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• Peripheral neuropathies are discussed

DM-PNP Information

• 107 million North Americans are diabetic
• 70% of diabetics suffer from DM-PNP
• Peripheral neuropathy is the first cause of hospitalization in DM
• Every year 100,000 limbs are amputated
• Peripheral neuropathy symptoms include ulcers, shooting pain, sensitivity, lack of sensation, increased falls, trouble sleeping, and difficulty walking
• Infrared therapy treatments of 20 minutes daily can increase blood flow by 400%, increasing balance and decreasing pain

Diagnosis Cube

• Diagnosis of peripheral neuropathies involves laboratory, examination findings, signs and symptoms, associated findings, neurophysiological evaluation, and biopsy

Motor Nerve Symptoms

• Loss of function motor nerve symptoms include wasting, hypotonia, weakness, hyporeflexia, and orthopedic deformity
• Disturbed function motor nerve symptoms include fasciculations and cramps

Sensory Symptoms

• Loss of function sensory symptoms for large fiber sensory nerves involve decreased vibration, proprioception, hyporeflexia, and sensory ataxia
• Disordered function sensory symptoms for large fiber sensory nerves include paresthesias
• Loss of function sensory symptoms for small fiber sensory nerves involve pain and temperature
• Disordered function sensory symptoms for small fiber sensory nerves include dysesthesias and allodynia

Autonomic Nerve Symptoms

• Loss of function autonomic nerve symptoms involve decreased sweating, hypotension, urinary retention, impotence, and vascular color changes
• Disturbed function autonomic nerve symptoms include increased sweating and hypertension

Associated Findings

• It's important to check for deformities
• Check for family history
• Check for metabolic, systemic, vasculitic diseases, and intoxications

Sensory Network

• Two major sensory pathways exist: lemniscal and spinothalamic
• The lemniscal system includes mechanoreception and proprioception
• The spinothalamic system includes nociception, thermoreception and visceroception

PNP Examination

• Lemniscal senses (deep sensation) include position sensation, vibration, and Romberg
• Spinothalamic senses (Superficial sensation) include pain and temperature

Symptoms of Peripheral Neuropathy

• Motor dysfunction/loss includes weakness and atrophy
• Sensory loss includes loss of position, vibration, heat, and pain sensations
• Autonomic symptoms include flushing, dizziness, ulcerations, and bowel or bladder dysfunction
• DTR loss exists

Laboratory Investigations

• Laboratory investigations include CBC, fasting blood sugar, TFTS, ESR, CRP, uric acid, BUN, creatinine, B12 (methylmalonic acid, homocysteine), and folate

Laboratory Screening

• Laboratory screening for treatable neuropathies includes B12, DM, ANA, TSH, ESR, HIV, medications, LFN, SFN & LFN, connective tissue diseases, PNP in long course, malignancies, very painful PNP, and chemotherapy

Neurophysiological Procedures

• Stimulation (usually motor or sensory) is used to get a response from a muscle, and then amplified and captured as an EMG

Electrodiagnosis

• A high specificity and moderate sensitivity exist
• useful for screening of distribution and progression
• SEPs somato sensory evoked potentials, and nerve conduction studies are used
• Electromyography is useful for distinction of symptoms and progression of the disease

NCSs and SEPs

• NCSS is a check of the response from top to toe to ensure the whole pathway and peripheral cord are checked
• SEPs stimulate sensory nerve fibers and measure compound responses from the cortex

Motor-NCSS

• In cases of extreme involvement, one must reexamine and see the response got smaller in amplitude
• If segmental slowing exists, this can be highlighted by slowing of a response
• If there are polyradiculopathies all segments are involved

Sensory-NCSS

• It is important to evaluate the median sensory NCS and sural NCS

SEPs and Peripheral Nerves

• Some peripheral nerve responses are compared to SEPs in amplitude
• Occasional response is not enough

ENMG

• ENMG can fail; several options are available using experimental blocks and specific organs
• Special techniques are: QST, skin biopsy, QSART, Autonomic Tests, CHEPS, and LEPs.

Injury Site Clues

• Clues for finding the injury site involve what modalities are injured, which fibers are injured, & whether axon or myelin (or both) injured

Sensory Network Modality

• The Plan of the Nervous System with Motor, Sensory, & Autonomic markers shows sensory modalities

Theoretical Modality

• Only LMN injuries lead to SMA and radiculopathies
• Only Spth or Autonomic injuries cause SFN
• Only Lemniscal injuries cause LF-sensory PNP
• Lemniscal + LMN injuries cause LF- sensorimotor PNP
• Spth + Lemniscal injuries create a mixed type sensory PNP
• LMN+ Spth+ Lemniscal injuries result in sensory motor PNP

Fibers

• Thicker axons cause faster conduction velocity
• the thickest axons, more myelin sheaths

Classifications of Fibers by Diameter

• A alpha fibers conduct motor proprioception with a diameter of 1-20 microns, and a CV of 70-110 m/s
• A beta conduct fibers vibration proprioception with a diameter of 5-10 microns, and a CV of 30-60 m/s
• A gamma fibers conduct fusimotor spindles with a diameter of 3-6 microns, and a CV of 20-30 m/s
• A delta fibers conduct sharp pain with a diameter of 2-5 microns, and a CV of 20-30 m/s
• B fibers conduct autonomic-preganglionic signals with a diameter of <3 microns, and a CV of 5-15 m/s
• C fibers conduct slow pain heat with a diameter of <1.3 microns, and a CV of 0.5-2 m/s

Theoretical Classes of Fibers

• C, BC, Ay fibres indicate SFN can exist
• Αβ- LF sensory N is present
• αΜΝ + Αβ- LF sensorymotor N is present
• C, BC, Ay and Aß fibres indicate sensory neuropathy covering all modalities
• ENMG helps determine affectation of axon, myelin or both

Normal Motor Units

• The motor unit is normal, and the Green motor unit is intact versus the Red motor unit

Axonal Degeneration

• Axonal degeneration occurs when axons atrophy in muscles

Reinnervation

• Reinnervation only occurs in Axonal polyneuropathic stage when atrophic muscles are supported by new muscle fibers

Segmental Demyelination

• Occurs with loss of myelin sheath, no atrophy, delayed response, and Polyneuropathy.

Mechanisms of Damage Include

• Demyelination, is disrupted in GBS-Post Diphteric-HSMN and hereditary Sensory Neuropathy
• Axonal degeneration and Axon damage from toxic neuropathies
• Wallerian degeneration and Nerve destruction
• Compression occurs via compression, such as CTS.
• Infaction/arteritis and Infitration/Obstruction exist.

ENMG Determinant

• ENMG can identify if axon, myelin, or both are damaged
• Axonal issues leads to low amplitude; with IN Axan seraphy, damage results in damage
• Demyelinating have disperian prespansmal inalital and slower responses

NCS and EMG

• NCSs test CMAPs
• EMG tests for denervation and reinnervation

Key Demyelination Signs

• Key signs are Hypertrophic nerves, areflexia, weakness, no wasting, Proximal CMAPs, distal motor lat ↑, Conduction block.

Assessment

• There are 6 "D" questions: distribution, duration, deficits, disease pathology, developmental pathology and drug/toxin exposure
• Is there an inherited (developmental) neuropathy?
• If there is a drug/toxin exposure identified ask if if the person takes one or more.

Deficit Distribution

• Asymmetry suggests Mononeuropathy of the carpal tunelsyndran type or the Mononeuritis multiplex of vessels
• Symmetric (glove/stocking) suggests a polyneuropathy Palsyindiabers situation.

Acute or Chronic Symptoms

• Many neuropathies become chronic over months or years
• Some neuropathies become acute over four to eight weeks due to the Guillain Barre syndrome
• The question about relapses and emissions regards the diabetic paly neuropathy related to intermittent toxin exposure

Predominant Deficits

• It its a Motor deficit: Guillain Barre syndrome, Lead toxicity, and Charcot-Marie-Tooth disease must be considered.
• If its a Sensory Puredeficit Carcinoma (paraneoplastic) or Vitamin B6 toxicity exists as potential causes

Autonomic Deficits

• Autonomic deficits are caused by:
  • Diabetes, Amyloid, Drugs like vincristine and other chemicals

Pathologies

• Axonal problems are the vast majority of the problems that exist
• Demyelination cases happen mostly in few amounts, it is hereditary
• Exclude many cases of chronic conditions like hypothyroidism, uremia and so on.

Inherited?

• The following are clues for inherited peripheral neuropathies
  • Bone deformities, long duration, indolent progression, few" positive" symptoms, examine Family members.

Lesion Questions

• The first 2 clinical neurology questions are: where is the lesion? and what is the etiology?
• Blocks to the peripheral nervous system occurs, such as in Peripheral Neuropathies, but it can be hard to get consistent readings from them

Dorsal Root Problems

• Asymmetrical sensory loss in one extremity involving more than 2 nerves involving different sections, it is likely something close to the spine
• "Between a spine and dorsal root is the sensory response"

Anterior Root Problems

• An asymetrical motor loss of one or more extremities may point to this type lesion

Peripheral Neural Problems

• It may indicate asymmetrical distribution in certain plexopathy such as an upper trunk problem; where as:
• Tumors may be on the lesion and near motors, and the demyelinating process could occupy lesion of tamarea

Neuropathies

• This is more likely in one extremity and nerve E.g., Carpal Tunnel sundrome, etc

Multiple Problems

• Indicates many problems with 2 and over extremes.

6- What are different Types of Length Dependant PNP?

• These usually involve a motor or sensory loss
• Contagious may include diabeties,sytemic diseases. Also can come from drugs or infections.

7- What are different types of Peripheral neuropathy-CIDP?

• Symmetrical Motor and sensery deficets
• Proximal weakness and motor fiber problem are main problem.

8- What does MADSAM neuropatiey type?

• Asymmetrical S&M
• Dmyelination.

9- What is differet Features about neuropatiey MfMN?

• Asymmetrical motor problems
• Is mainy hands and wrisrs are affected area are involved
• Ulna nervs and hands are affected areas

10: What features are neuropaties of MND

• Asymmetrical M
• Axonal area effected with drops with spilt hands and wrist area.

11- How Can treat nuropaties problems?

• Look for Diabeties with Vitamin B12 deficiency, look kidney problems with kidney diseases.
• Treat like Ankle to feet and weight reduction
• Presciba Tramodal and antidepressant for paitn reliever.