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Understanding Peripheral Neuropathy
Peripheral neuropathy is a general term for nerve damage that causes weakness, numbness and pain, usually in your hands and feet. It can also affect other areas of your body and bodily functions including digestion and blood pressure control.
The peripheral nerves make up a network that connects your brain and spinal cord to your muscles, skin, and internal organs. Damage to these nerves interrupts communication between your brain and other parts of your body. This can cause muscle weakness, tingling, and pain in your arms, hands, legs, and feet.
Muscle weakness in your legs and feet is a common symptom of peripheral neuropathy. (Photo Credit: iStock/Getty Images)
There are over 100 types of peripheral neuropathy, each with its own causes and symptoms that stem from a variety of issues. They range from carpal tunnel syndrome (an overuse injury) to diabetes-related nerve damage.
Doctors and researchers categorize peripheral neuropathies in many ways. Here are some of the terms you might hear:
Mononeuropathy
Damage to a single peripheral nerve is called mononeuropathy. Physical injury or trauma, such as from an accident, is the most common cause. Pressure on a nerve for a long time, caused by being sedentary for extended periods (such as sitting in a wheelchair or lying in bed), or continuous, repetitive motions, can trigger mononeuropathy.
Here are examples of mononeuropathies that can cause weakness, tingling, numbness, and other symptoms in affected parts of the body, such as your hands and feet:
Carpal tunnel syndrome is the most common type of mononeuropathy, making up about 90% of all cases. It's called an overuse or repetitive strain injury, which happens when the nerve that travels through your wrist is compressed. If your work requires repeated motions with your wrists -- for example, working on an assembly line or typing on a computer all day -- you are at greater risk.
Ulnar nerve palsy happens when the nerve that passes close to the surface of your skin at your elbow is damaged. You can often feel numbness in your fourth and fifth fingers.
Radial nerve palsy is caused by injury to the nerve that runs along the underside of your upper arm. It can happen with fractures of the humerus bone in the upper part of your arm. Poorly fitted crutches can also cause it by putting pressure on the inside of your arm near your armpit.
Peroneal nerve palsy happens when the nerve at the top of your calf on the outside of your knee is compressed. This leads to a condition called "foot drop," in which it becomes difficult to lift your foot.
Mononeuritis multiplex
Mononeuritis multiplex, also known as multiple mononeuropathy, happens when there is damage to at least two separate nerve areas. Unlike polyneuropathy, which generally affects the same nerves on both sides of your body, mononeuritis multiplex shows up in random areas. It also doesn't typically involve more than a few specific nerves. It can affect these nerves all at once or only a couple at a time.
Certain long-term (chronic) illnesses are often the cause of mononeuritis multiplex. These include diabetes, vasculitis, lupus, and rheumatoid arthritis. Sometimes a viral infection, such as Hansen's disease (leprosy), can also be responsible.
If you have mononeuritis multiplex, you may have pain, weakness, and unusual feelings in the areas where the affected nerves are. If your condition becomes worse, your symptoms may show up on both sides of your body, which is what happens with polyneuropathy.
Polyneuropathy
Polyneuropathy accounts for the greatest number of peripheral neuropathy cases. It occurs when multiple peripheral nerves throughout the body malfunction at the same time.
The most common symptoms of polyneuropathy are tingling and numbness or a burning sensation in the feet or hands. Symptoms of polyneuropathy typically show up in the same areas on both sides of the body.
Polyneuropathy can have a wide variety of causes, including exposure to certain toxins, alcohol abuse, poor nutrition (such as low vitamin B12), and complications from diseases such as cancer or kidney failure.
One of the most common forms of chronic polyneuropathy is diabetic neuropathy, a condition that can happen if you have diabetes. It is more severe if your blood sugar levels aren't well controlled.
Motor neuropathy
Motor neuropathy is damage to nerves that control the muscles you consciously use, such as those involved in walking, talking, sitting, or holding onto things.
Some motor neuropathies are acute, meaning symptoms come on suddenly and may quickly become severe. This type is most commonly seen in people with Guillain-Barré syndrome, a disorder that causes your immune system to attack your body's peripheral nervous system. About 95% of people recover fully or almost fully from Guillain-Barré syndrome.
Other motor neuropathies are chronic and generally get worse over time. This is more common if you have a motor neuron disease. These illnesses destroy brain cells that control movements such as walking, speaking, swallowing, and breathing. This includes conditions such as amyotrophic lateral sclerosis (ALS) and Kennedy's disease, a rare inherited condition that causes muscle loss and weakening, particularly in your arms and legs.
Sensory neuropathy
This type of neuropathy affects the nerves that transmit sensations, such as pain, touch, and temperature.
If you have sensory neuropathy, you might feel pins and needles or electric shock-like jolts in your arms and legs. Your skin may become ultrasensitive so even the lightest touch triggers pain. Or you may lose sensation, which can raise your risk of burning or hurting yourself and not being aware of it.
Sensory neuropathy is commonly linked with diabetes, especially when the condition isn't well controlled. A range of other illnesses and disorders can also bring it on, including HIV, Guillain-Barré syndrome, alcohol use disorder, herpes simplex, Hansen's disease (leprosy), and hepatitis C.
Autonomic neuropathy
Autonomic neuropathy involves nerves that control involuntary functions, such as breathing, digestion, urination, sweating, sexual response, and blood pressure regulation. It happens because damage to these nerves cuts off communication between your brain and important organs, such as your heart, lungs, bladder, and intestines.
Diabetes is the most common cause of autonomic nerve neuropathy. Autoimmune diseases, certain medications, and viral infections such as HIV and Lyme disease can also cause it.
Combination neuropathy
It's not uncommon for peripheral neuropathy to affect more than one body system or function. If this is your situation, your doctor might say you have a "combination neuropathy." They may also tell you that you have "predominantly" one type or another.
The most typical overlap of symptoms occurs between sensory and motor functions. This is often referred to as sensorimotor polyneuropathy. Diabetes is the most common cause of sensorimotor polyneuropathy, which can make you lose sensation in your feet and hands, for example. But muscle weakness and nerve damage can also affect your ability to stand or walk.
Autoimmune peripheral neuropathy
This refers to when your immune system – which protects your body from infections, viruses and other threats– mistakenly attacks your peripheral nerves. Conditions that can cause autoimmune neuropathy include Guillain-Barré syndrome, Sjogren's syndrome, lupus, and rheumatoid arthritis.
Inflammatory neuropathy
Most inflammatory neuropathies are also autoimmune neuropathies. This is because when the autoimmune system attacks peripheral nerves, it causes harmful inflammation.
Inflammatory neuropathies fall into three basic categories:
Acute. They are marked by a rapid and severe onset, such as with Guillain-Barré syndrome.
Chronic. These conditions come on gradually and can worsen over time. When doctors talk about chronic inflammatory neuropathy, they are often referring to chronic inflammatory demyelinating polyneuropathy. This condition attacks the fatty coverings that protect nerves, which then slows or stops communication from your brain and spinal cord to other parts of your body.
Peripheral nerve vasculitis. It happens when your immune system attacks and inflames blood vessels that supply peripheral nerves. As a result, you can develop neuropathy in parts of your body where that blood supply has been affected.
Causes of peripheral neuropathy are divided into three categories:
Acquired peripheral neuropathy. These are caused by environmental factors such as toxins, trauma, illness, or infection. Causes of acquired neuropathies include:
Hereditary peripheral neuropathy. This type is not as common. Hereditary neuropathy is passed down through your family. The most common of these is Charcot-Marie-Tooth disease type 1. Symptoms include:
These symptoms usually show up when you are a teenager or young adult.
Dejerine-Sottas syndrome is another hereditary peripheral neuropathy that starts when you are a baby and causes gradually worsening symptoms, such as:
Idiopathic peripheral neuropathy. In almost half of all cases, there isn't a specific cause. Your doctor may refer to your condition as "idiopathic."
Medicines that can cause peripheral neuropathy
Peripheral neuropathies can be a side effect of certain medications. This happens because the drugs, in some way, damage your peripheral nerves.
While the condition has been linked to any number of medications, peripheral neuropathy is commonly associated with the following types:
Complications and side effects of peripheral neuropathy depend a lot on the cause of your condition and your other health issues. Careful management and good medical care also play an important preventive role. In many, but not all cases, medication, physical therapy, diligent wound and foot care, assistive devices such as walkers and canes, and surgery can help minimize your risk for these and other problems:
Muscle weakness and atrophy. Damage to your peripheral nerves can weaken and shrink the muscles that are connected to them. This most commonly happens in your hands, lower legs, and feet. Such damage can weaken your grip, make you less stable on your feet, or make it difficult or even impossible to walk.
Foot ulcers. These slow-healing sores can affect anyone with peripheral neuropathy. But they are a particular problem for people with diabetes, who often have foot and leg numbness and aren't aware that they have a wound or irritation. Making things worse, high blood pressure from diabetes reduces the blood supply to your feet, making the ulcer slower to heal and more likely to get infected. In severe cases, loss of tissue and infection from a foot ulcer can lead to gangrene — loss of blood to an area of your body. This could require amputation or even cause death.
Injury. Loss of sensation can raise your risk of hurting yourself and not being aware of it. Since you heal more slowly when you have peripheral neuropathy, a wound can increase your risk for nonhealing ulcers and infection.
Falls. Muscle weakness, decreased coordination, and dizziness from poor blood pressure control can raise your risk of falling. This can bring on a host of other complications from broken bones to pneumonia caused by extended bed rest while recovering from your fall.
Circulatory, digestive, sexual, and vision issues. When peripheral neuropathy affects autonomous nerves that control involuntary functions, it can cause many problems. These include bowel changes (constipation or diarrhea) and loss of bladder control, sudden drops in blood pressure and spikes in heart rate, erectile dysfunction or an inability to achieve orgasm, swelling in your feet and hands, and blurred vision.
Peripheral neuropathy is common, especially among people who have diabetes. If you notice symptoms such as tingling, numbness, stabbing pains in your hands or feet, or other unusual sensations, see your doctor promptly. Early treatment and good management can help get symptoms under control and often prevent your peripheral neuropathy from getting worse.
Does peripheral neuropathy go away?
It can depend upon what's causing it. For instance, if any medication or vitamin deficiency is the cause, peripheral nerve damage can be treated and even reversed by stopping the drug, receiving vitamin therapy, and improving your diet. But in many cases, peripheral nerve damage can't be repaired. If a chronic illness such as diabetes is the root cause, managing your underlying condition can help prevent your peripheral neuropathy from getting worse.
What is the life expectancy of a person with peripheral neuropathy?
Peripheral neuropathy itself isn't generally life-threatening. But research suggests that it is associated with a higher risk of death from all causes. There are several reasons for this. If a chronic illness is causing your peripheral neuropathy, your life expectancy can be shortened by your underlying illness. Complications from peripheral neuropathy, such as foot ulcers, amputations, a sedentary lifestyle, and falls, are associated with death at an earlier age in older people. If peripheral neuropathy affects vital organs such as your heart, your symptoms can also be dangerous and even life-threatening.
What's the difference between peripheral neuropathy and neuropathy?
Peripheral neuropathy is a term used to describe many different types of neuropathies. So, they can be used interchangeably.
How do you deal with peripheral neuropathy?
If you notice symptoms such as tingling, numbness, stabbing pains in your hands or feet, or other unusual sensations, see your doctor as soon as possible. In many, but not all cases, medication, better management of any underlying conditions, physical therapy, diligent wound and foot care, assistive devices such as walkers and canes, and surgery can help minimize your risk for complications and improve your quality of life.
How do you treat peripheral neuropathy in the toe?
If you have an underlying condition such as diabetes that's causing neuropathy in your toes, your first and most important step is working with your doctor to manage your underlying condition as best as possible. You should also see a podiatrist (foot doctor) regularly to make sure your toes, toenails, and feet are well-groomed and carefully monitored for sores and wounds. The podiatrist or another doctor may also be able to reduce your discomfort with various treatments, such as injections, orthotics for your shoes, medications, and sometimes even surgery to ease pressure on affected nerves.
Diverse Clinical Trial Leads To Innovative, FDA Approved Treatment For Peripheral Artery Disease
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Peripheral artery disease or PAD, said Jennifer Jones-McMeans, Ph.D., divisional vice president of Abbott's vascular business, "is a highly prevalent disease that no one knows about."
The disease, according to the Mayo Clinic, occurs when arteries carrying blood to the legs narrow, usually because of a buildup of fat deposits in the arteries. This narrowing means blood no longer flows to the legs properly, which can cause leg pain and lead to poor wound healing. These symptoms can be very mild or nonexistent. Even when people experience symptoms, they may not think those symptoms are serious enough to visit a doctor.
"We have not been educated as a people, as a community, on what pain in the legs mean(s)," said Jones-McMeans. "When we have pain in our legs, we don't think that our arteries in our legs can be occluded. Instead we go, 'Oh, maybe I walk too much. Maybe I'm tired … Maybe I'm getting old.' And so there is a disconnect with understanding the signs and symptoms … especially if you consider that 50% to 70% of diabetics actually have (a) severe form of PAD and may not be aware of how devastating it can be."
At its most devastating, the disease can cause people to lose their limbs and their lives. For the severest form of PAD, chronic limb-threatening ischemia, where it is possible the leg may have to be amputated and where the leg is in pain even at rest, the survival rate over a five year period is worse than that of colorectal, breast and prostate cancer combined.
Before the disease is at its most severe, there are interventions, including medications for cholesterol and blood pressure, as well as medication to prevent blood clots and leg pain. Another intervention less drastic than amputation or bypass surgery is balloon angioplasty, where a balloon is inserted into a narrow artery and inflated to expand the artery. But this treatment comes with its own issues.
"In the landscape of treatment of below the knee disease, the only option over decades, the only innovation has been a balloon, a balloon with no drug, a balloon that's not permanent, a balloon that just pushes the plaque aside," said Jones-McMeans. "But when you just push the plaque aside, that doesn't sustain over time."
Dr. Brian DeRubertis, chief of the Division of Vascular and Endovascular Surgery at NewYork-Presbyterian/Weill Cornell Medical Center, recalled one patient he treated while working at UCLA. The patient was young, but had an "extensive amount of gangrenous changes in his foot … a lot of dead tissue." The young man also had a "large open wound that had to be healed to save his limb," and visited DeRubertis for treatment six times in two years.
Using balloon angioplasty, DeRubertis was able to open up the patient's arteries under the knee. But the procedure was time-consuming and only provided temporary relief.
"(He) had to come to the hospital. He had (to) undergo a procedure where we put devices inside his arteries. He'd then be off his feet for several days at home, and he had to come back every three months because these arteries kept shutting down," said DeRubertis. "I'd open them up, they'd shut down three months later. Unfortunately, (that's) not an uncommon thing for these very small arteries. "
Additionally, not everyone gets PAD at the same rate. Native Americans and Black people in the United States have the highest rates of PAD, with Black people having twice the rate of PAD of white people. In the case of Latino and Hispanic men and women, 22% are likely to develop PAD. Other factors that put people at a higher risk of PAD include being over 65 years old, having diabetes, smoking, obesity, or having high blood pressure or cholesterol.
But there is a new treatment option for chronic limb-threatening ischemia now – one that may take the place of balloon angioplasty.
On April 27, Abbott announced that its new treatment option for severe PAD had received approval from the Food and Drug Administration. This treatment – a dissolving stent called the Esprit BTK (standing for below the knee) system – is placed inside the artery to open it up and allow for more blood flow. Before dissolving in around three years, the system releases a drug called Everolimus, which encourages the arteries to stay open.
The stent went through an international clinical trial, with patients participating in the United States, Singapore, Japan, Hong Kong and Australia. In the case of the U.S. Patient population, the trial was deliberately designed to be diverse, with the demographics of patients seeking similar treatment from the Centers for Medicare & Medicaid Services (CMS) serving as a benchmark for the trial patient population.
"When you look at the white population in the U.S., CMS has the number who go under these endovascular treatments at 76%. We came in lower at 68%," said Jones- McMeans. "Our African American population was 15% in our trial compared to 16% for CMS. Our Hispanic and Latino population for ethnicity came in at 21% for the trial where the CMS benchmark is 3.4%. Our Asian population came in at 3.3%, where the CMS data came in at 1.1%. We were able to demonstrate comparability to metrics based on CMS."
"We felt that (a diverse patient population) was particularly important in this trial because up to now, many clinical trials have a very homogeneous patient population – generally more wealthy (and) Caucasian," said DeRubertis, who was a primary investigator for the clinical trial. "Chronic limb threatening ischemia disproportionately affects other people that are not necessarily white and affluent. We really wanted this trial to reflect the demographics of the patients that we treat. So we made a specific effort to identify physicians that work in communities that really serve this patient population."
For example, DeRubertis himself reached out to a site in the Southwest that didn't have a lot of experience with clinical trials. This was unusual for a clinical trial, since "generally speaking," according to DeRubertis, a national primary investigator for a trial selects sites and physicians based on their experience in trial participation. He specifically contacted this site, however, because of their patient population – Native American communities in the Southwest.
During the trial, patients were supported with information about the disease, treatment options and what trial participation entailed via a website developed for participants. There were also translation resources available. To make participation in the trial accessible, patients were able to have their transportation and lodging costs reimbursed. Those needing home health care had access to such care and could be "seen at home" during the trial.
The final results, published in October of this past year, were significant and promising.
"We saw a 31% difference where Esprit was superior (to) balloon angioplasty," said Jones-McMeans. "When it comes to disease and therapies, many times the messaging is (that) patients of diverse backgrounds may not do as well, but that's not necessarily the case. Our subgroup analysis (showed) that different groups of patients did just as well. It's not only a win for the technology, the physicians and the general patient population, it's a win for diverse patients as well."
While there have been other trials for similar treatment options in the past, not all have done as well as the Esprit BTK system.
"As we were enrolling for our trial, Boston Scientific had a stent called the SAVAL Stent," said DeRubertis. "We all expected that to work and for them to get approval first. And unfortunately their trial failed to meet its endpoint and that program has been shelved. There have been a lot of failures in this space and our patients really needed a win. We were able to deliver that."
Currently, the Esprit BTK system has started its limited market release, where various physicians who were trial investigators, including DeRubertis, have been able to use the device on patients who were not part of the clinical trial.
In the future, Jones-McMeans said she anticipates Medicare coverage for the stent.
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Best Peripheral Vascular Disease-Diabetic Gangrene Foot- Non Healing Ulcer Doctor In India [Top Interventional Radiologist Specialist In Delhi]
Dr Ashish Gupta has worked as a consultant in Sir Gangaram Hospital, Jaypee Hospital, Noida and Rajiv Gandhi cancer institute and research center, New Delhi.
![Best Peripheral Vascular Disease-Diabetic Gangrene Foot- Non Healing Ulcer Doctor in India [Top Interventional Radiologist Specialist in Delhi]](https://images.Mid-day.Com/images/images/2024/jun/health0406_d.Jpg "Best Peripheral Vascular Disease-Diabetic Gangrene Foot- Non Healing Ulcer Doctor in India [Top Interventional Radiologist Specialist in Delhi]")
Dr Ashish Gupta
Dr Ashish Gupta M.B.B.S, M.D, FVIR is a vascular and interventional radiologist. He did his MBBS from KIMS, Bangalore and post-graduation (M.D) Radiology from Bareilly, U.P. He completed his super speciality training (FVIR) from Sir Gangaram Hospital, Delhi, India.
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Dr Ashish Gupta has worked as a consultant in Sir Gangaram Hospital, Jaypee Hospital, Noida and Rajiv Gandhi cancer institute and research center, New Delhi.
Peripheral vascular disease (PVD) is the narrowing or blockage of arteries due to plaque formation in arteries, thereby leading to poor blood flow to the affected area. It commonly affects the legs but may be seen in arms, kidneys etc.
Diabetic foot ulcer, seen in diabetic patients with PVD and uncontrolled blood sugar levels, develops due to injury to foot or blisters in toes or heel of foot leading to ulcer formation.
Causes and risk factors of peripheral vascular diseases:
Smoking, diabetes mellitus, kidney disease, excessive alcohol consumption and poor hygiene.
Symptoms of PVD:
It is a slowly progressive disease. Most patients present with leg pain, or pain in buttocks, thigh or leg while walking which resolves after rest.
Non healing ulcers in leg or foot.
Numbness or fatigue in legs
The affected leg or foot is colder in comparison to other.
Changes in skin color from pale, redness to blue color.
Diagnosis of peripheral vascular disease:
Ankle brachial index: the first test conducted by interventional radiologist for the diagnosis of peripheral vascular disease.
Doppler ultrasound: Using the ultrasound machine, blood flow is checked in the affected limb to look for arterial blockage.
CT angiography: it is the most reliable non-invasive test to review the detailed images of blood vessels and for diagnosing blockage.
Angiography: it's the gold standard test to check flow and detect blockage or narrowing of arteries. In this, a thin flexible tube is inserted into the artery of a leg via which a dye is injected. The spread of the dye is seen on X-ray.
How to prevent peripheral vascular disease?
Treatment of peripheral vascular disease:
Medical management: medications are prescribed to control the progression of disease. If medications don't resolve symptoms then revascularisation may be recommended.
Angioplasty: in this, a thin tube with a balloon tip is inserted into the blood vessel and the balloon is inflated which leads to opening of the diseased vessel.
Stenting: in some cases, angioplasty alone is not sufficient and for those cases, a stent is placed inside the diseased blood vessel.
Vascular surgery / bypass surgery: consultation and evaluation by interventional radiologist should be considered before opting for surgery.
Frequently asked question from Dr Ashish Gupta
1. When to see interventional radiologist?Most of the patients don't have symptoms. A delay in diagnosis and treatment may lead to complications. If anyone experiences the above mentioned symptoms, it's best to consult a doctor.
2. How do you treat diabetic gangrene in the foot?Diabetic gangrene occurs when a foot ulcer or wound becomes infected and progresses to tissue death (gangrene) due to poor circulation, neuropathy, and impaired immune function commonly associated with diabetes. The treatment of diabetic gangrene in the foot is a complex and serious medical intervention that often involves a multi-disciplinary approach.Quick intervention is essential to prevent the spread of infection and also to prevent the need for more extensive amputations. Here are the steps and interventions involved in the treatment of diabetic gangrene:
Revascularization: An interventional radiologist assesses the blood flow to the affected foot. In some cases, revascularization procedures, such as angioplasty/stent placement may be necessary to improve blood circulation to the area.
Surgical Intervention: Depending on the extent of the gangrene, a surgical procedure may be required.
If you or someone you know is at risk for diabetic foot complications, it's crucial to manage diabetes properly, regularly inspect the feet, and seek medical attention for even minor wounds, sores, or signs of infection. Preventive care is essential in reducing the risk of diabetic foot complications, including gangrene.
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