Unnerving Damage

Physical therapy for patients with peripheral neuropathy.


Just as static on the line can interrupt a telephone conversation, peripheral neuropathy distorts messages being sent from the brain to the rest of the body, according to the National Institute of Neurological Disorders and Stroke.

According to an educational piece made available by The Foundation for Peripheral Neuropathy and The Neuropathy Action Foundation, peripheral neuropathy (PN) is an often painful and debilitating condition that is caused by damage to the peripheral nervous system-the complex web of nerves that connect the central nervous system to the rest of the body.

Peripheral neuropathy is a term used for damage of nerves of the peripheral nervous system, shared Daniel Seidler, PT, MS, executive director of Westchester Square Physical Therapy (WSPT) in Bronx, NY.

Twenty million people in the United States have PN, of which 13.8 million people are diabetic.

Individuals with PN will often be referred by a neurologist following a positive nerve conduction velocity test. These patients are often extremely hypersensitive or hyposensitive in the affected region and significant gait and balance abnormalities are common.

Patients often will present with burning, tingling, numbness and/or weakness of varying degrees. "Patients with diabetic peripheral neuropathy describe the feeling of walking on needles, glass, bricks, sand, rocks, or other discomfort," explained Seidler.

The causes of PN may be either hereditary, metabolic (such as diabetes mellitus or hypothyroidism), toxic (chemotherapy, drug/alcohol abuse), vitamin deficiency (B12, A, E, or B1), or physical trauma.

Diabetic Neuropathy

Diabetic peripheral neuropathy (DPN) describes a family of nerve disorders that are directly caused by complications from diabetes. DPN can strike at any time, regardless of age, gender, or racial/ethnic background. People with diabetes who have trouble controlling their blood glucose levels, along with high cholesterol, high blood pressure, and obesity are at an elevated risk.

The most common type of peripheral neuropathy, DPN causes pain or loss of sensation in the feet, legs, hands and arms. As the condition progresses, an individual can expect permanent damage to his body, with loss of sensation leading to sores, ulcers, and, in the worst of cases, lower-limb amputation.

While current research consistently shows the relationship between maintaining healthy glucose levels and nerve damage, DPN can be caused by a combination of different factors. Studies show that the longer an individual lives with diabetes, the more likely he is to develop some form of neuropathy. Furthermore, researchers believe that people who have lived with diabetes for more than 25 years are most likely to suffer from DPN.

PT Interventions

"Most patients who come to us with DPN have already entered a cycle of pain which leads to decreased activity, leading to increased symptoms, causing even further pain and so on," Seidler explained. "The most important thing is to get these patients active again. If you can do that, then the cycle tends to reverse and the patient will improve."

At WSPT, the therapists offer infrared light therapy, soft tissue mobilization to increase circulation, ankle and foot joint mobilizations if necessary, gastroc/soleus/plantar fascia stretching, static and dynamic stretching, gait training, and general conditioning exercises.

Many who suffer from diabetic neuropathy tend to have issues with blood flow and flexibility. WSPT has a stretching program to relieve the symptoms of diabetic neuropathy by improving blood flow and flexibility in the muscles.

The therapists at WSPT believe that massage helps increase local circulation of blood and lymph, thereby nourishing the body on a cellular level. This can help promote wound healing.

Due to increased levels of pain, diabetics tend to refrain from walking, which results in weakened leg muscles. The WSPT therapists focus on getting a patient's muscles back in shape to withstand daily activities. Furthermore, each patient receives a personalized fitness/conditioning program.

The PTs provide ambulation assessment and training, including the use of appropriate assistive devices, to improve and make changes to the patient's gait to prevent injury or correct a gait dysfunction.

The differing causes of PN respond differently to physical therapy treatments. "In our clinic, we see a large population of patients with diabetic peripheral neuropathy," shared Seidler. "We've had excellent results with infrared light therapy in order to increase normal sensation and decrease pain."

Infrared light therapy causes a patient's blood vessels to temporarily dilate, thereby increasing local circulation and reducing pain, stiffness and muscle spasm.

"PTs ought to be aware that these patients are typically extremely uncomfortable at first and treatment does not usually take until the third or fourth treatment," relayed Seidler. "We usually ease patients into the exercise portion of the program until their tolerance improves."

Seidler stressed the importance of monitoring the patient closely during the first few infrared light therapy sessions because of compromised sensation.

"Patients with neuropathy need to understand that altered sensation means that they can't rely on their sense of feel to know if there is any danger to the integrity of their skin-a vital defense organ," Seidler said.

Seidler suggests that the PT stays aware of the temperature of the infrared treatment because the patient may not know if the treatment is too hot. The PT also needs to assess the patient's fall risk because falls are common among this population.

"Following an 8 to 12 week program of PT, the patient's symptoms will typically return after two to three months if the patient does not comply with a home program and does not continue infrared light therapy treatments," Seidler explained.

These patients need to visually check their feet daily. One blister or laceration, particularly for patients with diabetes, can significantly increase their risk of ulceration, gangrene, and eventually amputation. Blood-glucose levels can affect the symptoms of DPN, so nutrition education is key. WSPT offers nutrition consultations with an emphasis on a low glycemic diet.

According to Seidler, neurologists play a crucial role for this patient population because they are familiar with neuropathy. An internist or endocrinologist can be important if the patient has comorbidities. The staff at the dialysis clinic will be involved if the patient has renal failure.

"The DPN patients we see often have renal and/or cardiovascular risk factors," Seidler explained. "If anything out of the ordinary occurs in PT we need to communicate that to the rest of the team and we also need to know if the patient has experienced any recent changes in their medical status or medication."

Rebecca Mayer is senior regional editor of ADVANCE and can be reached at rmayer@advanceweb.com


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