Non-Diabetic Peripheral Neuropathy

[Katie Long]

Hi All, I had an eval two weeks ago that I would like to get some input on.

Pt is an 84 year-old male referred to me from UVA’s prosthetics/orthotics clinic for peripheral neuropathy, with requested “pain management, desensitization, and contrast bath” interventions. His body chart included quadrilateral sx, with all distal extremities circled. My differentials included cervical myelopathy, cauda equine syndrome, peripheral neuropathy, diabetic nueropathy and adverse neural tension.

Subjective:
-Pt has a 25 year history of these sx, which have been managed with oxycodone and neurotinin (of which he is now taking the max dosage), which have recently become less effective in managing his sx.
-R foot sx are worse than L foot sx, both of which are worse than bilateral hand sx
-Denies PMH of DM or cardiac complications
-Describes pain as a dull ache, along with numbness
-AGGS: walking
-EASES: medication, ice pack
-Went to the ER 1 week prior to eval for sinus infection, he is on antibiotics that he does not think are helping
-Recent melanoma removal on L side of face
-Recent R leg swelling (below the knee), denies L leg swelling
-Requires several pillows under head to sleep (which he attributes to the sinus infection)
-States that he wakes up at 2:30/3:00AM every night and is unable to return to sleep by changing position, he needs to get up out of bed and move around
-Pt states that he has been chopping firewood despite the pain
-Pt’s only goal is to decrease pain
-LEFS: 53

Objective:
-Cervical clearing (-) for reproduction of any sx
-Lumbar clearing (-) for reproduction of any sx
-Tandem stance: <20 sec bilat
-Gait: pt demos inc L lateral trunk lean, dec transverse pelvic motion and dec arm swing bilat
-3+ pitting edema of R LE
-5TSTS: 22 sec
-Slump: Pt notes inc toe sx with dorsiflexion of R ankle, denies sx differentiation with CS extension
-2MWT: 345 ft, inc in R foot/toe sx
-Neuro: (-) UMN tests, Myotomes: L L2 fatiguable and weak, all others equal and intact bilaterally. DTR: Absent achilles bilaterally, Brisk patellar bilaterally, L biceps 2+, R biceps 1+, all other UE DTR absent bilaterally. Dermatomes: impaired medial foot sensation bilaterally (R>L), Right impairment from medial first toe to first web space and dorsal 1/3 of foot to medial calcaneus as well as medial 1/3 of plantar aspect. Similar distribution of L, decreased sensation of medial 1/4 of foot. UE sensation equal and intact bilaterally.

By the end of the eval, patient was reporting significant nausea and GI upset. I sent him home with HEP of tandem stance at a counter and instructions to call his PCP if his GI sx worsened.

At first follow up, pt was reporting increased pain and swelling of R LE and demonstrated increased heat and redness from IE. I didn’t treat him, and sent him home with education on s/s of DVT and instructions to go to the ER if anything changed. I also called his PCP and referring MD with my findings.

The morning of the second follow up, he called saying his leg was still hurting and swollen, so I had him go to the ER to clear DVT before his appointment with me during mentorship hours. Pt went to ER, they performed an US and blood work, which were (-) for DVT. At our treatment session, we did 12 minutes of aerobic activity (NuStep) and some ankle ROM on the wobble board. Pt reported dec sx following NuStep but inc sx following ankle ROM.

I have attached the only article I could find regarding pain reduction in those with chronic neuropathy, however the patient population was individuals with DM neuropathy, which my patient does not have. I am wondering if anyone has any other resources/experience/advice on treatment and interventions for this patient and outcomes to expect? I’m also wondering if anyone has any other subjective or objective measures that they would have looked at or asked about to help with their decision making process?

Thanks!

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[Michael McMurray]

With a 25 yr history, and complaints of everything (GI/nausea/possible DVT/swelling), You can easily chase random symptoms every visit until one of you gets frustrated.

I would get him to commit to functional goals, and work toward those functional functional goals by addressing impairments toward those functional goals. Did I mention functional goals?

Pain of 25 years that is unrelieved by Neurotin and Narcotics probably won’t respond to some magical PT experience/treatment.

? other thoughts ?

[Katie Long]

Thanks Eric, this is similar to what AJ and I talked about when I placed him on my mentorship time. I have gotten some positive results with aerobic activity and his swelling has come down as of last tx session. I will chat more with him next time about trying to set some more functional goals.

Thanks for the input!

[Michael McMurray]

This is a tool that can be helpful when trying to determine specific functional goals. It is based on fear of doing activities but may be helpful with your patient.

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[Katie Long]

Thanks Mike, this is an interesting read. Although not specifically assessed utilizing a specific fear-oriented assessment, this patient does not seem to exhibit fear of activity, so I wonder how applicable this could be. Last week he told me he seeded an area of his property with grass seed for a baseball field that he is building for his great-grandkids, so he is not avoiding activity, simply performing them despite his reported high levels of pain. After reading this article, I think I am going to try to have a more in-depth conversation with him regarding his activities and if he avoids/truncates any activities due to his symptoms and seeing if that is something we can utilize to create goals.

[Michael McMurray]

Hi Katie –
Have you considered intermittent claudication? If you haven’t already, you may want to check pedal pulses. Here is a link to an article which may be helpful: http://www.aafp.org/afp/2006/0601/p1971.html
If you are interested or think this may be a viable dx, I would be happy to provide articles regarding walking programs and studies once I get back to my office.

[Katie Long]

Hi! Yes, I had checked pedal pulses due to a differential of intermittent claudication, they were strong and equal bilaterally. He denies sx provocation with recumbent stepper and even reports improvements in sx following 12 minutes of activity. These charts in that article are amazing though, thanks for sharing!!

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