Rehab
PERIPHERAL NEUROPATHIES
Maria Luisa P. Santos-Carpio, MD
- Injury to the nerve
o myelin destroyed = demyelination
o axon destroyed = axonopathy
- 2 major categories
- Can be localized or generalized
- Can be traumatic in origin secondary to compression,
traction or transection
- Can be caused by toxic or metabolic derangements
2 General Classification of Nerve Injury
- Seddon
 Considers neural injury from the perspective of
a combination of functional status and
histologic appearance
- Sunderland
 Based on the results of trauma with respect to the
axon and its supporting connective tissue
structures
Seddon’s Classification
- Neuropraxia
 Mild neural insult that results in blockage of
impulse conduction across the affected segment
= example compression injury
 Reversible hence no muscle wasting
- Axonotmesis
 Only axon is physically disrupted with preservation
of the enveloping endoneural and other
supporting structures (perineurium & epineurium)
 Good prognosis = axon can regenerate up to
1mm/day
- Neurotmesis
 Complete disruption of the axon and all
supporting connective tissue structures
 Poor prognosis
Sunderland’s Classification
Type 1: same as Seddon’s neuropraxia
Type 2: Axonotmesis with preservation of all supporting
structures
Type 3: Loss of axonal continuity & endoneurial tubes (recovery is
possible but surgical intervention may be required)
Type 4: loss of axonal continuity, endoneurium & perineurium,
epineurium is intact (surgical repair is required)
Type 5: complete transaction or severance of entire nerve
Etiologies of Neuropathies
- Hereditary disorders (Charcot-marie)
- Toxic disorders (Amiodarone, Dapsone)
- Systemic disorders (Diabetes mellitus)
- Entrapment disorders (Carpal tunnel syndrome)
- Idiopathic disorders (Branchial plexitis)
- Nutritional disorders (Beriberi)
- Infectious processes (Leprosy, herpes zoster)
Evaluation of patient with Neuropathy
History
- Is the onset sudden or gradual
- Is the progression rapid or slow
- Is the predominant manifestation sensory, motor or both
- Is the distribution focal or generalized, distal or proximal,
symmetric or asymmetric
- Is there autonomic involvement
- Does patient have any associated diseases
Physical Examination
- Sensory exam
 Light touch, pinprick, proprioception,
vibration & cold temperature
- Motor exam
 Muscle strength graded by functional tests of
multiple muscles and muscle groups
Grade 1: movement of muscle can only be felt not
seen
Grade 2: can move without gravity
Grade 3: can move with gravity
Grade 4: can move with moderate resistance
Grade 5: can move with full resistance
- Reflex testing
 Often decreased or absent distally in
generalized peripheral neuropathy
- Test the reflexes at the biceps,
triceps, brachioradialis, ankle
and knee
 Brisk reflexes (or hyperreflexia) suggest a
CNS process is present rather than a
peripheral nerve problem
Electrodiagnostic examination
- Nerve conduction study
 Determines the conduction velocity of the nerve
as well as the amplitude of the resulting action
potential
- Electromyography
 Records the summated activity of the muscle
fibers controlled by individual anterior horn cells
 needle is inserted to record the muscle
activity
Common Complications of Neuropathies
- Muscle weakness
- Sensory loss
- Autonomic dysfunction
- Pain
Muscle weakness
- Associated with joint contractures & muscle shortening
- Daily ROM & stretching ex
- Avoid overworking as this results in paradoxical weakening
(overwork weakness)
Sensory loss
- Daily exam of hypoesthetic or anesthetic areas
- Feet most commonly & most severely affected in peripheral
neuropathy
- Custom-molded shoe inserts or shoes to evenly distribute
pressure forces
- Hygiene, moisturizing to prevent fissuring & scaling as well as
temperature testing to prevent scalding
Autonomic dysfunction
- Most commonly associated with DM & GBS
- CVS sx: orthostatic intolerance or cardiac arrhythmias
- GU sx: flaccid bladder & male impotence
- GI sx: vomiting, dysphagia, diarrhea & constipation
 - Sweating abnormalities
- May be life threatening
Pain
- Common but difficult problem to treat
- Reduction of pain rather than elimination is the goal in most
cases
- Gabapentin, Carbamazepine work best for prickling and
tingling sensations
- Tricyclic antidepressants (amitryptiline)
nd
 2 line of treatment
 Works best on aching, burning type of pain
- NSAIDS, paracetamol also has a role as well as topical
capsaicin & transdermal lidocaine
Mononeuropathy
- A disorder of a single nerve or nerve trunk
- May be due to entrapment, compression, stretch injury,
ischemia, infection or inflammation of a nerve
Most common mononeuropathies
- Carpal Tunnel syndrome
- Cubital Tunnel syndrome
- Radial neuropathy at the spiral groove (Saturday night palsy
or Honeymoon palsy)
o Saturday night palsy: after alcohol intoxication, the
person usually rest the head over the arm for
several hours and by time he wake up, his arm is
very difficult to move
o Honeymoon palsy: as the name implies it
happens after the honeymoon where the
woman rest her head to the husband’s arm
overnight and symptoms are experienced
usually in the morning
- Posterior interosseous neuropathy
- Long thoracic neuropathy
- Spinal accessory neuropathy = results to winged of the
scapula
- Peroneal entrapment neuropathy
- Meralgia paresthetica (lateral femoral cutaneous
neuropathy) = due to the dermatomal distribution of the
nerves; know the dermatome
- Tarsal tunnel syndrome (tibial neuropathy)
- Brachial plexopathy
- Lumbosacral plexopathy
Carpal Tunnel Syndrome
- Median nerve, flexor pollicis longus tendon, 4 tendons
from flexor digitorum superficialis and profundus
muscles
- Swelling or increased pressure inside carpal tunnel = CTS
st
- Paresthesias of the 1 3 ½ digits, deep aching pain in the
hand and wrist
- (+) flick sign = shaking of hands produce pain
- In advanced cases, sensory symptoms become
persistent & thenar weakness develops
- More common in women, occurs bilaterally in 50% of cases
- PE: weakness & atrophy of abductor pollicis brevis &
opponens pollicis muscles
- Provocative tests: Tinel’s (use reflex hammer) & Phalen’s
- Electrodiagnostics findings
- Treatment: anti inflammatory meds, wrist splints, ROM ex
of wrist & UE
- Surgery is done in severe cases
Cubital Tunnel Syndrome
nd
- 2 most common entrapment neuropathy
- Ulnar neuropathy at the elbow
- Ulnar nerve enters between medial epicondyle & olecranon
& beneath the humeroulnar aponeurotic arcade
- Potential sites of entrapment: ulnar groove just proximal to
the epicondyle, humero ulnar aponeurotic arcade and exit
site from deep flexor pronator aponeurosis
th th
- Paresthesias of the 4 & 5 digits and ulnar aspect of the
dorsum of the hand
- Weakness and muscle atrophy of the intrinsic hand muscles
- Flexor carpi ulnaris & flexor digitorum profundus to digits 4 &
5 are involved in severe cases
o Tinel’s sign at the elbow
- Reproduction of symptoms with elbow flexion or ulnar
groove compression
- Potential causes: routinely resting elbow on hard surface,
trauma, ligamentous thickening, soft tissue calcification,
ganglion cyst
- Conservative mgt: splint at night in mild flexion, elbow pad,
anti inflammatory meds
- Severe weakness or failure of conservative mgt in 3-6 mos =
surgery to decompress nerve, or do transposition of nerve
anterior to the medial epicondyle or medial epicondylectomy
Peroneal Entrapment neuropathy
- Most common lower limb compressive neuropathy
- Occurs most frequently at the fibular head
- Presents with partial or complete foot drop and sensory loss
involving the dorsum of the foot and lower lateral leg
- Conservative tx consists of decreasing aggravating activities
like prolonged squatting, eliminating ext compressive source
like brace or case, kneepads at the fibular head and neck
- AFO for those with foot drop, ankle ROM
Polyneuropathy
- A neurological disorder that occurs when many
peripheral nerves throughout the body malfunction
simultaneously
- Can be acute and appear without warning, or chronic
and develop gradually over a longer period of time
- May have both motor and sensory involvement and
some have autonomic dysfunction
- Often symmetric and frequently involve distal
extremities
Most common polyneuropathies
- Diabetic neuropathy
- Acute inflammatory demyelinating polyradiculopathy (GBS)
- HIV neuropathy
- Hereditary symmetric distal polyneuropathies (Charcot-
Marie-Tooth disease)
- Mononeuritis multiplex
- Ischemic monomelic neuropathy
Diabetic polyneuropathy
- Symmetric, sensory and located distally
- Burning, itching, pins & needles sensation
- Complain of muscle cramping or tightness at night
- PE: abn in light touch & vibration with
preservation of proprioception
- Fingers & hand become involve in a typical stocking
& glove distribution
 - Weakness presents later in the course and starts distally
and progresses proximally
- May present with foot slap, ataxic gait due to
weakness of ankle musculature
- Mgt includes daily inspection, moisturizing cream,
prevention of ingrown nails, proper footwear, avoid use of
heat on affected limbs and avoidance of foot trauma

Gullain Barre Syndrome

- Acute inflammatory demyelinating
polyradiculopathy
- Due to increased concentration of protein, but not
cells, in the CSF
- Symmetric, usually affects lower ext initially with
paresthesias followed by weakness which begins distally
and then ascends proximally
- Weakness progresses over days to about 4 weeks and can
produce total body paresis, including muscles of
respiration in severe cases
- Often follows a viral or bacterial infection,
immunization or surgery
- Diagnostic criteria: areflexia, acquired progressive weakness
in all ext
- Monitoring of pulmonary and cv systems are
important
- Complications of immobility to be considered
- Plasmapheresis or high dose IVIg effective in
shortening the course of attack
- Overwork weakness is avoided during rehab
sessions

Take home message:

- Neuropathy is a common diagnosis with many causes
and varied prognoses
- Diagnose accurately to treat neuropathy
appropriately
- Rehabilitation treatment in patients with neuropathy
can significantly improve the quality of life

--END--