Peripheral neuropathy

Definition

 Peripheral nervous system brings information

to and from the brain and spinal cord to the
rest of the body
 Peripheral neuropathy (PN) occurs when

damage occurs at one (mononeuropathy) or

multiple (polyneuropathy) nerves.
PERIPHERAL NEUROPATHY
 Generalized term including disorders of any
cause
 May involve sensory nerves, motor nerves, or

both
 May affect one nerve (mononeuropathy),

several nerves together (polyneuropathy) or

several nerves not contiguous
(Mononeuropathy multiplex)
 May have demyelination or axonal

degeneration
 An estimated 20 million people in the United
States have some form of peripheral neuropathy,
a condition that develops as a result of damage
to the peripheral nervous system
 Peripheral nerves send sensory information back
to the brain and spinal cord, such as a message
that the feet are cold. Peripheral nerves also
carry signals from the brain and spinal cord to
the muscles to generate movement. Damage to
the peripheral nervous system interferes with
these vital connections.
 Peripheral neuropathies can present in a
variety of forms and follow different patterns.
Symptoms may be experienced over a period
of days, weeks, or years. They can be
 acute
 or chronic
 In diabetic neuropathy, one of the most

common forms of peripheral neuropathy.

Causes
 Peripheral neuropathy may be either inherited or
acquired through disease processes or trauma.
In many cases, however, a specific cause cannot
be identified
Diabetes is most common cause of PN
 60-70% of individuals with diabetes have mild to
severe forms of PN
 Other causes:
 Autoimmune disorders
 Chronic kidney disease
 HIV and liver infections
 Low levels of vitamin B12
 Poor circulation in lower extremities
 Underactive thyroid gland
 Tumor
 Exposure to toxins
 Alcoholism
 Bone marrow disorders
 Trauma or pressure on the nerve
 Medications
 Infections
Risk factors
 Diabetes mellitus
 Alcohol abuse
 Vitamin deficiencies, particularly B vitamins
 Infections,
 Autoimmune diseases,
 Kidney, liver or thyroid disorders
 Exposure to toxins
 Repetitive motion, such as those performed for
certain jobs
 Family history of neuropathy
classification
 In general, peripheral neuropathies are
classified according to the type of damage to
the nerves.
 Mononeuropathy
 Polyneuropathy
symptoms
Symptoms vary depending on whether motor,
sensory, or autonomic nerves are damaged.
Motor nerves control voluntary movement of
muscles such as those used for walking,
grasping things, or talking.
 Sensory nerves transmit information such as

the feeling of a light touch or the pain from a

cut. Autonomic nerves control organ activities
that are regulated automatically such as
breathing, digesting food, and heart and
gland functions.
Symptoms

 Peripheral motor neuropathy:

 Weakness
 Cramping and fasciculation
 Muscle loss
 Bone degeneration
 Loss of ankle reflexes
 Changes in skin, hair, and nails
Peripheral sensory neuropathy

 Damage to large, myelinated nerves results in

impaired sense of
 Vibration
 Light touch discrimination
 Limb position
 people may feel as if they are wearing gloves

and stockings
 Difficulty in maintainig the balance
 Damage to small myelinated nerves result in
impaired sense of
 Temperature
 Pain
 Hypo or hyper sensitivity
 Loss of pain sensation is a particularly

serious problem for people with diabetes,

contributing to the high rate of lower limb
amputations among this population.
 Neuropathic pain
Peripheral autonomic neuropathy

 Diverse manifestation includes

 Impaired breathing
 GI dysfunction
 Difficulty swallowing
 Inability to sweat
 Loss of bowel and/or bladder control
 Loss of blood pressure control
 Mask angina
Functional Mobility

 Impaired postural stability

 Greater increase in postural sway seen with more difficult
tasks
 Mechanism is combination of impaired sensation and
proprioception
 Impaired gait
 Gait tends to be more conservative
 Decreased speed and stride length
 Greater time spent in double support
 Reaction time delayed
 In individuals with Type 2 DM, PN, BMI >30 kg/m2 and
decreased muscle strength were associated with a reduction in
daily walking activity
Incidence

 In a 2004 study of 795 community dwelling individuals:

 PN present in 26% between 65 and 74 years of age
 PN present in 54% age >85
 40% with known cause
 Risk factors:
 Increasing age
 Income less than $15,000
 History of military service
 High BMI
 Diabetes mellitus (DM)
 Vitamin B12 deficiency
 RA
 Absence of high blood pressure
 A 2011 Swedish based study in a population
of patients with Type 2 diabetes mellitus (DM):
 43% peripheral autonomic neuropathy (PAN)
 15-28% peripheral sensory neuropathy (PSN)
 15% peripheral motor neuropathy (PMN)
 Total of 67% experiencing PN
 Nather et al found longer duration since onset
of DM is associated with higher prevalence of
PN
complications
 Burns and skin trauma
 Infection
Diagnosis of peripheral
neuropathies
Based on the results of the
 neurological exam
 physical exam
 patient history
 any previous screening or testing
 Nerve conduction velocity (NCV)
 Electromyography (EMG)
 Magnetic resonance imaging (MRI)
 Nerve biopsy
 Skin biopsy
Treatment
 Address underlying conditions
The adoption of healthy lifestyle habits such as
maintaining optimal weight, avoiding exposure
to toxins, exercising, eating a balanced diet,
correcting vitamin deficiencies, and limiting or
avoiding alcohol consumption can reduce the
effects of peripheral neuropathy
Exercise can reduce cramps, improve muscle
strength, and prevent muscle wasting. Various
dietary strategies can improve gastrointestinal
symptoms
 prevent permanent damage
 Smoking cessation
 Self-care skills such as meticulous foot care

and careful wound treatment

 Strict control of blood glucose levels
 Immunosuppressive drugs such as

prednisone, cyclosporine, or azathioprine

may be beneficial.
 Plasmapheresis
Symptom Management

 analgesics
 antidepressants, anticonvulsant medications,

antiarrythmic medications, and narcotic

agents
 Topically administered medications
 Transcutaneous electrical nerve stimulation

(TENS)
 Other complementary approaches
 Acupuncture
 massage
 herbal medications also are considered in

the treatment of neuropathic pain

 Surgical intervention
Physical therapy
Examination/Evaluation

 Thorough history taking

 Observation of skin color, integrity, temperature
 Presence of pressure points or ulceration?
 Strength testing
 ROM/flexibility testing
 Neurological testing
 Reflexes
 Sensation
 Proprioception
 Balance/coordination
 Foot wear assessment
Sensation Testing

 Light touch discrimination

 Pin-Prick Testing
 Temperature testing
 Proprioception (joint position sense)
 Tuning fork
Intervention

 Aerobic conditioning
 Progressive flexibility/stretching exercises
 Progressive strengthening exercises
 Balance/coordination
 Gait training
 Alternative :
 Monochromatic infrared energy
 Vibrating insoles
 Tai Chi
Aerobic conditioning
 In 2006, a study investigated the effects of a
brisk walking program in diabetic patients
without signs and symptoms of PN.
 Improved nerve conduction velocity
 No increase in vibration perception threshold
 Decreased incidence of motor and sensory

peripheral neuropathy
Flexibility
 Balance and Strengthening

 In 2001, Richardson et al showed strengthening of the lower

extremities improved performance on clinical measures of
balance.
 Kruse et al found no increase in incidence of foot ulceration
following an exercise program consisting of leg
strengthening, balance exercises, and a graduated, self-
monitored walking program.
 Moderate increase in weight-bearing activity
 A follow up to this study in 2010 did not find any significant
differences in balance, lower extremity strength, or fall rate.
 Two studies by Van Schie et al found improvement in
balance and a trend towards increased lower extremity
strength
 Strengthening Exercises

 Initial focus is on core, hip, knee, and ankle

strengthening
 Progress into functional activities
Monochromatic infrared energy (MIRE)
 Monochromatic infrared energy (MIRE)
 Conflicting results in the literature
 Leonard et al (2004) showed MIRE to improve

sensation, decrease pain, and improve

balance in subjects with diabetic PN
Vibrating Insoles and Tai Chi

 Utilization of vibrating insoles improved

postural sway in quiet standing
 This is a pilot study and outcome measures

not applicable to functional activities

 Further investigation needed
 A long term (24 wk) Tai Chi program

improved functional gait, strength, and

plantar sensation in individuals with PN
Balance Exercises
Mononeuropathies
 Ulnar neuropathy
 Carpal tunnel syndrome
 Tarsal tunnel syndrome
 Bell’s palsy
Carpal tunnel syndrome
 Perhaps the most common mononeuropathy
 Entrapment of median nerve in the wrist
 Results in paresthesias of thumb, index, and

middle finger; Weakness of the abductor

pollicus brevis
 Tingling fingers, weak thumb
Carpal tunnel syndrome-Causes
 Usually due to overuse
 Other causes
◦ Arthritis
 Osteoarthritis
 Rheumatoid arthritis
◦ Infiltrative diseases
◦ Hypothyroidism
◦ Diabetes
◦ Pregnancy
Carpal tunnel syndrome-Treatment
 Ice packs
 Resting with the hands in elevation
 Wrist and hand exercises
 Ultrasound
 Splinting limiting wrist flexion
◦ Splints
 Cock-up wrist splints
 Treatment is usually surgical resection of carpal
ligament
Bell’s palsy
 Inflammation of 7th
cranial nerve
 One sided facial
paralysis
 Mechanism not
understood
◦ Virus implicated
Treatment
Polyneuropathies
 Can be due to a toxic or metabolic state
 Many symptoms possible
◦ Tingling/Prickling/Stabbing/Burning
◦ Later dysesthesias (Abnormal sensation where
light touch causes pain)
◦ Sensory or motor loss with possible decreased
reflexes
◦ Weakness, gait disturbance
◦ Flexor contractures
 Stocking-glove distribution (defects worse
distally)
Diabetic peripheral neuropathy
Diabetic Peripheral neuropathy is
nerve damage caused by chronically
high blood sugar and diabetes. It
leads to numbness, loss of
sensation, and sometimes pain in
your feet, legs, or hands. It is the
most common complication of
diabetes.
The highest rates of
neuropathy are among
people who have had
diabetes for at least 25
years.
Tretment
 Prevention
 Blood glucose monitoring
 meal planning
 physical activity
 diabetes medicines or insulin will help

control blood glucose levels

 lidocaine patches
 electrical nerve stimulation
Physical Therapy
 Transcutaneous electrical nerve stimulation
(TENS)
 interferential current (IFC)
 Off-loading techniques
 Exercise programs, along with manual therapy
 Aerobic exercise
 Heat
 therapeutic ultrasound
 hot wax
 short wave diathermy
Pure motor neuropathies
 Amyotrophic lateral sclerosis Lower motor
neuron disease. Death within 5 years.
 Poliomyelitis-Spinal cord disease
 Spinal muscular atrophies
 Guillain-Barre syndrome-A peripheral nerve

disorder
 Myasthenia gravis
Guillain-Barre syndrome (GBS)
 Acute (hours to days) fulminant
polyradiculoneuropathy
 Autoimmune inflammatory demyelination

Guillain-Barre syndrome is a rare disorder in

which your body's immune system attacks
your nerves.
Weakness and tingling in your extremities are
usually the first symptoms
GBS-Diagnosis

 Electrical diagnosis shows slow conduction

velocity
 GBS-Treatment
 High dose IV gamma globulin (IVIG). 2g/kg

five consecutive days

 Plasmapheresis
GBS
Physical therapy
 Acute Stage
 Provide patient and caregiver with education

and training for the prevention of

contractures, DVT and bedsores,
 Avoid prolonged hip and knee flexion;
 Change position at least every two hours in

bed
 Support weak upper extremities with

armrests, a wheelchair tray and/or pillows

Recovery
 passive to active-assisted range-of-motion
 active movement should be performed at low

repetitions and resistance with frequent rest

breaks
 various therapeutic modalities (e.g. TENS,

moist heat pack, or sensory desensitization

techniques)
 Several possible functional activities include

bed mobility, transfers, gait and/or wheelchair

mobility, sitting and standing balance
Myasthenia Gravis

There are four basic therapies used to treat MG:

(i) symptomatic treatment with acetylcholinesterase
inhibitors,
(ii) rapid short-term immunomodulating treatment
with plasmapheresis and intravenous
immunoglobulin,
(iii) chronic long-term immunomodulating
treatment with glucocorticoids and other
immunosuppressive drugs,
(iv) surgical treatment
Physical therapy
 strengthening the specific muscles weakened
 exercises with some assistance.
 gradually add strengthening exercises, such as weightlifting, to
your activity regimen.
 General advice for exercise programmes for people with MG:
 Aim to strengthen large muscle groups, particularly proximal
muscles of shoulders and hips
 Advise patient to do the exercises at their "best time of day" ie.
when not feeling tired - for the majority of MG patients this will
be morning
 Moderate intensity of exercise only: patient should not
experience worsening of MG symptoms (eg. ptosis or diploplia)
during exercise
 General aerobic exercise is also valuable, helping with respiratory
function as well stamina
Autonomic neuropathy
 Autonomic neuropathy is a nerve disorder that
affects involuntary body functions, including heart
rate, blood pressure, perspiration and digestion.
Postural hypotension ( syncope)
 No sweating
 Feel cold
 Bladder or bowel problems
 Dry mouth
 Impotence
Physical therapy
 physical activity
 The exercise prescription must address

recommendations on intensity, type,

duration, frequency, and rate of progression
of physical activity based on the findings of
careful evaluation
 Patient education
 use of custom fitted elastic stockings
 Management of orthostatic hypotension
Thank you