Peripheral Nervous System Therapy

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:009 Revision: 01 Page: 1 of 19

PHYSICAL THERAPY MANAGEMENT OF
PERIPHERAL NERVOUS SYSTEM TRAUMA AND DISEASE RELATED PATIENTS
NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health &
Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express
advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any
time.


SPEC. BY: Abdulrehman S. Mulla

DATE: 04/09/2009

REVISION HISTORY

REV. DESCRIPTION CN No. BY DATE
01 Initial Release PT009 ASM 04/09/2009

MEDICINE:IT’S A NOBLE PROFESSION, IT SERVES HUMANITY
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TABLE OF CONTENTS PAGE

1.0 PERIPHERAL NERVOUS SYSTEM: 3
1.1 PERIPHERAL NERVOUS SYSTEM DISORDERS: 7
1.1.1 CAUSES OF PERIPHERAL NERVOUS SYSTEM DISORDERS: 7
1.1.2 CLINICAL CLUES TO CAUSES OF PERIPHERAL NERVOUS SYSTEM* DISORDERS: 8
1.3 TREATMENT: 8
1.4 TYPES OF PERIPHERAL NERVOUS SYSTEM DISORDERS: 9
1.4.1 COMPRESSIVE NEUROPATHY: 9
1.4.2 SCIATICA: 10
1.4.3 PERIPHERAL NEUROPATHY: 11
A. CAUSES OF PERIPHERAL NEUROPATHY: 11
1.4.4 SPINAL INFECTIONS: 12
A. SYMPTOMS; 12
B. DIAGNOSIS: 12
C. TREATMENT OPTIONS: 12
1.4.5 SPINAL MENINGITIS: 14
1.2 NEUROLOGY PHYSICAL THERAPY: 15
1.2.1 MEDICALLY-BASED FITNESS WORKS WITH A BROAD RANGE OF CONDITIONS INCLUDING: 16
1.2.2 NERVE DISORDERS SPECIFIC PROGRAMMING: 17
A. PHYSICAL THERAPY FOR SPINAL NERVE DISORDERS: 17
B. VESTIBULAR THERAPY: 18

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PERIPHERAL NERVOUS SYSTEM TRAUMA AND DISEASE:

1.0 PERIPHERAL NERVOUS SYSTEM:

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The human peripheral system has two types of nerves based on location:
 Spinal nerves (31 pairs) connect with the spinal cord and innervate most areas of the body.
 Cranial nerves (12 pairs) connect vital organs directly to the brain.

SPINAL NERVES:

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I Olfactory II Optic
III Oculomotor IV Trochlear
V Trigeminal VI Abducens
VII Facial VIII Auditory
IX Glossopharyngeal X Vagus
XI Accessory XII Hypoglassal

CRANIAL NERVES

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Spinal and cranial nerves can also be classified on the basis of function:
 The somatic nerves relay sensory information from receptors in the skin and muscles and motor commands
to skeletal muscles (voluntary control).
 The autonomic nerves sends signals to and from smooth muscles, internal organs (visceral functions)
cardiac muscle, and glands (involuntary control).

There are two types of autonomic nerves the parasympathetic and sympathetic nerves:
 Parasympathetic nerves tend to slow down body activity when the body is not under stress. They originate in
the brain and the sacral region of the spinal cord. Their ganglia are in walls of organs. They promote
housekeeping responses, such as digestion.
 Sympathetic nerves increase overall body activity during times of stress, excitement, or danger. They also
call on the hormone epinephrine to increase the "fight-flight" response. They originate in the thoracic and
lumbar regions of the spinal cord. Their ganglia are near the spinal cord.

Most organs receive input from both sympathetic and parasympathetic nerves, usually with opposite effects on
the organ. Most organs are continually receiving both sympathetic and parasympathetic stimulation. For
example, sympathetic nerves signal the heart to speed up

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1.1 PERIPHERAL NERVOUS SYSTEM DISORDERS:

1.1.1 CAUSES OF PERIPHERAL NERVOUS SYSTEM DISORDERS:

SITE TYPE EXAMPLES
Spinal muscular atrophy types I–IV
Inherited Polio, infections by coxsackievirus and other enteroviruses (rare)
Acquired, acute Amyotrophic lateral sclerosis, paraneoplastic syndrome, postpolio syndrome,
Motor neuron* Acquired, chronic progressive bulbar palsy
Nerve root Acquired Herniated disk, infections, metastatic cancer, neurofibroma, trauma
Acute brachial neuritis, diabetes mellitus, hematoma, local tumors (eg,
schwannoma), metastatic cancer, neurofibromatosis (rare), traction during
Plexus Acquired birth, severe trauma
Hereditary adult-onset neuropathies, hereditary sensorimotor neuropathies,
Peripheral nerve Hereditary hereditary sensory and autonomic neuropathies
Hepatitis C, HIV infection, Lyme disease, syphilis In undeveloped nations:
Infectious Diphtheria, parasites
Chronic inflammatory demyelinating polyradiculoneuropathy, Guillain-Barré
Inflammatory syndrome and variants, vasculitis
Amyloidosis, diabetes mellitus, dysproteinemic neuropathy, ethanol with
undernutrition (particularly deficiency of B vitamins), ICU neuropathy,
Metabolic leukodystrophies (rare), renal insufficiency
Botulism in infants, congenital myasthenia (very rare), Eaton-Lambert
Neuromuscular syndrome, myasthenia gravis, toxic neuromuscular junction disorders (eg,
junction — due to nerve gas)
Distal muscular dystrophy (late distal hereditary myopathy; rare),
Duchenne's muscular dystrophy and related dystrophies,
fascioscapulohumeral muscular dystrophy, limb-girdle muscular dystrophy,
Muscle fibre Dystrophies oculopharyngeal dystrophy (rare)
Channelopathies Familial periodic paralysis, myotonia congenita (Thomsen's disease),
(myotonic) myotonic dystrophy (Steinert's disease)
Central core disease, centronuclear myopathy, nemaline myopathy (very
Congenital rare)
Acromegaly, Cushing's syndrome, diabetes mellitus, hypothyroidism,
Endocrine thyrotoxic myopathy
Inflammatory Infection (viral more than bacterial), polymyositis and dermatomyositis
Acid maltase deficiency, carnitine deficiency, glycogen storage and lipid
Metabolic storage diseases (rare)
Upper motor neuron disorders (e.g. spinal muscular atrophies) technically involve the CNS
because the cell body of the motor neuron is located in the spinal cord.

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1.1.2 CLINICAL CLUES TO CAUSES OF PERIPHERAL NERVOUS SYSTEM* DISORDERS:

Finding Cause to Consider
Diffuse disorders (e.g., toxic-metabolic, hereditary,
infectious, or inflammatory disorders; most immune-
Symmetric, diffuse deficits mediated disorders)
Unilateral deficits Focal disorders (e.g., mononeuropathies, plexopathies)
Deficits localized to one or more peripheral
nervous system structures (e.g., nerve root,
spinal nerve, nerve plexus, single peripheral
nerve, multiple mononeuropathy) Lesion in a peripheral nervous system structure
Stocking-glove distribution of deficits Diffuse peripheral polyneuropathies, possibly axonal
Disproportionate weakness of proximal muscles Diffuse muscle dysfunction, as occurs in diffuse
(eg, difficulty walking stairs, combing hair) with myopathies Possibly disorders of the neuromuscular
no sensory deficits junction if the eyes are affected
Chronic, progressive weakness affecting mostly
distal muscles with no sensory deficits Motor neuron disorders
Buzzing and tingling with motor weakness and
decreased reflexes Demyelination
Profound motor weakness with minimal atrophy Acquired demyelinating polyneuropathy
Deficient pain and temperature sensation;
weakness proportional to atrophy;
disproportionately mild reflex abnormalities,
usually more distal than proximal Vascular disorders (e.g. vasculitis, ischemia)

1.3 TREATMENT:
 Treatment of underlying disorder
 Supportive care, often by multidisciplinary team
Treatment is directed at the underlying disorder when possible. Otherwise, treatment is supportive. A
multidisciplinary team approach helps patients cope with progressive neurologic disability:
 Physical therapists may help patients maintain muscle function.
 Occupational therapists can recommend adaptive braces and walking devices to help with activities
of daily living.
 Speech and language therapists may provide alternative communication devices.
 If pharyngeal weakness develops, nurses feed patients with extreme care.
 A gastroenterologist may recommend percutaneous endoscopic gastrostomy.
 If respiratory weakness develops, pulmonary specialists are needed to determine whether
noninvasive respiratory support (e.g. bilevel positive airway pressure) or tracheostomy with full
ventilatory support should be used.
Early in fatal disorders, health care practitioners must talk frankly with patients, family members, and
caregivers to determine the level of intervention acceptable (see Medicolegal Issues: Advance
Directives). These decisions should be reviewed and confirmed at various stages of the disorder.

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1.4 TYPES OF PERIPHERAL NERVOUS SYSTEM DISORDERS:
 Compressive neuropathy  Spinal infections
 Sciatica  Spinal meningitis
 Peripheral neuropathy 

1.4.1 COMPRESSIVE NEUROPATHY:
Compressive Neuropathy (nu-rop-ah-thee) occurs when nerves in the spine are
compressed. This disorder often affects older people. The nerves that exit the spinal canal
become trapped, compressed, and swollen. Foraminal stenosis can be extremely painful and
debilitating. The effects may temporarily damage or permanently destroy nerves. Foraminal
stenosis (foe-ray-min-al sten-oh-sis, e.g. spinal stenosis) is an example of a compressive
neuropathy.

A slipped, herniated (her-knee-ate-ed), ruptured or bulging disc may cause nerve
compression. Nerves may also be compressed or even displaced by the growth of bone spurs. A
compressive neuropathy may cause pain to radiate into one or both buttocks, down the legs
below the knees and may be felt in the ankles and feet. Pain may be accompanied by sensations
of tingling, numbness, and weakness. These types of symptoms are generally referred to as
"sciatica."

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1.4.2 SCIATICA:
Sciatica (sy-attic-ka) is a symptom of a compressive neuropathy involving one or several of
the lower spinal nerves that make up the sciatic nerve. It is a common ailment named for the
sciatic nerve, which is a collection of smaller nerves descending from the spine and joining
together to resemble a cable. The spinal nerves come together in the pelvis to form the sciatic
nerve. The sciatic nerve then travels down through each buttock into the legs. At certain points,
such as in the posterior thighs, nerves branch off from the main sciatic cable. This is why sciatic
pain may be felt in various muscles of the leg.

SCIATIC NERVE

The spinal cord ends in the lumbar area and continues through the vertebral canal as spinal nerves.
Because of its resemblance to a horse's tail, the collection of these nerves at the end of the spinal
cord is called the cauda equina. These nerves send and receive messages to and from the lower
limbs and pelvic organs.

A direct blow to the sciatic nerve in the leg may occur when falling down. This may injure the
sciatic nerve. The force from falling down could initiate bleeding around the nerve and cause nerve
compression and pain. If a disc or bone spur protrudes into the spinal nerves that become the sciatic
nerve, the problem may become severe. A bone spur could displace a spinal nerve creating intense
pain. Fortunately there are non-surgical treatments available to help reduce inflammation and
associated pain. These treatments include medication and steroid injections.
When nonsurgical treatment fails and, depending on the patient's symptomatology, surgery may
be considered. In some cases a surgical procedure called a laminotomy (lamb-in-ah-toe-me) may be
performed to give the surgeon greater access to the offending intervertebral disc. Removal of the
disc is called a discectomy or microdiscectomy (under magnification).

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1.4.3 PERIPHERAL NEUROPATHY:
Peripheral Neuropathy is a degenerative, toxic, or nutritional condition affecting the nerves
that branch into the body's extremities such as the arms, hands, legs, and feet. Diabetes or even
certain drugs can cause peripheral neuropathy. The disease causes the peripheral or distant
parts of nerves to shrink. Eventually the affected nerves may deteriorate to the point that the
nerves can no longer carry impulses. Sensory (feeling) and motor (movement) function may be
lost. Symptoms may include burning or a feeling of pins and needles, numbness in the toes or
fingers, and weakness when gripping an object or while walking. Medication may help to slow
the effects of peripheral neuropathy but may not cure or stops its progression.
Peripheral Neuropathy may be generally categorized by the type of nerve that is damaged
(e.g., motor, sensory or autonomic). However, this condition may also be categorized by where it
occurs in the body. For instance, nerve damage that occurs in only one area of the body is called
mononeuropathy. If the damage is present in multiple areas of the body it is referred to as
polyneuropathy. When the condition is present on both sides of the body the condition is called
symmetric neuropathy.
Peripheral Neuropathy may also be categorized by cause. For example: Diabetic
Neuropathy (the result of diabetes), nutritional neuropathy (the result of a nutritional deficit), etc.
When a cause cannot be identified the condition is called idiopathic neuropathy.

A. CAUSES OF PERIPHERAL NEUROPATHY:
 Diabetic peripheral neuropathy  Prolonged use of crutches
 Charcot-Marie-Tooth syndrome  Staying in one position for too long
 Uremia  Tumor
 AIDs  Intraneural hemorrhage
 Nutritional deficiencies  Cold exposure
 Nerve entrapment  Radiation exposure
 Nerve compression  Certain medicines
 Carpal tunnel syndrome  Certain toxic substances
 Trauma  Atherosclerosis
 Penetrating injuries  Systemic lupus erythematosus
 Contusions  Scleroderma
 Fractures  Sarcoidosis
 Dislocated bones  Rheumatoid arthritis
 Polyarteritis nodosa 

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1.4.4 SPINAL INFECTIONS:
Spinal Infections are rare and painful. Immediate medical attention is always necessary. If an
infection is not detected and treated, the effected area swells and causes pain to radiate into
adjoining tissue. A spinal infection may cause permanent injury or take root in the epidural cavity
(ep-e-do-ral). This cavity is a fatty area near nerve roots and provides space for an infection or
abscess. Epidural cavities are found in the cervical (sir-ve-kal), thoracic (thor-as-ick), and lumbar
(lum-bar) spine. An MRI may be performed to confirm a spinal infection. Nonsurgical treatment
may include intravenous or oral antibiotics combined with bed rest. In some cases surgical
intervention may be necessary to eradicate the infection.

A. SYMPTOMS;
The symptoms of a spinal infection include fever, chills, headache, neck stiffness, pain,
wound redness and tenderness, and wound drainage. In some cases patients may notice
new weakness, numbness, or tingling sensations in the arms and/ or legs.
The symptoms may be very severe, or they may be very subtle in some cases.
Your doctor may order a series of tests to look for an infection if one is suspected.

B. DIAGNOSIS:
These tests may include plain x-rays, computerized tomography (CT or CAT) scans, or MRI
scans. In some cases further, specialized testing is required when the diagnosis is still in
question. These include nuclear medicine bone scans and nuclear medicine tagged white
blood cell scans. Your doctor will want to obtain cultures to determine the type of bacteria or
fungus that is causing the infection. Blood cultures are often obtained to screen for evidence
of infection. Cultures of your wound or the area of infection may be taken. In cases of deep
infections of the vertebrae (bone) or the intervertebral disk, a needle culture may be
required. This is often done with x-ray guidance with local anesthetic medication given at the
needle entry site. Your doctor may also order additional blood tests to screen for signs of an
infection. These tests include a white blood cell (WBC) count, c-reactive protein (CRP) and
an erythrocyte sedimentation rate (ESR). These values may be slightly elevated after an
operation, but usually return to normal values within a few weeks. Abnormal elevation may
represent a sign of infection.

C. TREATMENT OPTIONS:
The nonsurgical management of spinal infections consists of antibiotic or antifungal
medications. The type and the duration of the treatment depends on the severity of the
infection and the organism causing the infection. Antibiotics or antifungal medications may
be necessary intravenously (IV) and/ or orally. The duration of the treatment typically ranges
from as short as 7-10 days, to as long as 6-12 weeks. You may need to have a special
intravenous line, called a central line, placed for a long course of antibiotics. This allows, in
some cases, for the medications to be administered at home with the assistance of a home
health care agency or a visiting nurse. Your doctor may recommend using a brace to support
the spine until healing occurs and to help with the pain.
Surgery may be required for many postoperative infections to wash away much of the
bacteria and infected tissue. In addition, surgery may be required in cases where there is
evidence of instability of the spine as a result of the infection. In cases in which there is
severe weakness as a result of a spinal infection, surgery may be required to relieve the
pressure on the spinal cord caused by the infection.

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The surgical options to treat spinal infections range from simply washing out the wound
and re-closing to more extensive debridements and removal of infected tissues. In some
cases it is not possible to close the wound at the time of surgery, and a packing dressing is
left in place. This is often changed two to three times a day until the wound heals over a
period of several weeks. A combination of surgery and long term antibiotics are often
required to completely treat some spinal infections. During the course of your treatment, your
doctor may follow your white blood cell (WBC) count along with your C-reactive protein
(CRP) or erythrocyte sedimentation rate (ESR) as markers of the response to therapy.
These levels may be elevated in the early period after surgery, but they usually return to
normal within a few weeks. Re-elevation or failure of these values to return to normal after
treatment may indicate recurrent or residual infection.

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1.4.5 SPINAL MENINGITIS:
Spinal Meningitis (men-in-ji-tis) is an infection that causes inflammation of the membranes in
the brain and spinal cord. This is a serious disease and may require hospitalization. Treatment
includes intravenous or oral antibiotics combined with bed rest. Symptoms may include fever,
weakness, pain that radiates from the spine, muscle spasm, sensitivity to touch, decreased
spinal flexibility, fatigue, sweating, and weight loss. When a child is affected, symptoms may
include his refusal to stand or sit because it is painful. Increased backache may be an indication
in older children and adults. Neck pain and sensitivity to light are common symptoms.

The organs of the central nervous system (brain and spinal cord) are covered by 3 connective
tissue layers collectively called the meninges. Consisting of the pia mater (closest to the CNS
structures), the arachnoid and the dura mater (farthest from the CNS), the meninges also
support blood vessels and contain cerebrospinal fluid. These are the structures involved in
meningitis, an inflammation of the meninges, which, if severe, may become encephalitis, an
inflammation of the brain.

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1.2 NEUROLOGY PHYSICAL THERAPY:
High velocity accidents and sporting incidents carry a risk of causing a spinal cord injury (SCI), a
serious but uncommon condition which can also be caused by ischaemia, infections or tumours. Younger
people are the biggest group likely to suffer this injury due to their risky pursuits but it can occur in
someone of any age, road accidents accounting for the greatest proportion. Due to the complex nature of
the condition a multi-disciplinary approach is essential, involving several health care professionals, to
facilitate the highest degree of independence in the patient. Paraplegia and quadriplegia are the terms
used for the resulting conditions.
The emergency medical situation is dealt with first, keeping the person alive and ensuring their
breathing is clear. Once in the hospital the doctors test the patient to find out what spinal level has been
damaged as this determines much of the physiotherapy and medical management. Low spinal injury
such as in the lumbar area will not have consequences for the patient's ability to breathe and they will
have good arm and trunk power to work on independence. A high thoracic or cervical injury paralyses
some of the rib muscles, reducing the ability for spontaneous breathing and limiting arm power, making
rehabilitation much more difficult.
Assessment of the patient's respiratory status is the initial concern of the physiotherapist, often in the
intensive care unit. The physiotherapist will attempt to encourage the patient to expand their lungs, deep
breathe and cough any secretions up to clear their chest. Paralysis of the lower trunk can reduce
propulsive force and thereby the effectiveness of coughing, a process which the physiotherapist helps by
stabilizing the lower abdomen during attempted coughing. Suction may be needed in severe cases and
coughing can be promoted by using a cough assist machine.
Transfer of the patient to the ward follows the intensive care period and by now they should be
medically stable. The patient may undergo spinal fusion surgery with internal fixation to stabilized the
fractured segments, avoiding the need to wait for the typical healing period of the spine which is three
months. Now the early rehabilitation of the patient can begin, with the physiotherapist checking closely
on the patient's respiratory ability, exercising the non-paralyzed areas for strength and mobility and
undertaking regular passive movements to the paralyzed limbs to keep and to increase the ranges of
motion.
If the spine is unstable, which it often is in spinal trauma resulting in paraplegia, a spinal surgeon will
stabilized the spine, usually with instrumentation and bone grafting. This allows the patient to start their
rehabilitation without the long wait for the spinal fractures to heal naturally. Initial physiotherapy
management is to monitor the respiratory status, encourage active movement of unaffected areas and
perform passive movements of paralyzed body parts to retain and improve the ranges of motion which
will be required later for independence.
Positioning the spinal cord injured patient is very important for safety of the fracture site, for pressure
care of the skin and for preparing the patients body for the positions they will need to live as
independently as possible. The frog position is one of the postures the physiotherapist will place the
patient in, with the hips bent up and the knees placed out to the side so the soles of the feet are
touching. The patient will need this position to manage their sitting balance to lean forward to move the
legs, to self-catheterise and to get to their feet to put on socks and manage foot care.
The next stage of rehabilitation involves getting the patient up into a wheelchair but initially the
patient's blood pressure can react badly by dropping strongly so they are sat gradually up in bed and
then transferred to a chair with the back on a slope and with elevating leg rests. Tolerance of being
upright is gradually extended and sitting balance practiced on the edge of a plinth, with the
physiotherapist closely monitoring any poor trunk control. The physiotherapist will move on to
strengthening and to teaching transfers into a wheelchair and once the patient has developed
reasonable sitting balance and accustomed themselves to transfers and being out in a wheelchair for

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periods of time it is appropriate for them to be transferred to a spinal injuries unit where they can receive
specialized help from a multi-disciplinary team for the many aspects of their condition they need to
master to be as independent as possible.

1.2.1 MEDICALLY-BASED FITNESS WORKS WITH A BROAD RANGE OF CONDITIONS INCLUDING:
 Balance Deficits  Stroke
 Nerve disorders  Polyneuropathies
 Multiple Sclerosis  Dizziness
 Brain Injury  Vestibular
 Spinal Cord Injury  Coordination
 Peripheral Neuropathy 
MBF Physical Therapy restores physical function and improves the efficiency of movement by
addressing the individual client's functional limitations. Our therapists treat the functional deficits you
have in order to improve your daily life. MBF takes an active approach in treatment, and problem solves
long-term solutions with individualized programs treating the whole body. Our care is transferable to daily
life activities making clients happier, healthier, and more independent.
MBF Physical Therapists excel in treatment of the neurological system. MBF has been working with
individuals with neurological impairments since 1996. There have been three Master's and two PhD
degrees earned through research performed at Medically-Based Fitness. We utilize outcome based
research and the most current research to guide our programming. We have concrete outcomes that
improve the active approach to therapy in order to advance the life of every client.

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1.2.2 NERVE DISORDERS SPECIFIC PROGRAMMING:
MBF is a resource to individuals with NERVE DISORDERS disease for information,
education, and treatment. MBF Physical Therapy enables an individual to compensate for the
changes brought on by NERVE DISORDERS disease by providing programming that is
specifically developed for individuals limited by this disease. The treatment will include therapies
to address immediate limitations and develop long term programs to promote functional
independence through the disease process. The physical therapy includes education for the
individuals and their caregivers.

A. PHYSICAL THERAPY FOR SPINAL NERVE DISORDERS:
 Balance and Coordination  Immobility
 Gait  Trunk and Joint Mobility
 Weakness  Motor Programming
 Pain  Fatigue
 Posture 

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B. VESTIBULAR THERAPY:
Vestibular therapy encompasses a multitude of diagnoses and subjective complaints. A
vestibular therapist can effectively treat patients who are dizzy for reasons including:
 Benign Paroxysmal Positional Vertigo (BPPV);  Fall risk,
 Vestibular Hypofunction or Injury;  Deconditioning,
 Meniere's Disease;  Neurological injuries such as
MS, TBI, or concussion with
resultant complaints of
 General imbalance, dizziness.
The treatment received will vary depending on the etiology/cause of the patient's
complaints. Some patients are seen only a few visits and are symptom-free very quickly.
Other patients have to be seen for a longer duration of time, but will also notice dramatic
changes in their subjective complaints, dizziness, or imbalance; as well as in objective
measures.

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Filename: PTP&M009 PTM of Peripheral Nervous System trauma
and disease Medical Journal
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Title: PHYSICAL THERAPY MANAGEMENT OF
PERIPHERAL NERVOUS SYSTEM TRAUMA AND DISEASE RELATED
PATIENTS
Subject:
Author: Abdulrehman Mulla
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Creation Date: 4/11/2009 8:12 AM
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Last Saved By: Abdulrehman S. Mulla
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Peripheral Nervous System Therapy

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