INTRODUCTION

Peripheral neuropathy is the term for damage to nerves of the peripheral nervous system, which may be caused either by diseases or trauma to the nerve or the side-effects of systemic illness, which leads to symptoms such as pain, numbness, tingling, burning, and weakness most commonly affecting the hands and feet.

PERIPHERAL NERVOUS SYSTEM

TYPES OF PERIPHERAL NERVES: y Motor y Sensory y Autonomic MOTOR NERVES which carry messages from the brain to the body and are responsible for the ability to move any part of the body (e.g., hands, feet)

PERIPHERAL NERVOUS SYSTEM

SENSORY NERVES which carry information from organs to the central nervous system where it is processed into sensation (e.g., touch, temperature changes, and vibrations) nerves that control AUTONOMIC (involuntary) functions including heart rate, blood pressure, breathing, digestion, and bladder function

PATTERNS OF PERIPHERAL NEUROPATHY

Polyneuropathy mononeuropathy mononeuritis multiplex autonomic neuropathy

POLYNEUROPATHY
many nerve cells in different parts of the body are affected, without regard to the nerve through which they pass the axons are affected Diabetic neuropathy is the most common cause of this pattern. In demyelinating polyneuropathies, the myelin sheath around axons is damaged, which affects the ability of the axons to conduct electrical impulses

MONONEUROPATHY
a type of neuropathy that only affects a single nerve most common cause is by physical compression of the nerve, known as compression neuropathy inflammation can also cause

MONONEURITIS MULTIPLEX
sequential involvement of individual noncontiguous nerve trunks, either partially or completely The pattern of involvement is asymmetric

AUTONOMIC NEUROPATHY

is a form of Polyneuropathy which affects the non-voluntary, nonsensory nervous system (i.e., the autonomic nervous system) affecting mostly the internal organs such as the bladder muscles, the cardiovascular system, the digestive tract, and the genital organs.

TYPES

Idiopathic Pre-diabetic/Diabetic
y Pre-diabetic y Diabetic

Hereditary
y Charcot-Marie-Tooth Disease y Hereditary Neuropathy with Liability to Pressure

Palsies (HNPP)

Toxic / Secondary to drugs

y Toxins y Secondary to Drugs y Alcohol

TYPES
Inflammatory Infectious (with a specific casual agent identified) Lyme disease HIV / AIDS Leprosy Herpes Zoster (Shingles) Hepatitis B & C

TYPES
y Autoimmune or possibly infectious (but with no

specific causal infectious agent identified) Sarcoidosis Guillain-Barr Syndrome / Acute Inflammatory Demyelinating Polyneuropathy (AIDP) Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) Vasculitis Polyarteritis Nodosa (PAN)

TYPES

Autoimmune or possibly infectious (but with no specific causal infectious agent identified) Rheumatoid Arthritis Systemic Lupus Erythematosus (Lupus) Celiac Disease Cryoglobulinemia POEMS

TYPES

Systemic / Metabolic y Pre-diabetic y Diabetic y Alcohol y Nutritional / Vitamin deficiency y Kidney Failure

TYPES
Compression y Carpal Tunnel Syndrome y Tarsal tunnel syndrome y Thoracic outlet syndrome Other Types of Peripheral Neuropathy y Bell's Palsy y Radial nerve palsy (wrist drop) y Ulnar nerve palsy y Median nerve palsy

IDIOPATHIC NEUROPATHY
unknown cause occurs in people over 60 years old progresses slowly

SIGNS AND SYMPTOM

Numbness, tingling and pain Unsteady when standing, walking Muscle weakness (including weak ankles) or cramps

PRE-DIABETES NEUROPATHY
"pre-diabetes" or "borderline diabetes"a condition where the body has higher than normal blood sugar levels, but not high enough to be diagnosed as true diabetes. SIGNS AND SYMPTOM y Frequent urination y Blurred vision y Constant thirst y Fatigue y Frequent infections y Cuts and bruises that heal slowly y Tingling or numbness in the hands or feet

DIABETIC NEUROPATH

complications associated with diabetes with nearly 60 percent of diabetics having some form of nerve damage The first sign of diabetic neuropathy is usually numbness, tingling or pain in the feet, legs or hands. Over a period of several years, the neuropathy may lead to muscle weakness in the feet and a loss of reflexes, especially around the ankle As the nerve damage increases, the loss of sensation in the feet can reduce a person's ability to detect temperature or to notice pain

DIABETIC NEUROPATH
SIGNS AND SYMPTOM y Numbness, tingling, or pain in the toes, feet, legs, hands, arms, and fingers y Indigestion, nausea, or vomiting y Diarrhoea or constipation y Dizziness or faintness due to a drop in blood pressure especially when rising to a standing position y Problems with urination y Erectile dysfunction (impotence) or vaginal dryness

Charcot-Marie-Tooth Disease (CMT) (Hereditary Neuropathies)

group of inherited neurological disorders characterized by a slowly progressive degeneration of the muscles in the foot, lower leg, hand, and forearm, and a mild loss of sensation in the limbs, fingers, and toes. start between mid-childhood and early adulthood The first signs are usually foot abnormalities, such as an unusually high arch or flexed ("hammer") toes Sprained ankles and fractures of the ankles and lower legs are common.

CHARCOT-MARIE-TOOTH DISEASE
As the disease progresses, muscle weakness and wasting leads to difficulties with walking, running and balance. If the hands are affected, daily activities such as turning doorknobs, fastening buttons, or writing can become difficult

TYPES y Type 1: affect only the myelin sheath y Type 2: affect nerve fiber (axon) itself y Type 3: peripheral nerve become enlarged or thickened

SIGNS AND SYMPTOMS

Symptoms range in patients from very mild to severe weakness; clinical symptoms generally occur by age 30. The more severe symptoms are related to an earlier age of onset. CMT can progress to extreme weakness, atrophy, and loss of sensation, over time. Foot drop (foot can't be picked up or held horizontal) Progressive deformity of leg ("inverted champagne bottle") or foot (abnormally high arched feet, flat feet, hammer toes) Decreased sensation or numbness in the foot or leg Awkward gait and balance Poor hand coordination

Hereditary Neuropathy with Liability to Pressure Palsies (HNPP)

mild pressure or trauma to a single nerve results in episodes or periods of numbness and weakness, similar to an arm or leg going to sleep progressive hereditary disorder The most common sites are the wrists, in conjunction with carpal tunnel syndrome, the elbows, and the knees. There is no treatment other than symptomatic measures and avoiding positions that can create pressure such as leaning on elbows, crossing legs or ankles, or sitting for too long without changing position.

SIGNS AND SYMPTOMS

Weaknessunable to move an entire limb Unable to use certain muscles of the arm (can't reach, wash hair, eat) or hand (difficulty gripping things or grasping small objects) or face Episodes of numbness, weakness or tingling that do not go away Leg/ankle foot swelling Fatigue Muscle cramps Diminished or absent ankle reflexes

TOXINS
can happen through drug or chemical abuse or through exposure to industrial chemicals in the workplace or in the environment (lead, mercury, arsenic and thalium. Some organic insecticides and solvents Certain herbal medicines, especially Chinese herbal medicines, are particularly rich in mercury and arsenic and taking them can lead to peripheral neuropathy SIGNS AND SYMPTOMS

y Pain, tingling, numbness in feet y Weakness y Difficulty in walking

SECONDARY TO DRUGS
side effect of certain medications, especially those used to treat HIV/AIDS and those used in chemotherapy, to fight cancer. Some of the drugs that may cause peripheral neuropathy include: Anti-alcohol drugs

Disulfiram

Anticonvulsants
Phenytoin (Dilantin)

Cancer medications
Cisplatin Vincristine

SECONDARY TO DRUGS
Heart or blood pressure medications Amiodarone Hydralazine Perhexiline Infection fighting drugs Metronidazole (Flagyl) Nitrofurantoin Thalidomide INH (Isoniazid) Skin condition treatment drugs Dapsone

ALCOHOLIC NEUROPATHY
Alcohol can have a toxic effect on nerve tissue may feel burning and tingling sensations in their feet, which may persist or may last from a few months to a few years Damage to nerve usually permanent Chronic alcoholism is often associated with malnutrition and nutritional and vitamin deficiencies, including B12, B1 (thiamin), folate and other B vitamins. It may be hard to distinguish nutrition-related neuropathies from alcoholic neuropathy

SIGNS AND SYMPTOMS

Abnormal sensations
y Pain
Feels like "pins and needles"

y y y y

Numbness Muscle weakness, cramps, or aches Muscle spasms / contractions Tingling

Constipation Diarrhea Incontinence (leaking urine) or difficulty with urination Impotence in men Nausea / vomiting

LYME DISEASE

inflammatory disease that rapidly progresses SIGNS AND SYMPTOM

Lyme disease progresses in three stages of severity: First Stage:

y y y y y y

Fatigue Fever and chills Muscle and joint pain Red circular rash Stiff neck Swollen lymph nodes

LYME DISEASE
Second

Stage:

y Facial paralysis (Bell's palsy) y Irregular heartbeat y Meningitis (fever, stiff neck, severe

headaches) y Numbness and pain in arms and legs y Stiff neck y Poor coordination

LYME DISEASE

Third Stage:
y Chronic arthritis and swelling in large joints, y y y y

especially the knees Chronic pain in muscles Problems with sleeping Numbness and pain in arms and legs Nervous system problems
Difficulty concentrating Memory loss

y Numbness and tingling y Peripheral neuropathy

Pain, numbness and tingling in limbs Paralysis of facial muscles (Bell's palsy)

HIV / AIDS
peripheral neuropathy can by caused by the virus itself, by certain drugs used in the treatment of HIV/AIDS SIGNS AND SYMPTOMS burning, stiffness, prickling, tingling, and numbness or a loss of feeling in the toes and soles of the feet

LEPROSY
damage caused by leprosy may result in sensory loss, particularly in the hands and feet. SIGNS AND SYMPTOMS Muscle weakness Numbness, pain or tingling in feet or hands Skin lesions

HERPES ZOSTER
infection caused by the same virus that causes chickenpox develops when the virus become active again SIGNS AND SYMPTOM There may not be specific symptoms, but the most likely symptoms include: Itchy skin Pain on the skin Rash or blisters on one side of the body, usually in a belt-like pattern

HEPATITIS B & C
Hepatitis B virus can cause liver infection. The virus, transmitted through blood and bodily fluids that contain blood, attacks liver cells These chronic sufferers of hepatitis B may also develop peripheral neuropathy SIGNS AND SYMPTOM

For peripheral neuropathy:

y Numbness, pain, tingling in hands or feet

For hepatitis B:
y y y y y y y

Abdominal pain near the liver Fatigue lasting for weeks or months Fever Jaundice Joint pain Loss of appetite Nausea

Sarcoidosis

is a chronic inflammatory disease that usually involves the lungs, but may affect any organ in the body. It is characterized by granulomasabnormal collections of inflamed cells, tissue and blood vesselsthat appear in the affected organs may affect the nervous system and cause neurological problems, including peripheral neuropathy. It might be the result of a disorder of the immune system, caused by a virus, or be due to exposure to an unknown substance in the environment

Arthritis or myositis (an inflammatory muscle disease) Blurred vision Enlarged and tender lymph glands, especially in the chest Fatigue Fever, night sweats Lung problems, such as shortness of breath, dry cough or chest pain Painful, swollen ankles Red or teary eyes Skin problems, such as a tender red or purple raised skin rash. Weakness Weight loss Numbness Pain Tingling

GUILLAIN-BARR SYNDROME / ACUTE INFLAMMATORY DEMYELINATING POLYNEUROPATHY (AIDP)

rare inflammatory disorder in which the body's immune system attacks the protective covering of the peripheral nerves (myelin sheath), preventing the nerves from sending signals to the muscles The first symptoms of GBS usually include varying degrees of weakness or tingling sensations in the legs. In many instances, the weakness and abnormal sensations ascend and spread to the arms and upper body. In extreme cases, the patient has difficulty breathing and must be placed on a ventilator.

GBS

GBS improves spontaneously, but the recovery period may take from several weeks to more than a year. Most patients make a total recovery, from even the most severe cases of GBS, although some continue to have a certain degree of weakness, numbness or occasional pain. GBS can strike anyone, regardless of age or sex it may follow a bacterial or viral infection, such as campylobacterial infection (caused by a bacteria found in undercooked food, especially poultry) or Epstein-Barr virus (EBV).

SIGNS AND SYMPTOMS

ONSET y 50 - 60% of cases occur days or weeks after a viral or bacterial infection, such as a sore throat, the flu, or diarrhea. y Surgery, childbirth or vaccinations may also trigger the syndrome Pain in spine and limbs Reflexes such as knee jerks are lost Weakness and tingling sensation in legs, possibly spreading to upper body and arms Weakness in breathing, swallowing and the muscles used to cough In extreme cases, paralysis Full recovery (even from extreme cases) probable for most patients

CHRONIC INFLAMMATORY DEMYELINATING POLYNEUROPATHY (CIDP)

Chronic inflammatory demyelinating polyneuropathy (CIDP) is a neurological disorder characterized by slowly progressive weakness and a loss of sensation in the legs and arms. more common in young adults it affects men more than women SIGNS AND SYMPTOM: y Fatigue y Loss of reflexes y Tingling y Numbness y Pain y Weakness y Paralysis

VASCULITIS

Vasculitis is an inflammation of the blood vessel (includes the veins, arteries, and capillaries) Vasculitis may affect blood vessels of any type, size, or location, and therefore can cause dysfunction in any organ system, including the central and peripheral nervous system Vasculitis can be caused by infection of the blood vessel walls or an immune or "allergic" reaction in the vessel wall The second cause of vasculitis, an immune reaction

SIGNS AND SYMPTOMS

Anemia Fatigue Fever Muscle pain, numbness or tingling Night sweats Pain when chewing Severe headaches Stiffness Tenderness in the temple area Weight loss Vision loss

SIGNS AND SYMPTOMS

Red or purple rash on skin, usually on the legs Aching in joints, and arthritis with pain, swelling, and heat in joints Headaches, behavioural disturbances, confusion, seizures, and strokes Peripheral nerve symptoms, including numbness and tingling Inadequate blood flow in the intestines causing abdominal pain and bloating Feeling of heaviness in the chest

POLYARTERITIS NODOSA (PAN)

Polyarteritis nodosa (PAN) is a type of vasculitis (inflammation of the blood vessels) It occurs when the small and medium-sized arteries in your body become inflamed This inflammation damages the walls of these arteries and reduces their ability to carry blood to nearby tissues and organs. Without the blood they require, the tissues and organs become injured and may cease to function properly most commonly affects the tissues associated with the peripheral nerves, kidneys and abdominal organs also can affect the skin, heart, joints, muscles, eyes and reproductive organs

SIGNS AND SYMPTOMS

ONSET y Fever y Sweating y Weight loss y Weakness y Malaise y Abdominal pain Nervous system: y Decreased alertness y Peripheral neuropathy y Muscle pain, numbness or tingling y Seizures y Slurred speech

SIGNS AND SYMPTOMS

Kidney failure Renal hypertension Nodules and rashes in skin Chest pain Congested heart failure Heart attack Pain in pelvic Pain in testicles

RHEUMATOID ARTHRITIS

Rheumatoid arthritis is an autoimmune disorder that is characterized by inflammation, pain, and loss of function in the joints The swelling, inflammation and damage to the joints occur when the body's immune system attacks the tissue around the joints rheumatoid arthritis patients will develop carpal tunnel syndrome or other mild forms of peripheral neuropathy SIGNS AND SYMPTOMS y Anemia y Fatigue, at times accompanied by fever y Loss of appetite y Tender, warm or swollen joints y Difficulty moving affected joints y Pain and stiffness y Rheumatoid nodules (lumps under the skin)

SYSTEMIC LUPUS ERYTHEMATOSUS (LUPUS)

Lupus is a broad term for several autoimmune disorders that weaken the body's immune system by producing antibodies that attack healthy cells, tissues and organs it can affect many parts of the body. It is characterized by inflammation and damage to different tissues and organs with many symptoms including fatigue and fever, swollen or painfully inflamed joints, and skin rashes Lupus may affect the kidneys, heart, lungs, blood and blood vessels, central nervous system and peripheral nerves

SIGNS AND SYMPTOMS

Anemia Fatigue Fever Hair loss Rash across the face and nose Raynaud's phenomenon (pale or purple fingers or toes from exposure to cold temperatures) Skin ulcers inside mouth and on the tongue Sensitivity to sun Serositis (inflamed linings of organs such as the heart and lungs causing chest pain and difficulty breathing) Swollen joints Swollen glands Pain, numbness and tingling in hands or feet

SJGREN'S SYNDROME

an autoimmune disease in which the body attacks its own healthy moisture-producing glands it is characterized by inflammation in joints, muscles, skin, or other body tissue Sjgren's is caused by a combination of genetic and environmental factors the disease may be triggered by a viral or bacterial infection damage to important organs such as the kidneys, liver and lungs

SIGNS AND SYMPTOMS

Dry eyes Dry mouth Dental cavities and mouth infections Difficulty swallowing or chewing Enlarged parotid glands (glands behind the jaw, in front of the ears) Fatigue Inflammation of lungs, kidneys or liver Joint pain Low-grade fever Nosebleeds Oral yeast infections Skin rashes or dry skin Vision problems

CELIAC DISEASE
an autoimmune inflammatory disease that damages the villi - the small, finger-like projections that line the small intestine eating foods containing gluten - a protein found in wheat and other grains - sets off an autoimmune reaction that causes the villi to shorten and eventually flatten Without healthy villi, a person becomes malnourished, regardless of the quantity of food eaten. Left untreated, celiac disease can lead to serious long-term conditions such as cancer, osteoporosis, anemia and seizures, and may become life threatening. triggered by surgery, viral infection, pregnancy, childbirth, or a stressful event

SIGNS AND SYMPTOMS

Anemia Change in weight Chronic diarrhea or constipation (or both) Failure to thrive in infants or delayed growth General weakness Neuropathic symptoms
y Burning, tingling and numbness in hands and feet y Loss of feeling in the hands and feet y Numbness, tingling or reduced sensation in the face and

body

Oily, foul-smelling stools Stomach problems, cramping, gas, distention, bloating, vomiting

CRYOGLOBULINEMIA

"cold antibody in the blood. antibodies that precipitate, or clump together, under cold conditions SIGNS AND SYMPTOMS
y Symptoms are prevalent in cold weather.
Blanching, pain, numbness in fingers and toes (Raynaud's phenomenon) Bleeding under the skin (purpura) General weakness Joint pain

y For peripheral neuropathy: Pain, numbness or tingling in the hands or feet

POEMS

multisystem disorder caused by the improper growth of bone marrow cells, resulting in an abnormal accumulation of proteins (immunoglobulin) in tissues and organs P - Peripheral neuropathy, affecting many nerves O - Organomegaly (i.e., abnormal enlargement of organs, such as the spleen and liver) E - Endocrinopathy (i.e., abnormal hormone levels that may inhibit normal growth, sexual development, metabolic functions) M - Monoclonal gammopathy or M protein (an immunoglobulin that results from a collection of bone marrow cells that have abnormally proliferated) S - Skin changes, darkening of skin pigment, thickening of skin, increased body hair

SIGNA AND SYMPTOMS

Changes in vision Easy fatigue Enlarged breast area tissue (in both women and men) Failure of ovaries and testes to function Fluid retention in the abdomen Swollen ankles and legs Weakness in the feet, legs, hands and arms caused by nerve damage

EVALUATION
Physical examination Neurological evaluation Electromyography Nerve conduction velocity test Standardized tests to measure:

y Muscle strength y Loss of function of sensory and autonomic nerves

Blood and urine tests to identify potentially treatable causes for neuropathy (e.g., vitamin B12 and folate levels; thyroid, liver and kidney functions; vasculitis evaluation); antibodies to nerve components (e.g., antiMAG antibody); antibodies related to celiac disease; Lyme disease; HIV/AIDS; hepatitis C and B)

EVALUATION
To test for diabetes: y Blood test y Oral glucose tolerance test y Comprehensive foot exam y Quantitative sensory testing (QST) HERIDITARY DISEASE y A muscle biopsy or nerve biopsy may confirm the diagnosis y Genetic testing is available for most forms of the disease y For diagnosis of foot fracture: X-ray Bone scan

EVALUATION
TOXINS y Blood test for toxins y Urine test for toxins ALCOHOLIC NEUROPATHY y Lab tests Serum chemistries Upper GI and small bowel series LYME DISEASE y Blood tests, including tests for antibody against the agent that causes Lyme disease and tests to detect the agent itself

EVALUATION
HEPATITIS y Blood tests including tests for hepatitis B virus and antibody directed against this virus y Test liver enzymes y Liver biopsy SARCOIDESIS y X-ray (typically of chest) y CAT scan y Eye exam y Pulmonary function (breathing) tests y Blood tests SLE y Antinuclear antibody (ANA) test

EVALUATION

Sjgren's syndrome: y Blood tests: ANA (anti-nuclear antibody) Anti-SSA and SSB antibodies (tests for antibodies that are often present in people with Sjgren's) RF antibody (rheumatoid factor) Erythrocyte sedimentation rate Immunoglobulin electrophoresis y Lip biopsy or biopsy of minor salivary glands(tests for evidence of inflammation) y Urine test (to test for kidney damage) y Additional tests relating to the mouth and eyes (e.g., Schirmer's test to determine whether eyes are excessively dry)

EVALUATION
celiac disease: y Blood tests y Biopsy of the lining of the small intestine

DIAGNOSTIC APPROACH

Neuropathies can be categorized according to the fiber type that is primarily involved. Most toxic and metabolic neuropathies are initially sensory and later may involve the motor fibers. Pure sensory neuropathies can result from drug toxicity or nutritional deficiencies. Primarily motor neuropathies include Guillain-Barr syndrome. Alcoholism and diabetes can both cause small-fiber, painful neuropathies Autonomic involvement occurs in Guillain-Barr syndrome and is sometimes life-threatening

DIAGNOSTIC APPROACH
It is important to distinguish whether the neuropathy is axonal, demyelinating, or both. This differentiation is best achieved using nerve conduction studies (NCS) and electromyography (EMG). Diabetes, HIV infection and alcoholism can cause distal, symmetric axonal sensorimotor neuropathy.

DIAGNOSTIC APPROACH

HISTORY

A chronic, slowly progressive neuropathy over many years occurs with most hereditary neuropathies or with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) Neuropathies with a rapid course include Guillain-Barr syndrome Ischemic neuropathies often have pain as a prominent feature Many medications can cause a peripheral neuropathy, typically a distal symmetric axonal sensorimotor neuropathy. Detailed inquiries about drug and alcohol use, as well as exposure to heavy metals and solvents, should be pursued.

ASSESSMENT

The neurological examination includes:

y Evaluation of cranial nerve function y Assessment of sensory responses to various types y y y y y

of stimulation, (e.g., vibration, light touch, cold temperature, pinpricks) Assessment of proprioception - balance and sensation in maintaining an erect stance with eyes open and closed Inspection for signs of muscle wasting Muscle and movement coordination Examination of deep tendon reflexes Observation of walking on toes, heels, tandem walking, hopping on either foot, or getting up from a chair or squatting position

TREATMENT
The goal of treatment is to manage the underlying condition causing the neuropathy and repair damage, as well as provide symptom relief Medications

y Analgesics y For diabetic y For infection

PHYSICAL THERAPY

The objectives of Physiotherapy management for peripheral neuropathy includes y Pain Relief-TENS, Transcutaneous Electrical Nerve Stimulation therapy has shown to be effective and safe in the treatment of diabetic peripheral neuropathy y Flexibility or stretching exercises-They are important for improving muscle mobility, function and blood circulation in the affected area.It also helps in maintaining range of motion.

PHYSICAL THERAPY
y Strengthening of muscles-It improves muscle

strength and reduces the feeling of numbness and tingling. It can be done by using weights or strengthening bands to target the necessary muscle. y Braces or splints- To improve balance and posture. It can be used for compression neuropathies like carpal tunnel syndrome. y Practicing functional activities are also important. y Balance training provides stability and prevents falls
y Endurance training provides good muscular and

cardio-vascular fitness

PHYSICAL THERAPY

A comprehensive physical activity routine includes four kinds of activities:

y Aerobic Exercise y Flexibility Exercise y Strength Training Exercise y Balance Exercise

AEROBIC EXERCISE

Increases your heart rate, works your muscles, and raises your breathing rate. some examples of aerobic exercise: y Take a brisk walk (outside or inside on a treadmill) y Take a low-impact aerobics exercise y Swim or do water aerobic exercises y Stationary bicycle indoors

Flexibility Exercises
Flexibility exercises, also called stretching Gentle stretching for 5 to 10 minutes helps your body warm up and get ready for aerobic activities such as walking or swimming

FLEXIBILITY

CALF STRETCH

SEATED HAMSTRING STRETCH

PLANTARFASCIA STRETCH

STRENGTH TRAINING

SEATED DORSIFLEXION

CHAIR SQUAT

CALF RAISES

Balance

STANDING BALANCE

HIP FLEXION

HIP EXTENSIONS

BALANCE

SIDE LEG RAISE

SAFETY MEASURES

Safety is an important consideration for patients with peripheral neuropathy. Muscle weakness and loss of sensation increase the risk of falls. It can be prevented by following measures y Testing water temperature before bathing y Avoiding open toes or high heels and not to walk barefoot y Take care while cooking by using heat resistant ladles and pot holders y Inspect your feet regularly for any cut, bruise or blister

SAFETY MEASURES
y Wear socks and gloves when needed y keep the skin moisturised. y Make environment safe by removing obstacles

in home, use adequate light at night, use handrails while ascending or descending stairs, Use non slip bath mats in bathroom

TIPS TO ADL

The following tips may help to make your daily activities easier: y Use large diameter tools like a thick pen or pencil; y Tape pipe insulation around tools to increase the size of handles (e.g., a fork); y Use liquid soap or gels instead of a bar; y Use a rubber thimble or a pencil eraser to turn the pages of your book; y Choose long necklaces that do not require clasps;

TIPS TO ADL
y Use a rubber glove or pad to help you grip and

open jars better; y Attach the rough part of Velcro to an object (e.g., a glass or bottle) so that you can feel the object more easily; y Button your shirt before putting it on;

PREVENTION

Prevention of diabetics
y Lose weight y Eat a balanced diet y Exercise y Stop smoking y Foot care: inspect your feet daily for injuries y Special therapeutic shoes (which may be

covered by Medicare and other insurance)

y Avoid prolonged activity on hands and knees

that could cause nerve compression

PREVENTION
y Avoid crossing legs at the knee y Avoid sitting with legs crossed, tailor-style y Avoid sitting in one position too long without

readjusting y Avoid holding the telephone in one position too long y Avoid tying shoes too tight or using tight shoe straps y Avoid high heels (even 1 inch), which can make toes numb

PREVENTION
y Take safety measures to compensate for loss of

sensation y Eliminate exposure to occupational or environmental toxins y Discontinue drugs that cause peripheral neuropathy y Maintain adequate nutrition

OCCUPATIONAL THERAPY

Occupational therapy is instrumental in helping a patient cope with the functional, vocational, and social impact of peripheral neuropathy by: y Improving sensory-motor skills y Teaching the patient to avoid exposure to environmental or industrial toxins y Teaching self-care activities y Teaching the patient safety issues, (e.g., paying more attention to the terrain when walking since falling or tripping may pose a risk for patients with PN) y Teaching the patient to pay attention to issues which involve automatic functions (e.g., learning how to change positions smoothly to avoid a sudden drop in blood pressure and the risk of falling)