Electrical Effects
Monday September 28, 2009
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Mueller’s recent focus has been to apply the physical stress theory to improve functional outcomes in diabetic peripheral neuropathies. “The idea is to provide the appropriate overload stress without injuring [the tissue]. You give them enough stress so that it positively influences them without too much stress that causes injury. The injury that we’re most interested in here is skin breakdown of the foot,” he says. “We are working with a group of people in a study right now that have shown considerable increases in their weight-bearing capacity following a progressive exercise program.”
However, Mueller stresses, the technique still is being investigated. “Readers should understand that the American Diabetes Association generally recommends non-weight bearing exercise for people with diabetes and neuropathy. Any kind of weight-bearing exercise program really needs to be done very carefully for this population.”
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Surgery, pain-relieving medications, and “just living with it” aren’t the only options for those dealing with peripheral nerve injuries. Physical therapy treatment can make a significant impact on decreasing symptoms and improving functional outcomes.
“Just because somebody comes in to a PT clinic with a neuropathy doesn’t mean that they’re doomed, that we are going to splint them and send them on their way. There are many [interventions] ... in many different clinical settings that have been effective for management of people with neuropathies,” says John E. Garzione, PT, DPT, DAAPM, president of the Pain Management Special Interest Group of the APTA Orthopedic Section. Garzione also owns Chenango Therapeutics, an orthopedic pain-management clinic in Norwich, N.Y.
What those interventions are depends largely on the cause and symptoms of the neuropathy. According to the National Institute of Neurological Disorders and Stroke, more than 100 types of peripheral neuropathies have been identified, including those of both genetic and acquired origins.
“Just because somebody comes in to a PT clinic with a neuropathy doesn’t mean that they’re doomed, that we are going to splint them and send them on their way. There are many [interventions] ... in many different clinical settings that have been effective for management of people with neuropathies,” says John E. Garzione, PT, DPT, DAAPM, president of the Pain Management Special Interest Group of the APTA Orthopedic Section. Garzione also owns Chenango Therapeutics, an orthopedic pain-management clinic in Norwich, N.Y.
What those interventions are depends largely on the cause and symptoms of the neuropathy. According to the National Institute of Neurological Disorders and Stroke, more than 100 types of peripheral neuropathies have been identified, including those of both genetic and acquired origins.
Compression Causes
Common causes of acquired peripheral neuropathies include physical trauma, repetitive stress leading to nerve entrapment, tumors, toxins, autoimmune responses, vascular and metabolic disorders, alcoholism, and nutritional deficiencies — particularly of vitamins E, B6, B12, niacin, and thiamine. There is some evidence that although decreased serum blood levels of B vitamins may be a contributing factor to sensory neuropathic symptoms, high intake of B vitamins, particularly vitamin B6, may have a neurotoxic effect.
Symptoms may include paresthesias such as numbness, pain, or tingling; muscle weakness; sensitivity to touch; and accompanying functional deficits such as lack of coordination or gait deficits.
When treating a person with a peripheral neuropathy, Garzione carefully considers the neuropathy’s origin: “Is it compression due to scar tissue? If it is and we can identify the point of compression, can we loosen the scar tissue? Can we protect the joints? Can we strengthen the muscles?” he asks.
Garzione feels it is critical to improve blood flow to the affected area. “In my mind, if you lose blood flow to a nerve, you’re going to get a neuropathy,” he says. “A nerve that is starved of blood will not be able to regenerate. If you can get blood flow to it, you might be able to cause regeneration.” With adequate blood supply, motor nerves typically regenerate at a rate of 1 mm/day, and sensory nerves 0.7 mm/day.
Common causes of acquired peripheral neuropathies include physical trauma, repetitive stress leading to nerve entrapment, tumors, toxins, autoimmune responses, vascular and metabolic disorders, alcoholism, and nutritional deficiencies — particularly of vitamins E, B6, B12, niacin, and thiamine. There is some evidence that although decreased serum blood levels of B vitamins may be a contributing factor to sensory neuropathic symptoms, high intake of B vitamins, particularly vitamin B6, may have a neurotoxic effect.
Symptoms may include paresthesias such as numbness, pain, or tingling; muscle weakness; sensitivity to touch; and accompanying functional deficits such as lack of coordination or gait deficits.
When treating a person with a peripheral neuropathy, Garzione carefully considers the neuropathy’s origin: “Is it compression due to scar tissue? If it is and we can identify the point of compression, can we loosen the scar tissue? Can we protect the joints? Can we strengthen the muscles?” he asks.
Garzione feels it is critical to improve blood flow to the affected area. “In my mind, if you lose blood flow to a nerve, you’re going to get a neuropathy,” he says. “A nerve that is starved of blood will not be able to regenerate. If you can get blood flow to it, you might be able to cause regeneration.” With adequate blood supply, motor nerves typically regenerate at a rate of 1 mm/day, and sensory nerves 0.7 mm/day.
Pain Reduction
Although some peripheral nerve injuries are not painful, many are. Getting control of that pain can make the difference in achieving functional gains, says Joe Kleinkort, PT, MA, PhD, CEAS, CEASII, CIE, a pain-management consultant in the Dallas/Ft. Worth area of Texas. “You need to cancel out the pain and the peripheral paresthesias first, and then you start adding the exercise and it works beautifully. If you try to make [patients] exercise over pain, a lot of people aren’t interested in that.”
Kleinkort uses 635-nanometer low-level laser therapy to alleviate pain in some peripheral neuropathies. “When you ‘lase’ the patient, you’ll get increased blood flow. You’ll get increased muscle function,” he says. “When you do these techniques, you can radically improve the paresthesias, which concomitantly improves the proprioception.”
For a patient with a painful peripheral neuropathy of non-compressive origin, Garzione says, a typical treatment session may include increasing blood flow by deep heat such as diathermy, with infrared lasers, or with “iontophoresis with mecholyl, which is a vasodilator which continues to open blood vessels for two hours after the treatment is done.”
That might be followed by “electrical stimulation, whether it be microcurrent stimulation for healing or muscle stimulation to get the muscle stronger by stimulating it,” Garzione says. “Then we start working with the person moving the part and start working on strengthening there as well.”
Once pain levels are under control, patients are able to work on regaining function.
Although some peripheral nerve injuries are not painful, many are. Getting control of that pain can make the difference in achieving functional gains, says Joe Kleinkort, PT, MA, PhD, CEAS, CEASII, CIE, a pain-management consultant in the Dallas/Ft. Worth area of Texas. “You need to cancel out the pain and the peripheral paresthesias first, and then you start adding the exercise and it works beautifully. If you try to make [patients] exercise over pain, a lot of people aren’t interested in that.”
Kleinkort uses 635-nanometer low-level laser therapy to alleviate pain in some peripheral neuropathies. “When you ‘lase’ the patient, you’ll get increased blood flow. You’ll get increased muscle function,” he says. “When you do these techniques, you can radically improve the paresthesias, which concomitantly improves the proprioception.”
For a patient with a painful peripheral neuropathy of non-compressive origin, Garzione says, a typical treatment session may include increasing blood flow by deep heat such as diathermy, with infrared lasers, or with “iontophoresis with mecholyl, which is a vasodilator which continues to open blood vessels for two hours after the treatment is done.”
That might be followed by “electrical stimulation, whether it be microcurrent stimulation for healing or muscle stimulation to get the muscle stronger by stimulating it,” Garzione says. “Then we start working with the person moving the part and start working on strengthening there as well.”
Once pain levels are under control, patients are able to work on regaining function.
Anne Federwisch is a medical writer forT oday in PT. To comment, e-mail pteditor@gannetthg.com.
Monday September 28, 2009