Peripheral Neuropathy

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Neurological Institute MDA/Neuromuscular Clinic

Neuropathies can be either acute or chronic — in acute neuropathies, symptoms appear suddenly, progress quickly and resolve slowly; in chronic forms of the condition, symptoms begin as subtle signs and progress slowly but tend to last for a long time.

Neuropathic pain is difficult to control and can seriously affect your emotional well-being and quality of life. 

More than 100 types of peripheral neuropathy have been identified, each with a unique set of symptoms, development patterns and prognoses. Peripheral neuropathy, Guillain-Barré Syndrome (GBS) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) are three of the conditions that affect your peripheral nerves.

Peripheral Neuropathy 
Peripheral neuropathy results from damage to your peripheral nerves and may cause weakness and numbness and pain in your hands and feet, although it can affect other parts of your body. The nerve damage can be from trauma, infection, metabolic problems, exposure to toxins or genetic inheritance. A common cause of peripheral neuropathy is diabetes mellitus.

The condition may affect a single nerve, two or more nerves or many nerves. 

You may have an extreme sensitivity to touch, lack of coordination and balance and muscle weakness or paralysis. Your tolerance to heat may be reduced and your sweat patterns may alter. You may experience digestive, bowel and bladder problems and dizziness (from a change in blood pressure).

Alcoholism, autoimmune diseases, tumors, vitamin deficiencies, bone marrow disorders, kidney and liver diseases and certain medications may also influence peripheral neuropathy.

Guillain-Barré Syndrome 
GBS is a relatively rare disorder that results in your body's immune system attacking your nerves. Weakness and tingling in the extremities are the first symptoms, but it can rapidly spread and paralyze your entire body. In the case of total paralysis, the condition should be considered an emergency.

The syndrome occurs in three forms:
  • Acute inflammatory demyelinating polyradiculoneuropathy (AIDP)
  • Miller Fisher syndrome (MFS)
  • Acute motor axonal neuropathy (AMAN) and acute motor-sensory axonal neuropathy (AMSAN)

The syndrome often starts with tingling and weakness in your feet and legs and then spreads to your arms and upper body (although symptoms may begin in the arms or face). You may feel a prickling sensation; weakness in your legs may make you unsteady when walking or climbing stairs. You may have trouble speaking, chewing or swallowing and have difficulty with bladder and bowel control. You can experience an achy, cramping pain that worsens at night. Your blood pressure may be too low or high and your heart rate too fast.

You will probably experience your most significant weakness about two to four weeks after symptoms and start to recover about two to four weeks after that.

Guillain-Barré syndrome has no cure; the cause of is not known, but it often follows an infectious respiratory illness or flu. 

Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP)
Chronic inflammatory demyelinating polyneuropathy (also called chronic relapsing polyneuropathy), an autoimmune disease, is a neurological disorder in which you experience progressive weakness and inability to feel in your arms and legs. This condition is caused by damage to the myelin sheath of your peripheral nerves (the myelin sheath is the fatty covering that surrounds and protects nerve fibers). 

Symptoms of this condition include tingling or numbness that begins in your toes and fingers, weakness of your arms and legs, loss of deep tendon reflexes (associated with muscle stretching) and fatigue. 

CIDP can occur at any age and in both genders, but it is more common in young adults and in men. CIDP is considered the chronic counterpart of Guillain-Barré syndrome.

Diagnosis of Neuropathies

Peripheral Neuropathy 

Since peripheral neuropathy is not a single disease, our team will need to determine what is causing the nerve damage. We will take a full medical history of your symptoms, lifestyle and exposure to toxins, alcohol and drugs. We will perform a thorough physical exam which may include blood tests and we will probably recommend a neurological exam to check tendon reflexes, muscle strength and tone, ability to feel sensations and posture and balance.

We may ask for imaging tests. Our team may also request nerve function tests to record the electrical activity in your muscles (an electromyography), an autonomic nerve test, a sweat test and other sensory exams, as well as a nerve biopsy to examine the tissue for abnormalities and a skin biopsy to check the number of nerve endings (since in neuropathies, the number of nerve endings tends to reduce over time).  

Guillain-Barré Syndrome and Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP)
These syndromes can be difficult to diagnose in early stages based on only history and physical examination. Our team will probably perform many of the same tests and examinations as we would to diagnose peripheral neuropathy (electromyography and nerve function and conduction tests). 

Diagnosis of GBS requires a lumbar puncture (spinal tap) to withdraw a small amount of spinal fluid for testing; diagnosis of CIDP requires a nerve biopsy for microscopic examination.

Treatment Options for Neuropathies
Pain management, of course, is a cornerstone of management of these conditions. 

Peripheral Neuropathy 
If the cause of your neuropathy is identified, specific medications, therapies, surgery and/or lifestyle changes may address your symptoms and relieve your pain  by treating the underlying condition. For example, if exposure to a toxin (including alcohol) is discovered, avoidance may improve symptoms. Watchful waiting with pain control as needed may be the most appropriate initial treatment.

Medications will include over-the-counter pain relievers and antidepressants to relieve pain. We may prescribe a cream with capsaicin to help lessen neuropathy pain symptoms. Our team may also prescribe medication to treat the underlying condition; often this will be a drug to reduce your immune system response, but it could also be intravenous immunoglobulin to help reduce inflammation.

Certain therapeutic procedures may reduce your neuropathy symptoms, including transcutaneous electrical nerve stimulation (TENS), the application of a gentle electric current at varied frequencies across your skin surface; plasma exchange (removing antibodies from your blood) and intravenous immunoglobulin to help suppress immune system activity; and physical therapy.

Surgery may be suggested if you have neuropathies caused by physical pressure on nerves.

We will also suggest lifestyle change suggestions to help you manage peripheral neuropathy:
  • Exercising
  • Quitting smoking 
  • Eating healthy 
  • Avoiding alcohol 
  • Taking care of your feet (especially if you have diabetes); check daily for blisters, cuts or calluses; wear soft, loose cotton socks and padded shoes; use a semicircular hoop to keep bedcovers off your feet when you sleep
  • Monitoring your blood glucose levels (if you have diabetes)

Guillain-Barré Syndrome 
A GBS patient with respiratory failure is an emergency that requires admission to an intensive care unit (ICU). Two specific therapies — plasma exchange (plasmapharesis, the removal of antibodies from your blood) and intravenous immunoglobulin to help suppress immune system activity — can help you recover faster. Intensive rehabilitation is given when the patient starts improving.

Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP)
A patient with CIDP is treated with corticosteroids as a maintenance therapy. One of the many corticosteroid-sparing (also called immunomodulating) agents may be used if side effects develop or if corticosteroid therapy is not effective. For exacerbations, you may receive intravenous immunoglobulin or undergo plasmapharesis. 

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