Peripheral Neuropathy

Three types of Neuropathies that DO NOT deal with Diabetic Peripheral Neuropathy include...

1. Inherited 2. Acquired 3. Systemic Diseases

5.07 Monofilament

10 g of force and is indicitive of protective sensation loss

Cold hard facts:

23.6 Million children/adults have diabetes. 50% of those are affected by peripheral neuropathy.

Common pharmacotherapies for DPN or PHN

Anticonvulsants Antidepressants (Tricyclic/SNRI) Opiod analgesic Dermal and topical treatments

What is Alpha-Lipoic Acid? Used to slow progression.

Antioxidant nutritional supplement with claims to reduce pain.

Alternative therapies for PN

Herbals Infared Therapy (Anodyne increases microcirculation to nerves) Electric Stimulatory Physical Therapy Acupuncture Magnetic insoles Spinal Stimulator

What tests can you run for DPN

Blood tests to diagnose Diabetes M. and to rule out reversible causes EMG (Electromyography) Nerve/Skin biopsy Lumbar MRI to rule out radiculopathy

Patient would describe what type of pain when dealing with Small Fiber DSP.

Burning prickling stabbing jabbing tight pressure.

Inherited peripheral neuropathy

Charcot-marie tooth

Systemic Diseases peripheral neuropathy

DM Liver D Hypothyroid Vitamin Deficincies Alcohal Vascular (Tumor) HIV CRPS

Patient would describe what type of pain when dealing with Large Fiber DSP.

Deep-seated gnawing, dull, crushing, cramp like.

Motor symptoms of DPN

Deformity Difficulty walking

Lower Extremity Neurological Exam DPN: What happens to: Vibratory Percetion Reflexes Protective Sensation Proprioception

Diminished vibration Decreased reflexes loss of protective sensation loss proprioception

Autonomic

Dry Cracked skin

Electrophysiology detects Small fiber nerve damage. (T/F)

False. EP may not detect nerve damage.

Large Fiber (DSP)

Fibers (A-alpha/Beta) Sensory and motor nerves Feet affected first Loss vibration and proprioception Muscle wasting (hammertoes)

Small fiber (DSP)

Fibers (A-delta and C) Pain/hyperalgesia (heightened sense) FIRST Loss of sensitivity LATER Autonomic symptoms Predisposition to Diabetic foot disease

Loss of Motor Nerves can result in deformities..

Hammertoes

Vascualar Mechanism for neuropathy

Ischemia to nerve fiber; demyelination.

Topical treatments for DPN include

Lidocaine patch (inhibits Na) Capsaicin (substance P) Limited in patients with allodynia or hyperalgesia. (Skin sensitive)

Oral Medications for PN

NSAIDs [Naproxen (Naprozen), Ibuprofen (Advil), Celecoxib (Celebrex)] Tri-cyclic Antidepressants (Amitriptyline) Gabapentin (Calcium Channel Blocker) Pregabalin (Calcium Channel Blocker) Duloxetine (SNRI) Non-narcotic analgesics Opiates [Vicovan (Hydro+Aceta), Noroco (H+A), Lortab (H+A), Darvocet (Prop+A), Percoet (Oxy+A), Percodan, (O+Asp)]

What is Peripheral Neuropathy

Nerve damage in the hands or feet.

When you cut a nerve what is formed...

Neuroma

PHN (Postherpetic neuralgia)

Neuropathy mostly associated with shingles. Adult chickpeapock associated with herpes complex.

Nociceptive vs. Neuropathic Pain.

Nociceptive arises from stimulus outside of nervous system while Neuropathic pain arises from a primary lesion or dysfunction in nervous system.

What causes the damage in DPN

Not known. Nerve damage thought to be due to combination of hyperglycemia (high blood sugar) and ischemia (reduced blood flow)

Sensory symptoms of DPN

Numbness (progressively worse) Pain (progressively better)

DPN clinical manifestation will include...

Numbness, prickling, tingling, and pain. They may also include diminished vibration perception, ankle reflexes, and nerve conduction velocity measurements. Eventually, these vascular and neural deficits can lead to ulcer formation.

Why would PN and diabetic foot ulcers go hand-in-hand?

PN (Peripheral Neuropathy) is major contributor to DFU (Diabetic foot ulcers) because PATIENT CANT FEEL THE ULCER. 85% of lower limb amputations with diabetes are proceeded by ulceration.

Diabetic peripheral neuropathy refers to

Peripheral Neuropathy caused by Diabetes type I or type II

Biomechanical mechanism for neuropathy

Peripheral nerves cross areas of anatomical narrowing.

Some complaints of DPN involve pain...

Pins needles Burning Sharp Gnawing Dull Cramping

Describe Distal Symmetric Polyneuropathy (DSP)

Result of sensory nerve damage. Sock/glove distribution very common. Painful sensations are initially localized to the toes but may spread to the legs and even the hands and arms LARGE AND SMALL FIBERS CAN BE AFFECTED

How to treat pain for DPN

Topicals Oral Therapies Surgical Intervention

Acquired peripheral neuropathy

Trauma (compress nerve)

How does one slow the progression of DPN

Treat the underlying condition. -Treat Tight, Glucose filled blood vessels with diet exercise and medication. -Treat Vitamin deficiencies with B12 injections; Supplements. Limit Alcohol Quit Smoking

Decompression procedures can relieve pain and improve sensibility in properly selected patients.

True

Diabetic peripheral neuropathy is the leading cause of peripheral neuropathy and neuropathic pain (T/F)

True

The most important criteria for a successful out come is the presence of Tinel's sign at a know area of entrapment.

True

Electrophysiology detects Large fiber nerve damage. (T/F)

True. It is readily detected by electromyography

Due to numbness in DPN increase risk of what two things arise

Ulceration/Amputation

Tinel's Sign

Way to detect irritated nerves. It is performed by lightly tapping (percussing) over the nerve to elicit a sensation of tingling or "pins and needles" in the distribution of the nerve.

Can DPN affect all 3 nerve types? Name the ones it can affect.

Yes. Sensory-touch, pain, temp Motor-Control muscles Autonomic - involuntary functions (sweating and digestion)

Metabolic Mechanism for neuropathy

increase sorbitol causes damage nerve conduction. Osmotic gradient leads to nerve swelling.

What is Metanx? Used to slow progression.

medical food marketed for the nutritional support of diabetic neuropathy. Active forms of Folate, B6, B12