Peripheral Neuropathy: what is it and how can physiotherapy help?

What is it?

Peripheral neuropathy is a condition that damages the peripheral nerves. These are nerves that carry messages to and from the brain and spinal cord. Peripheral nerves exist throughout our bodies, connecting the brain and spinal cord to our muscles and internal organs. There are 3 types:

·       sensory - allowing us to feel through our skin

·       motor-allowing us to initiate and control movement

·       autonomic -allowing normal internal function, for example heart rate, blood pressure, digestion.

Peripheral neuropathy disrupts the nerves’ ability to send and/or receive the signals our bodies require: they may send pain signals when they’re not needed, or they may be unable to send a signal that is needed.

What are the symptoms?

Symptoms include pain, tingling and/or numbness, often starting in the hands and feet, but this may spread into your limbs. Some people describe the pain as sharp, freezing or burning, and they may be unable to cope with even the slightest touch in the affected area. People may drop things, or find it difficult to move as easily; balance may be affected. If the autonomic system is involved, people may feel unwell; they may have low blood pressure or digestive problems, for example.

What are the causes?

Diabetes is a major cause of peripheral neuropathy, but it can also result from infection, trauma, metabolic disorders (such as hypothyroidism or kidney disease) alcoholism and long term exposure to toxins. The condition can also be inherited, for example in Charcot-Marie-Tooth disease. If you are experiencing any symptoms, you should see a doctor immediately. As the causes vary considerably, the doctor will want to know your full medical history and a complete list of your symptoms.

Is there a treatment?

If the underlying cause of the neuropathy can be treated the nerve function should also improve; for example if the neuropathy was caused by trauma, from which the limb is expected to recover, then the neuropathy should also diminish in time. Pain medication and non-pharmaceutical pain management treatments also offer relief, as do splinting for hands and feet that are painful or have diminished motor control.

What can physiotherapy do to help?

A physiotherapist will assess your physical function, liaise with your doctor regarding the cause, and then provide a treatment program that will target areas of weakness and risk. For example you may have poor balance, reduced mobility,stiff limbs, weak muscles and/or low heart fitness. The physiotherapist can also provide you with appropriate walking aids, braces and splints, as well as non-pharmaceutical pain relief such as Transcutaneous Electrical Nerve Stimulation (TENS) or acupuncture.

R. Sian Owen

Registered Physiotherapist 

Links

The Mayo Clinic has some good information at http://www.mayoclinic.org/diseases-conditions/peripheral-neuropathy/home/ovc-20204944

Recent research on the effectiveness of TENS can be found at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2746624/

A feat of biological engineering.

Image: Daniel Reche

“These feet were made for walking, and that’s just what they’ll do….”

Nancy Sinatra was, in fact, singing about boots, but she wasn’t wrong when she said that those appendages at the bottom of our legs were meant for walking. Then there’s standing, tip-toeing, running, jumping, dancing, skating, skipping, swimming; keeping us hooked to a bike or a horse; tight rope walking. Feet can even do the work of hands for some people. Our feet do an incredible job for us; here are some of their amazing every-day achievements.

1.     Our feet keep us grounded.

Our large, oval shaped feet are what keep us connected to the ground. Together with our magnificent brains, they give us the ability to balance on different surfaces, or in different conditions (ice, wet, high wind, for example). Multiple bones and joints form two arches (longitudinal and transverse) that react to different stimuli, such as sandy or rough ground, and help keep us upright. Our feet have thousands of nerve endings that detect information about the surface they’re on. This information travels at high speed to our brain, which relays urgent messages back to the foot muscles to get working. End result – we don’t fall over.

2.     They’re at the centre of things.

We all have an invisible base of support, a no-falls safe zone. When we’re upright, with feet shoulder width apart, it’s a rough circle around the feet, about as wide as our shoulders. The closer together our feet are, the narrower the base of support. If we’re standing our body needs to be perpendicular to this circle, but if we’re running it will move a little beyond the circle as we gather momentum. If we move too far beyond our base of support we’ll start to fall. Our feet are key to helping us stay within this safe zone, informing our brain when we move too far beyond it, and activating the right muscles to bring us back in.

3.     They’re team players.

Our feet work with muscles in our legs to enable us to move. Strong calf muscles (plantar flexors) push the front of the foot into the ground. The heel rises, and bingo, you’re off walking! Next we swing our leg through space, preparing to land the heel. Shin muscles (dorsiflexors) automatically pull up the foot, so that our toes don’t get caught on the ground. Muscle work is all about sharing the load: some muscles work as prime movers such as the dorsiflexors to lift the foot, others work as stabilisers such as the muscles in the other leg to hold us up.

4.     They are super-adaptable.

Some people use their feet to draw and write. Take a look at these beautiful pictures drawn by an artist using his right foot. https://www.youtube.com/watch?v=8Mtxh

All this work is pretty hard on your feet. Here’s how you can help keep them healthy and rested.

1.     Wear shoes that support but that aren’t too tight. Beware of shoes that pinch, especially those that squish your toes together. The shoes may look cool, but damaged toes and bunions don’t.

2.     Include a foot and ankle strengthening routine in your work-out. You can get information on specific strengthening exercises from a physiotherapist.

3.     Don’t over-do any activity, including the above-mentioned strengthening exercises. Over-use of tendons or muscles that move the foot, for example, can cause peroneal tendinitis or shin slints.

4.     See a foot specialist if you have problems with your feet (corns, bunions, pain, swelling). Regular care by the right professional will keep your feet strong and healthy and ready to work wonders for you.

5.     Pamper your feet occasionally with a home foot-spa. Even a basin of warm water and some soft towels will make them feel loved.

For more information about feet and foot care visit the College of Chiropodists of Ontario. You can search for a licensed chiropodist or podiatrist here www.cocoo.on.ca

R. Sian Owen PT

Physiotherapy in the management of Persistent Post Concussion Symptoms Part 2

Post traumatic headaches - how can physio help?

What is a post-traumatic headache?

It is a headache which can occur following any brain injury, and is one of the most common complaints following a mild traumatic brain injury. (Ref 1-4)

Often the headache will resolve quickly following the original injury, but in some clients the headache persists. If it continues beyond 3 months, it is termed chronic.

What types of post traumatic headaches are there?

There are many causes and types of headaches and it is important to have a reliable diagnosis, so that the appropriate treatment can be determined.

The Ontario Neurotrauma Foundation has identified four common types in adults following a mild traumatic brain injury:

1.     Migraine without aura

2.     Frequent episodic tension-type headache

3.     Primary stabbing headache

4.     Occipital neuralgia

Headaches may be made up of more than one of these types.

You can get more detailed information here:  http://braininjuryguidelines.org/concussion/

It’s important to note that headaches can also be caused by medication over-use. These are called rebound headaches. Your doctor will assess whether medication is the possible cause and develop a plan with you to deal with the problem.

What can physio do to help?

Once an assessment has been completed, your physiotherapist can help by advising, guiding and treating the following areas:

1.     Pain, by using modalities such as heat, ice, acupuncture, manual therapy or Integrative Manual Therapy as needed.

2.     Head and neck posture.

3.     Stretches for the neck and upper body.

4.     Strengthening for the neck and upper body when appropriate.

5.     Cardiorespiratory exercise. Some headaches are aggravated by exercise. Your physiotherapist will guide you to the most appropriate program for you.

6.     All exercise must be performed in a graduated way so that there are minimal injuries, and you are successful in getting the benefits from your program.

R. Sian Owen PT

Registered Physiotherapist

1.Gladstone J. From psychoneurosis to ICHD-2: an overview of the state of the art in post-traumatic headache. Headache. 2009;49(7):1097-1111.

2. Dikmen S, Machamer J, Fann JR, Temkin NR. Rates of symptom reporting following traumatic brain injury. J Int Neuropsychol Soc. 2010;16(3):401-411.

3. Lew HL, Lin PH, Fuh JL, Wang SJ, Clark DJ, Walker WC. Characteristics and treatment of headache after traumatic brain injury: a focused review. Am J Phys Med Rehabil. 2006;85(7):619-627.

4. Lew HL, Poole JH, Guillory SB, Salerno RM, Leskin G, Sigford B. Persistent problems after traumatic brain injury: The need for long-term follow-up and coordinated care. J Rehabil Res Dev. 2006;43(2):vii-x.

Physiotherapy in the Management of Post Concussion Syndrome (Persistent Post Concussion Symptoms)

I just got back from a most informative and exciting course on Post Concussion Syndrome with Jacquie van Ierssel PT, a physiotherapist who has developed “R2P”, a systematic and evidence- based approach to identify causes of concussion symptoms and create a treatment plan. It was great to see how much physiotherapy can do to help. Thank you Jacquie!

I want to share some of my learning with you, and in the next few blogs I plan to do just that.

First of all:

What is post concussion syndrome, or persistent post concussion symptoms as it is now being called?

Up to 15% of people with concussion may have persistent symptoms. The Ontario Neurotrauma Foundation guidelines recommend a referral for a specialized assessment if symptoms persist at one month post injury. (1)

The diagnosis is based on symptoms (see below) and your Doctor may use diagnostic criteria from the World Health Organisation and/or the Diagnostic and Statistical Manual of Mental Disorders. Because symptoms can be the same as in a variety of other conditions, obtaining the correct diagnosis can be difficult.

The following are common symptoms: (from Willer and Leddy (2))

Physical: headache, nausea, vomiting, blurred or double vision, seeing stars or lights, balance problems, dizziness,sensitivity to light or noise, tinnitus.

Behavioural or emotional: drowsiness, fatigue or lethargy, irritability, depression, anxiety, sleeping more than usual, difficulty falling asleep. 

Cognitive: feeling “slowed down”, feeling “in a fog” or “dazed”, difficulty concentrating, difficulty remembering. 

Symptoms do vary.  Some people experience three or four while others may be dealing with more, and they can persist for months and even years.

What happens in treatment?

Education is a key component. Treatment will focus on addressing the physical/cognitive/psychological challenges arising from the concussion.  A team approach works best for managing persistent post concussion symptoms.

What can the physiotherapist do to help?

The physiotherapist can help treat post traumatic headaches, dizziness and poor balance (vestibular problems), fatigue, and vision (ocular motor). After an in-depth assessment the physiotherapist can provide a program specifically designed to address your problems. Appropriate exercises will help to improve sleep and mood, as well providing physical benefits such as increased strength, better balance and posture and improved exercise tolerance. The physiotherapist will also work with other healthcare providers as needed.

I will go into more detail about treatment in my next blog.

(1) onf.org/documents/guidelines-for-concussion-mtbi-persistent-symptoms-second-edition

(2) https://www.ncbi.nlm.nih.gov/pubmed/16901381

R. Sian Owen PT

Registered Physiotherapist

How To Climb Stairs Safely With A Cane

This can be tricky if you don't know how! 

First, make sure your cane is adjusted to the correct height. Ask your physio to do this. If you don't have access to a physio, look at my blog entitled "how to get your cane height right."

The general rule for stair climbing is put the good leg up first when going up, and put the affected leg first when going down. 

With a rail

Facing forwards, put the cane in the opposite hand to to rail.

Going up

1. Take the first step up with the good leg. Leave the cane on the step with your affected leg. (Unless your physio asks you to do this differently). Take weight through the cane and rail when stepping up with your good leg. 

2. Then move the cane followed by the affected leg.

Going down

1. Hold the rail. Put your cane down first, then your affected leg. 

2. Step down with the good leg.

What happens if you don't have a rail? 

If your physio tells you that you are ok with just one cane, (you could use 2 for more support on steps with no rail), then:

Keep the cane in the hand opposite your affected leg, as you would for normal walking and follow the general rule for stairs. 

Put your good leg up first when going up, and your cane then affected leg down first when going down. 

This link has some nice pictures to make everything clear.

http://www.hamiltonhealthsciences.ca/documents/Patient%20Education/SafeStairClimbingCane-th.pdf

R. Sian Owen PT

Registered Phystiotherapist

How To Get Your Cane Height Right

Here are a few tips if you don't have access to a physiotherapist to do this for you.

Why is it important to have your cane at the appropriate height? 

It is easy to alter your posture to accommodate a cane at the wrong height, and then very easy to cause other injuries because of this poor posture/alignment. 

How do I measure? 

I think the easiest way to measure the height is to use the wrist crease. You will find this on the inside of your wrist. Stand and relax your arm by your side. Adjust your cane height vertically to the ground from the wrist crease. 

Check that your elbow remains slightly bent (about 15◦) and is not fully straight when you apply weight. 

How do I adjust an aluminum cane? 

Most will have an anti-rattle collar. Unscrew this, then press in the push button and adjust the height. Once you have the correct height, remember to tighten the anti-rattle collar. 

Watch out for my video on this, coming in 2017! 

R. Sian Owen

Registered Physiotherapist

7 Benefits of Resistance Training

7 Benefits of Resistance Training

1.     It makes you feel good.

When we exercise, the body releases endorphins which reduce pain and make us feel great!

2.     It maintains healthy bones.

Our bones anchor our muscles. As we strengthen our muscles, the bone quality improves, which is a win-win. Less risk of osteoporosis!

3.     It gives you great posture.

Core exercise and a program that involves all your major muscle groups (front and back) will set you up to hold your head high, walk tall and avoid that slumped shoulder look.

4.     It makes everyday life easier.

For example, work on quadriceps and hamstrings (thigh) and take stairs in your stride.

5.     It helps with pain.

Bad pain stops us doing exercise, then we get weak and unfit, and the pain just gets worse. But you can do a program specifically designed to accommodate your pain. And remember those endorphins!

6.     It improves your balance.

I’ve written about balance in other blogs. Resistance training helps our muscles stay strong and that helps balance.

7.     It gives you a good night’s sleep.

A good work-out uses up energy, deals with stress and gets your body and mind ready to sleep. For best results make sure you don’t exercise too late in the day.           

Stay tuned for more on resistance training!

If you have any medical problems consult your MD for recommendations or restrictions to exercise, and then your physiotherapist for the program that is right for you.

R. Sian Owen PT

References

For more information on the health benefits of resistance training and types see

https://www.betterhealth.vic.gov.au/health/healthyliving/resistance-training-health-benefits

https://www.ncbi.nlm.nih.gov/pubmed/11676593

We all need Vitamin N!

Richard Louv is the best-selling author of ‘Last Child in the Woods’ (Algonquin Books 2005). In it he coins the term “Nature Deficit Disorder” to describe the multiple harms that come from living a life devoid of nature: lives that are increasingly common in our urbanized, digital age.

Louv has just published another book ‘Vitamin N: The Essential guide to a Nature-Rich Life.’ (Algonquin Books 2016) in which the benefits of Vitamin N, or nature, are clearly set out.

Here are my top four. What are yours?  I’d love to hear from you.

·      Vitamin D production. Vitamin D is a soluble vitamin naturally present in very few foods. It is produced when ultra-violet rays from sunlight strike the skin and trigger its synthesis in our bodies. It is vital to our bone health as it enables calcium to be absorbed from our gut. Taking Vitamin D (in food or as a supplement) has to be balanced, as we can take too much. However, there is no risk of producing too much from the sun. The body doesn’t allow for this to happen.

There is some evidence (not conclusive) to show that a lack of Vitamin D may be a risk factor in certain diseases involving nerve tissue like Multiple Sclerosis.

https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/

·      Improved cognition and mood. Dr. Marc Berman and his colleagues have researched this intensively. They have found that spending time in nature refreshes our brain, improves attention and memory performance. They are also finding that the same effects apply for individuals with depression.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3393816/

·      The shade of trees helps keep us cool in the heat.  Have you noticed when you walk in the city in the summer it can be overwhelmingly hot with no respite. I often see people crowded under one tree.  Trees also absorb carbon dioxide and other harmful gases such as sulphur dioxide and carbon monoxide; they produce oxygen. Having enough trees around your home will certainly reduce cooling costs in the summer, and clean the air!  

https://www.ncsu.edu/project/treesofstrength/benefits.htm

·      Biodiversity. When nature is in balance, many species will co-exist. Over long periods of time, if nature is left alone, species come to co-exist in a harmonious, mutually beneficial manner. If radical disturbances occur, however, (e.g. clearing land for building), one or two species will come to dominate for a while until nature can re-assert its balanced view of things. In the plant kingdom we will often call these dominant plants weeds. If the disruption is big enough (e.g. removing a whole forest), then animals may not survive, as their source of food has disappeared.

How do we benefit from biodiversity? A diverse, stable ecosystem provides us with food, fuel, shelter, medicine and allows for our continued survival.

Now is the time of year to plant. If you are interested in planting for biodiversity look for native species. These have adapted to survive in our region over many years.

For more information contact the North American Native Plant Society   http://www.nanps.org/index.php/home/what-is-nanps

R. Sian Owen

Registered Physiotherapist

How To Walk Correctly With A Cane.

If you ever watched House MD, you may have noticed how awkwardly Dr. House walked with his cane. That's because it was the wrong height for him, and he was holding it in the wrong hand. 

Canes must fit your body height and proportions. See last month's blog for how to make sure your cane is the correct height.

Then, 

1. Put the cane in the opposite hand to the injured leg. If you have a problem with the right leg, put the cane in your left hand. This is important because it allows normal arm swing when we walk, and normal biomechanics. Thus, we reduce the risk of injuring other parts of our body. Remember how twisted House's body looked when he walked? He was at risk of back and/or shoulder pain. 
2. Put the cane forward in line with your right leg. Weight bear through the cane at the same time as you take weight through the leg. Try and keep good posture throughout, and you will minimize the risk of other problems. 

How do I walk with 2 canes? 

There are 2 ways of doing this, depending on your balance and how bad your injury is. 

1. Put both canes forward at the same time as weight bearing through the injured leg. This works well if your injury is severe or your balance is not so good.
2. Start as for one single point cane. Left hand with right leg, then the second cane in the right hand with left leg. This takes a bit of practice, but if you can master it, it is close to normal walking and will help your body minimize the risk of any injuries from using the canes. This method is easier if your injury is less severe and your balance is ok. 

You'll be able to check out my video on this - coming soon! 

Next time, I'll talk about how to go up and down stairs with a cane. 

R. Sian Owen PT, Registered Physiotherapist