look
to see what's online,
but to get resources that are
good resources,
and not get misinformation.
To be engaged in their care
is important.
There's tools out there,
provided sometimes
by patient advocacy
groups and others, that can
track symptoms.
Some of these are applications
that one can use
on a smartphone, for instance,
or other.
JOHN WHYTE: I gave you
the old-school diary type.
But nowadays, it could
be electronic.
RICHARD NOWAK: Exactly.
And people can keep things
on pen and paper, for sure.
But many patients do track
their symptoms.
And
that's helpful
in
the patient-physician
relationship in terms
of understanding
what are
the unmet and unaddressed
symptoms to the point
of physical deconditioning
that comes up,
or other issues that might not
necessarily be directly related
to myasthenia gravis,
but those other health issues
that emerge that we do
need to pay attention to as part
of a health care team.
JOHN WHYTE: What do you find
are most on people's
minds, going
through this patient journey
with myasthenia?
Are there some common themes
that they ask you, that they're
most concerned about?
RICHARD NOWAK: I think it really
depends on where they are
in their disease course.
Are they just diagnosed today?
Have they had the condition
for a number of years?
But common questions that come
up is, can I work?
Can I take care of my kids?
Can I do the things that I need
to do as part of daily living?
Does having a diagnosis
of myasthenia gravis,
as the gravis implies, a very
significant or serious illness?
So these are top of mind
for patients that come to see us
in the office.
And everyone is different.
And their questions might be
slightly different.
But what I encourage patients
to do is to write down
their questions.
So when they come
to the appointment,
we can address them as best
we can.
JOHN WHYTE: I want to talk
about the role of caregivers,
of spouses.
And how they play into the
care plan.
So what's your counsel when you
see patients-- and sometimes you
might see them with their spouse
or loved ones, or
family members?
How should they be involved?
And how can they be involved?
RICHARD NOWAK: I think,
education is key.
So not only educating
the patient, but their family
members, to understand
the expectations about this
being a fluctuating condition.
So, involving them in the care
plan, I think, is
critically important.
Because some patients might need
help, especially when they're
newly diagnosed,
or have moderate to severe
myasthenia gravis.
And spouses or family might not
necessarily understand that.
JOHN WHYTE: And even
with treatment, they still may
need some support.
RICHARD NOWAK: Yeah, education.
I can say it three times,
but I'll just say it once.
Education about the condition,
and the variability from one
person to the next.
Some people have called
myasthenia gravis
a snowflake disease.
That's not something that
I coined.
And that everyone's condition
might follow a slightly
different pattern.
And tailoring that
to individuals in terms
of our approach is important.
JOHN WHYTE: What's the biggest
misconception that you find you
constantly have to talk
to patients about?
RICHARD NOWAK: I think
that there is
misinformation about what
myasthenia gravis can cause
in terms of the symptomatology.
So some of my patients
will say, "Well, I have
back pain.
And that's my myasthenia gravis.
Or I have difficulty with
doing something.
And that's my
myasthenia gravis."
So pain is not necessarily
a symptom of myasthenia gravis,
but it does come up a lot,
to what we discussed earlier
about addressing
physical deconditioning
and listening to patients,
and teasing out what's what.
One question that sometimes
comes up is, patients might be
well-controlled MG for a number
of years.
They develop shortness
of breath.
"Oh, that must be my
myasthenia gravis."
But rather, it's
another medical issue.
So we've diagnosed other health
issues, like heart failure
or cardiac.
JOHN WHYTE: Sure.
And that can be
totally unrelated.
JOHN BACH: Or a combination
of things.
It could be a combination
of things.
I think the most dangerous
misconception is the thought
that, if you're too
weak to breathe,
you need an invasive
airway tube.
Because that causes pneumonia
and other problems,
and is potentially lethal.
It's the most
dangerous misconception.
JOHN WHYTE: What is your message
to viewers?
RICHARD NOWAK:
That autoimmune myasthenia
gravis is most certainly
a treatable condition.
It has a range of severities
from mild to severe.
And we need to understand how
an individual patient will do
over time.
Weakness and/or fatigue does not
necessarily equal
myasthenia gravis.
Over the last several years,
there's been more attention
about autoimmune
myasthenia gravis,
likely driven by the fact
that we have newer
tailored treatments.
But I think
that any individual suffering
with weakness or
fatigue needs
a comprehensive
neurologic evaluation.
And that weakness and fatigue
does not necessarily mean
myasthenia gravis.
JOHN BACH: And the team.
A team approach is--
JOHN WHYTE: Absolutely.
Sure.
Well, doctors, thanks
for joining me today.
JOHN BACH: Such a pleasure.
RICHARD NOWAK: It was
a pleasure.
Thanks so much.
[MUSIC PLAYING]
What Is Tingling in Hands and Feet?
Tingling in hands and feet is an extremely common and bothersome symptom. Paresthesia is the medical term for this, which in addition to tingling, can feel like pricks, numbness, or burning under the skin.
The tingling sensation can often be benign and temporary. For example, it might happen when there's weight or pressure on an arm under your head as you sleep. Or it could result from pressure on your nerves when you cross your legs for too long. In either case, the "pins and needles" effect, usually painless, is soon relieved by removing the pressure that caused it.
However, sometimes tingling in your hands and feet can be severe, episodic, or chronic. It can also come with other symptoms, such as pain, itching, numbness, and muscle wasting. In these cases, tingling may be a sign of nerve damage from causes as varied as traumatic or repetitive stress injuries, bacterial or viral infections, toxic exposures, or diseases such as diabetes.
This type of nerve damage is known as peripheral neuropathy because it affects nerves distant from the brain and spinal cord, often in the hands and feet. There are more than 100 types of peripheral neuropathy. Over time, the condition can worsen, making you less mobile and even disabled. More than 20 million Americans, most of them older adults, are estimated to have peripheral neuropathy.
It's important to get medical help right away for any tingling in your hands and feet that’s lasted a while. The earlier the cause of your tingling is found and brought under control, the less likely you are to develop long-term problems.
Causes of Tingling in Hands and Feet
Diabetes is one of the most common causes of peripheral neuropathy, accounting for about 30% of cases. In diabetic neuropathy, tingling and other symptoms often first develop in both feet, then go up the legs, and subsequently affect both hands and go up the arms. About two-thirds of people with diabetes have mild to severe forms of nerve damage. In many cases, these symptoms are the first signs of diabetes.
In another 30% of peripheral neuropathy cases, the cause is unknown, or "idiopathic." The remaining 40% of cases have a variety of causes that produce tingling in the upper limbs, lower limbs, or both.
Tingling in hands
The following conditions can cause numbness and tingling in fingers, hands, and arms:
- Carpal tunnel syndrome occurs when your median nerve is squeezed at the wrist, causing fingers and forearms to tingle or become numb. Fluid retention and other bodily changes during pregnancy can compress the median nerve and cause carpal tunnel syndrome.
- Ulnar nerve entrapment syndrome can cause tingling in fingers and affects the nerve that supplies feeling to the inside of your forearm, some of your palm, and your last two fingers.
- Radial nerve palsy comes from stress on the nerve that runs along the bottom of your arm, such as when your arm is wedged between a hard surface and your head while you're asleep or intoxicated.
Tingling in feet
The following conditions typically cause tingling or numbness in feet, toes, and legs:
- Peroneal nerve palsy, also called fibular neuropathy, comes from a damaged nerve that travels down your leg. It affects the outside of the leg or the top of the foot and may cause your foot to drop.
- Tarsal tunnel syndrome is the foot version of carpal tunnel syndrome. In this, the nerve that runs along the inside of your ankle is compressed.
- Sciatica is caused by herniated disks in the lower back that can compress nerves and cause tingling in the legs.
Tingling in both hands and feet
- Anxiety. It can trigger tingling in your hands, fingers, feet, and toes as well as on your face and around your mouth.
- Fibromyalgia. This chronic pain disorder can cause tingling in both sets of limbs.
- Cervical spondylosis. This typically occurs as the disks in your neck begin to wear with age and compress the nerves in your spinal column. Cervical spondylosis can cause numbness and tingling in your arms, legs, hands, and feet.
- Systemic diseases. These include kidney disorders, liver disease, vascular damage, blood-related diseases, amyloidosis, connective tissue disorders, chronic inflammation, hormonal imbalances (including hypothyroidism), as well as cancers and benign tumors that impinge on nerves.
- Vitamin deficiencies. You need vitamins E, B1, B6, B12, and niacin for healthy nerves. A B12 deficiency, for example, can lead to pernicious anemia, an important cause of peripheral neuropathy. But too much B6 can cause tingling in the hands and feet.
- Alcoholism. People with alcoholism are more likely to lack thiamine or other important vitamins because of poor dietary habits, a common cause of peripheral neuropathy. It's also possible that alcoholism itself can cause nerve damage, a condition some researchers call alcoholic neuropathy.
- Toxins. These include heavy metals such as lead, arsenic, mercury, and thallium, and some industrial and environmental chemicals. They also include certain medications, especially chemotherapy drugs used for lung cancer, as well as some antiviral and antibiotic drugs.
- Infections. These include Lyme disease, shingles (varicella zoster), cytomegalovirus, Epstein-Barr, herpes simplex, and HIV and AIDS.
- Autoimmune diseases. These include chronic inflammatory demyelinating polyneuropathy, Guillain-Barre syndrome, lupus, and rheumatoid arthritis.
- Inherited disorders. These include a group that may have sensory and motor symptoms; the most common type is known as Charcot-Marie-Tooth disease.
- Injury. Often related to trauma, nerves can be compressed, crushed, or damaged in other ways, resulting in nerve pain. Examples include nerve compression caused by a dislocated bone.
- Multiple sclerosis. The disease causes your body’s immune system to attack the fatty myelin sheath around nerve fibers in your brain and spine. Tingling in the hands and feet is a common symptom.
- Medications. Certain medicines as well as street drugs, can cause tingling.
Diagnosis of Tingling Hands and Feet
If you seek care for your tingling hands or feet, your health care provider will do a physical exam and take an extensive medical history addressing your symptoms, work environment, social habits (including alcohol use), toxic exposure, risk of HIV or other infectious diseases, and family history of neurological disease.
They also may perform other tests, such as:
- Blood tests. These can include tests to detect diabetes, vitamin deficiencies, liver or kidney dysfunction, other metabolic disorders, and signs of abnormal immune system activity.
- An examination of cerebrospinal fluid. This can identify antibodies associated with peripheral neuropathy.
- An electromyogram (EMG), a test of your muscles' electrical activity.
- Nerve conduction velocity (NCV).
Other tests may include:
- CT scan
- MRI
- Nerve biopsy
- Skin biopsy to look at nerve fiber endings
Treatments for Tingling Hands and Feet
Treatment of tingling in hands and feet depends on the underlying cause. As long as peripheral nerve cells have not been killed, they can regenerate.
Although there are no treatments for inherited types of peripheral neuropathy, many of the acquired types can be improved with treatment. For example, good blood sugar control in diabetes can help keep diabetic neuropathy from getting worse, and vitamin supplements can correct peripheral neuropathy in people with vitamin deficiencies.
In some cases, tingling and other symptoms of peripheral neuropathy may be eased with prescriptions developed for treating seizures and depression.
You also may be prescribed physical therapy or undergo surgery to mend the underlying issue.
Therapies that ease symptoms
- Physical therapy can be prescribed as well as assistive devices such as canes, walkers, braces, and wheelchairs.
- Neurostimulation devices are placed inside the body to short-circuit pain signals before they reach the brain.
- Scrambler therapy involves sending electrical impulses that trick the brain into believing there's no pain.
- Plasma, intravenous immune globulin, and steroid injections can be used in the event your tingling nerves produce weakness or balance issues.
At-home treatment for tingling in hands and feet
- Rest
- Splints
- Cold or heat
- Over-the-counter, prescription or topical pain relievers
- Specific exercises
Preventing Tingling in Hands and Feet
If you have an underlying condition such as diabetes and peripheral neuropathy contributing to the tingling in your hands or feet, you should adopt lifestyle changes to safeguard your nerves.
Generally, it helps to:
- Keep your weight in check
- Eat a balanced diet
- Avoid or limit alcohol
- Follow a doctor-supervised exercise program
- Avoid exposure to toxins
- Stop smoking. It constricts blood supply to the blood vessels supplying nutrients to peripheral nerves.
When to See a Health Care Provider
If the tingling in your hands and feet starts during repetitive motion, affects your quality of life, or causes muscle weakness or a rash, have your doctor take a look. However, some cases of tingling and numbness require more urgent attention. They include:
- Changes in speech, vision, or breathing
- Numbness or tingling throughout an arm, leg, or area of your body, or that spreads rapidly across your body
- Paralysis or loss of feeling in your face or chest
- Loss of bladder or bowel control
- Sudden onset of weakness or numbness
- Confusion or losing consciousness
- Symptoms in your thighs, genital area, or buttocks
Takeaways
There are many conditions, from mild to serious, that can cause your hands and feet to tingle. Long-term, chronic tingling may be caused by compression of a nerve due to damage, tumors, herniated disks, or expanded blood vessels. Other times, it might be a disease or chronic condition that leads to tingling in your hands and feet.
Tingling in Hands and Feet FAQs
What is tingling in hands and feet a symptom of?
Tingling in hands and feet can be a symptom of multiple conditions, but the immediate sensation stems from irritation, damage, or compression of a nerve.
When should I worry about tingling in my hands?
If the tingling in your hands and feet doesn't go away after a while, you should see your doctor. The quicker you can get diagnosed and treated, the more likely you are to stop further damage to your nerves.
How do I stop my hands and feet from tingling?
First, see your doctor to find out the underlying cause of the tingling. They might prescribe over-the-counter or prescription medicines to treat your symptoms. There are various therapies you can try, including complementary therapies such as acupuncture. Certain changes to your lifestyle can help treat whatever condition leads to the tingling.
