Neuropathy

Understanding Neuropathy

Assessment and treatment of neuropathic pain

Neuropathy—a disorder of the peripheral nerves—may not get as much press as obesity or cancer, or even fibromyalgia. However, it is a condition that affects approximately 20 million Americans.

Peripheral neuropathy has always been present, but has not received much attention. Its extent and importance have not yet been adequately recognized. It is apt to be misdiagnosed, or thought to be merely a side effect of another disease like diabetes, cancer, or kidney failure. The development of new therapies has, unfortunately, been slow and underfunded.

NEUROPATHY BASICS

There are many causes of neuropathy. Approximately 30% of neuropathies are "idiopathic," or of an unknown cause. In another 30% of cases, the cause is diabetes. Other neuropathy causes include autoimmune disorders, tumors, heredity, nutritional imbalances, infections, or toxins.

Some types of peripheral neuropathy can be cured, but most cannot. However, many can be helped. Therapy is directed at treating the underlying disease and at improving the symptoms with the right medications. An experienced neurologist can help patients feel more comfortable and can greatly improve their quality of life. But it is extremely important to get to an experienced neurologist as soon as you notice the symptoms before the disease has a chance to cause too much permanent damage.

Peripheral neuropathy symptoms and signs can vary in how they begin. Some neuropathies come on suddenly; others occur gradually over many years.
Three types of peripheral nerves are affected, and symptoms depend on these nerves and their location:

1. sensory nerves: affect sensation;
2. autonomic nerves: affect internal organ functions; and,
3. motor nerves: affect muscles.

Many types of neuropathy affect all three types of nerves to various degrees, but some affect only one or two.

Here are some neuropathy symptoms and warning signs that your patients may experience:

Weakness in the Arms or Legs

Legs: Usually caused by damage to the motor nerves, leg symptoms often include difficulty walking or running; a feeling of "heaviness" in your legs; finding it takes a lot of effort just to climb the stairs; and stumbling or tiring easily. Muscle cramps may be common. Arms: In the arms, you may find it difficult to carry groceries, open jars, turn doorknobs, or take care of your personal grooming. A common frustration is dropping things.

Numbness, Tingling, and Pain

Sensory nerves, when damaged, can cause various symptoms. Early on, there may be spontaneous sensations, called paresthesias, which include numbness; tingling; pinching; sharp, deep stabs; electric shocks; or buzzing. These sensations are usually worse at night, and sometimes become painful and severe. Patients also may experience unpleasant abnormal sensations when they touch something; these sensations are called dysesthesias because they are caused by stimuli. Or, they may find themselves feeling nothing at all—in this case experiencing anesthesia, a lessening or absence of sensation.

Impaired Sense of Position

When patients lose the ability to "sense" or feel their feet, they may find themselves being uncoordinated because when they walk they are not sure about where their feet are placed. Patients may find themselves walking differently without really knowing how or why they are doing so. Chances are they have either widened their style of walking (in an unconscious effort to keep their balance) or they may be dragging their feet.

DIABETIC EFFECTS

When talking about diabetes, people usually focus on the direct effects of a person's blood sugar level. In addition, some common conditions that people do associate with diabetes are sensory neuropathy, retinopathy, nephropathy, and amputations. One of the conditions that we might not associate with diabetes is the changes in connective tissue that lead to a loss of range of motion. This occurs when collagen binds to glucose, resulting in glycosylated collagen fibers that act differently from regular collagen fibers. This causes a stiffness that is primarily manifested in the feet, atrophic changes in the skin, as well as loss of range of motion of the ankle and in the tarsal bones of the foot. This is something that PTs can intervene in if we recognize or assess it correctly.

Sensory neuropathy is something we readily associate with diabetes. However, there is also a motor component to that neuropathy—it is subtle, and, certainly, sensory nerves are much more likely to be involved than motor nerves. However, there is a weakness that tends to manifest itself more in the distal muscles of the foot and ankle. It is significant enough that patients have changes in gait and balance, which PTs can easily treat with exercise. However, there is limited research to show the effectiveness of exercise. The last thing that people might not associate with diabetes is the memory or cognitive changes that happen. These are also very subtle, and they tend to have more to do with the speed of processing information and with complex problem-solving.

Autonomic neuropathy is neuropathy that affects the autonomic nervous system in the body. The autonomic nervous system is what regulates our heart, digestive tract, and all of the things that we don't think about—things that are automatic and do not require conscious effort on our part toward making them work. When we have a neuropathy of the autonomic nervous system, we do have adequate baseline functioning of those organs. However, we do not respond to any stimulus that might cause a change in function. For example, when someone exercises, takes a deep breath, or holds their breath, you would expect there to be an increase or decrease in the heart rate. What happens in people who have autonomic cardiac neuropathy is that their heart rate just does not change. If they are exercising, breathing deeply, or holding their breath, or if they stand up suddenly, their heart rate stays very constant.

This is actually a problem, because our bodies are designed to respond to these stimuli; if we change our breathing, our heart rate responds accordingly. And when we do not have that change, it puts a lot of stress on the cardiac system. In addition, people can have underlying ischemia of the cardiac muscle that really has never been diagnosed. People may be less likely to have symptoms of chest pain or angina because of neuropathy. Diagnosing cardiac neuropathy requires that they have to get hooked up to an electrocardiogram (ECG) machine and go through a series of breathing or exercise tests; it is not an easy diagnosis, and there is also very little information in the literature on what the standards are for diagnosis. If PTs are the ones saying, "Let's start an exercise program," we need to know that if the patient is diabetic, then there is a possibility that there is a neuropathy that affects the cardiac system. Therefore, we need to be more cautious than we would be with someone who does not have diabetes.

REHABILITATIVE OBJECTIVES

Physical therapy may be helpful in maintaining strength, mobility, and function regardless of the underlying cause of peripheral neuropathy. The objectives of physical therapy include:

• Maintaining a range of motion—passive range of motion exercises consist of progressive stretching.
• Strengthening muscles—this includes exercising against increasing resistance, use of weights, and isometric exercise

PTs also can recommend braces and/or splints to enhance balance and posture. Splinting also can be used in the treatment of compression mononeuropathies, such as carpal tunnel syndrome.

Occupational therapy also is instrumental in helping patients cope with the functional, vocational, and social impact of peripheral neuropathy. Goals of occupational therapy include: improving sensory-motor skills; teaching self care activities; and teaching the patient safety issues (for example, paying more attention to the terrain when walking since falling or tripping may pose a risk for patients with peripheral neuropathy).

-Whats different about this program?

Whether due to diabetes, chemotherapy or other disorders, neuropathy symptoms share common causes. Nerve tissues are highly vulnerable to damage from diseases that impair the body’s ability to transform nutrients into energy, process biochemical waste products, circulate oxygen, or manufacture some components of cellular repair.

Diabetes mellitus is a major cause of peripheral neuropathy in the United States. About 60 percent to 70 percent of people with diabetes have mild to severe forms of neuropathy. Chemotherapy is another leading cause in our age advancing populations of patients in most communities.

What we have discovered is that only by simultaneously addressing the biochemical and disease management components that our neuropathy patients are afflicted with, can lasting results be obtained, with dramatic improvements coming in just 5 weeks of clinical care. Plus ,effective targeted nutrition therapies and rehab measures accelerate the process of recovery in many patients.

Combined Electro Stimulation at 7.83 Hz: A pain-free electrical dual frequency signal (one to stimulate the nerve cells and the other to trigger muscle cells) is pulsed on and off at the frequency of 7.83 cycles per second. *We have found that the human body is particularly sensitive to this frequency. One postulation for this sensitivity is that the electrical potential between the earth’s atmosphere and the earth’s surface is also approximately 7.83 Hz. Using this signal frequency, *research by Dr. David Phillips has found that the body not only responds favorably but the brain is induced to release large amounts of endorphins. The effect of this endorphin release is a generalized sense of well-being, a reduction in pain and anxiety levels elsewhere in the body, and even a reduction in emotional pain. Long term clinical applications suggest some normalization of function is occurring*. This ensures a very high level of patient compliance not only because you feel good physically during the treatment period but because you feel better emotionally afterward experiencing a reduction in pain for a period of 4 to 6 hours.

What about Skeletal Alignment, Nutrition and Exercise? In most patients, the lumbar and hip (piriformis) areas experience muscle spasms, blood flow is restricted through muscles resulting in reduced oxygen availability to the surrounding tissue, including nerve cells. Because muscles can use either oxygen or glucose metabolic pathways, they can recover quickly from a temporary reduction in circulation. Nerve cells, on the other hand, are limited to a different system and must take immediate defensive steps to survive. Our program provides the right combination of manual therapies and home exercise and self-care programs to effect lasting changes in circulation and maximum treatment independence.

Can’t I just Treat Myself?

You can treat yourself. However, we have found the vast majority of patients that we treat are far better off having an initial period of supervision. Furthermore, it is our opinion and experience that peripheral neuropathy patients need to be very thoroughly evaluated and monitored by a central treating licensed healthcare professional. This allows the patient to have one person to coordinate their care and ensure that any necessary diagnostic tests that should have been done have been done, and that the patient’s other healthcare conditions are fully addressed.

We firmly believe that one of the greatest reasons for our success has been that we insist our patients undergo a five-week clinical trial in the office. This trial includes often a nutritional and extensive clinical baseline and follow-up exams. We administer con-current manual therapies, prescriptive exercises, nutritional support, communication lines with your other doctors, and really spend the entire 5 weeks educating and training you in all the important factors and co-factors to best insure your recovery of function, and reduction in severity of your symptoms, some of my patients have reported up to 90% improvements, and rarely has a compliant patient ever reported less than 20% improvement during the initial period.

Its important to note, most patients have also reported a progressive worsening of their symptoms on the 4-5 years prior to coming under the care with this protocol.