Detailed Information About Peripheral Neuropathy
General: Peripheral neuropathy refers to conditions that affect nerves primarily in the feet and legs and occasionally in the hands or arms. There are many types of peripheral neuropathy and many causes. Neuropathies that primarily cause discomfort in the feet and lower leg are perhaps the most common type. Causes: There are 3 categories of causes: mechanical, metabolic and hereditary. • Mechanical neuropathies account for about 10% to 15% of the patients you will see. These are people with conditions such as herniated discs, degenerative discs, stenosis and nerve impingement. • Metabolic neuropathies make up about 85% of the neuropathy patients. These are people with metabolic conditions such as diabetes. • Hereditary neuropathies are very uncommon and make up less than 1% of the neuropathy patients. These are caused by diseases such as Friedrich’s Ataxia, Charcot-Marie Tooth Disease, Multiple Sclerosis, etc. Generally, these are not painful, sensory neuropathies. They normally involve motor dysfunction, although some degree of sensory dysfunction is also commonly present. NOTE: It is very common to see a patient who has both a mechanical cause and a metabolic cause. Clinical Features: Peripheral neuropathies generally affect the longest nerves first and thus the symptoms are often initially described in the feet. Symptoms can progress and affect the lower leg. There are two types of peripheral nerves: 1) sensory nerves that bring information to the brain enabling one to determine what is touching the skin, and 2) motor nerves that bring information to muscles to command them to carry out intended movements. Both types of nerves are intermixed. However, some neuropathies preferentially affect sensory nerves. There are two categories of symptoms that can occur with sensory neuropathies: 1) negative symptoms causing a lack of sensory perception 2) positive symptoms causing discomfort. Negative Symptoms reduce the ability to feel what one is standing on (rough, smooth, cold, warm). At times it may be severe enough to prevent the feeling of pain. Another negative symptom is lack of proprioceptive information. Proprioception refers to the ability to know what muscles are doing (contracting or relaxing) and what joints are doing (bending one way or the other). Normally, this information reaches lower (subconscious) parts of the brain and one is not aware of this information which is used to maintain balance. When proprioceptive information is lacking one naturally compensate by substituting visual information to determine where the body is in space. However, when sight is temporarily lost (such as when eyes are closed in the shower) or reduced (such as walking in the dark) there can be a marked feeling of unsteadiness. NEGATIVE SENSORY SYMPTOMS Reduced or absent touch perception Reduced or absent pain perception Instability when standing with eyes closed
Positive Symptoms are caused by nerves discharging spontaneously on their own causing one to “feel” things that are not truly occurring. For example, there maybe a feeling of burning pain or a sensation of walking on ground glass, or feeling knife-like jabs in the legs when these are not actually occurring at the skin. Sensory neuropathies can also cause an increased sensitivity to light touch to the skin when contact is made to the feet and lower leg resulting in discomfort and lingering pain (allodynia and hyperpathia). Painful sensations are frequently worse at night and after walking longer distances. POSITIVE SENSORY SYMPTOMS Burning sensations Stabbing sensations Squeezing or band-like sensations Hypersensitivity to touch Diagnosis: Sensory peripheral neuropathy is suggested by descriptions of negative and positive symptoms affecting feet and lower legs. The specific diagnosis of a painful sensory neuropathy is based on descriptions of positive symptoms and few negative symptoms. Neurologic examination usually shows some degree of negative signs with reduced perception of light touch to the foot or reduced ability to sense the vibration of a tuning fork applied to the toe. There can be reduced ability to sense the sharpness of a safety pin applied to the foot. However, sometimes there are no sensory abnormalities. Tendon reflexes may be reduced or absent at the ankles. Nerve conduction studies may show reduced sensory nerve responses. However, sometimes these studies are normal. While the diagnosis of a painful sensory neuropathy comes primarily from descriptions of positive symptoms, the diagnosis also relies on consideration for many other factors because not all positive and negative symptoms are due to problems in peripheral nerves. Pathogenesis: When the cause of a painful sensory neuropathy is not obvious from routine laboratory tests it is rare to find a cause even after more detailed tests are run. When no cause is found the neuropathy is called “idiopathic” or “cryptogenic”. Peripheral neuropathy indicates damage to nerves and nerve endings. This accounts for negative symptoms. Sometimes only the smallest nerve endings in the skin are affected. The nerve endings die back and a neuropathy can progress over time with shorter lengths of nerves affected. Unfortunately, the cause of nerve damage is rarely found. Spontaneous discharges in nerves likely occur because there are tiny channels in nerve fibers that open when they should be closed and cause nerve to fire on their own without being stimulated. These spontaneous firings reach the brain and are perceived as burning, stabbing, and so forth (similar to a loud noise being painful). Conventional Treatment Results: Few types of peripheral neuropathy can be completely stopped with treatment. Just about the only time you’ll see a complete correction is if the cause of the neuropathy is mechanical and you are able to fix the mechanical cause completely with no residual stuff (arthritis, degeneration, etc.). That’s usually not the case, so the likelihood of a complete correction is small. Unfortunately, painful sensory neuropathies are rarely correctable with drugs.
Drugs: Most medications are designed to temporarily reduce positive symptoms. Since the cause of positive symptoms is felt to be spontaneous nerve discharges due to open channels, many drugs are designed to reduce or block these channels. Medications include gabapentin (Neurontin®) and pregabalin (Lyrica®). These were originally approved by the FDA as anti-convulsants, but recently approved for the treatment of neuropathy. Most patients will tell you they initially felt tremendous relief with these drugs, but over time the dose had to be continually increased. Eventually, the side effects (swelling of the joints, stomach upset, dizziness) got so bad that they decided to discontinue taking them. Other medications were initially designed as antidepressants but have been found to be affective at lower doses for positive symptoms. These medications include amitriptyline (Elavil®), imipramine (Tofranil®) and duloxitine (Cymbalta®). Home Management: Choosing comfortable shoes can help reduced pain while walking. When there are negative symptoms it is important not to walk barefoot or wear open-toe shoes to prevent injury. Perhaps the most important issue is foot inspection on a daily basis to identify cuts, blister and sores. It is wise to have a podiatrist cut toenails to prevent inadvertent nicks to the skin. Clinical Course: Painful sensory neuropathy can progress up the leg but rarely beyond the knee. The exceptions are those caused by diabetes. Painful sensations generally reach a maximum and do not increase further. Increased pain after walking a long way does not mean that the neuropathy is getting worse nor does walking further damage nerves. Painful sensory neuropathies do not affect strength and will not result in the need for a wheelchair. With the exception of diabetes painful sensory neuropathy, where there is also decreased blood flow, non-diabetic painful sensory neuropathy does not lead to loss of a toe of limb.
ChiroCenter’s Ultimate Peripheral Neuropathy Treatment Program: • This was developed over several years by organizing many different treatment approaches that have proven effective in treating the symptoms of Peripheral Neuropathy. • There is no known cure for Peripheral Neuropathy, and our program will not cure it either. It is designed to eliminate or greatly reduce the symptoms associated with PN. We make no representation that our treatment program will cure Peripheral Neuropathy. • Once a patient has reached a level of maximum improvement, some degree of maintenance care will be necessary. This will be rendered as infrequently as possible, according to the patient’s needs. • Our Peripheral Neuropathy Treatment Program includes the use of light therapy. Light therapy has been shown to “bio-stimulate” or “bio-modulate” all types of tissue at the cellular level. The exact mechanism is not totally understood. Some of the more popular explanations include: A. stimulation of the mitochondria to increase ATP production B. release of NO2 in the hemoglobin to allow for greater O2 saturation • High Power Laser Therapy is used to reach the deep nerves. • Electrotherapy is used to reduce inflammation and stimulate healing by changing the polarity of the surrounding tissues. • Infrared light therapy (light boots) is used to reach the more superficial nerves. • Oxygen is administered to increase the blood oxygen volume to enhance healing. • Total body vibration increases the circulation to the lower extremities and stimulates the dorsal columns (proprioception) • Extremity manipulation reduces the mechanical component of the PN symptoms by reducing localized nerve irritation • Spinal manipulation reduces the mechanical component of the PN symptoms by reducing nerve irritation at the spine • Sensorineural stimulation (wire brush and “Stick”) stimulate the affected nerves through daily use at home.
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