Evaluation

The Peripheral Neuropathy Solution

Peripheral Neuropathy Solution By Dr. Randall Labrum

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Thorough evaluation of a patient's mobility warrants a detailed knowledge of the anatomy of the muscles in the affected limb(s). A well-trained clinician is knowledgeable ofmuscles in the upper and lower limbs, origins, insertions, nerve supply, and finally their function. Many of the pathologies originating from the muscles in the limbs could be diagnosed by recognized diagnostic tests for the particular muscle/tendon. In regards to the nerve supply, it is very important to become familiar with the innervations to the upper and lower limbs (Perotto 2005). Basically, these nerves originate from the brachial plexus for the upper limb and the lumbar plexus to the lower limb. Tables 14.1 and 14.2 summarize sample muscles in the upper and lower limbs, respectively, with the corresponding innervations. Adequate knowledge of these structures anatomically and functionally will enable the clinician to narrow down the list of differential diagnoses after a complete history and physical examination.

Table 14.1 Selected muscles in the upper limb with the corresponding innervation and function.

Muscle

Peripheral nerve

Nerve root

Function

Deltoid

Axillary

C5, C6

Abduction of the arm

Biceps

Musculocutaneous

C5, C6

Flexion of the forearm

Triceps

Radial

C7, C8, T1

Extension of the elbow

Flexor carpi radialis

Median

C6, C7, C8

Flexion of the wrist

Extensor pollicis longus

Posterior interosseous

C7, C8

Extension of the thumb

Abductor pollicis brevis

Median

C8, T1

Abduction of the thumb

Table 14.2 Selected muscles in the lower limb with the corresponding innervation and function.

Muscle

Peripheral nerve

Nerve root

Function

Gluteus maximus

Inferior gluteal

L5, S1,S2

Extension of the hip

Tensor fascia lata

Superior gluteal

L4, L5, S1

Abduction of the thigh

Vastus lateralis

Femoral

L2, L3, L4

Extension of the knee

Extensor hallucis longus

Deep peroneal

L5, S1

Extension of the big toe

Gastrocnemius

Tibial

S1, S2

Flexion of the foot

Abductor hallucis

Medial plantar

S1, S2

Abduction of the big toe

During the initial evaluation, the physical therapist will also perform a physical and environmental evaluation of the factors contributing to the patient's pain problem. The therapist will review the medical history and inquire about the patient's clinical course, limitations, deficits, and aggravating and alleviating factors. The physical therapist will then perform a biomechanically based physical examination which includes evaluation of range of motion, flexibility, strength, sensation, and reflexes; performing special tests; testing functional limitations; and finally observing movement patterns that may be causing or perpetuating injury. Also, in this section they evaluate the patient's gait, posture, and activity-specific patterns. These data are used in conjunction with the subjective evaluation to formulate the prognosis and short- and long-term risk of injury. The patients are then educated about their physical therapy diagnosis, the risks and benefits of treatments involved, and finally what is expected from them throughout and the role they can play in their own recovery. A personalized plan of care is then developed based on the patient's dysfunction, goals, and schedule.

We should now discuss the issue of altered movement patterns in pain patients. If a patient has pain, he/she will try to compensate by using other muscles and modifying movement patterns. Often these compensations lead to the development of myofascial pain (Table 14.3) on top of the original pain source and may even cause injury to other body segments or systems. If the patient is unable to compensate (or as pain of compensation increases), his/her function will decline. As function decreases, the muscles become weaker, joints become stiffer, motor control decreases, and cardiovascular performance suffers. In fact, over time, the patient does less and less. This decline in function might result in emotional distress which could present itself as anxiety, decreased self-esteem, loss of stress management strategies, decreased social interaction, isolation, inactivity, and depression. The dysfunction also causes strain on relationships due to increased workload on the partner and family as well as financial hardship if the person in pain must decrease overall participation in the home, recreational, and employment activities.

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