mononeuritis multiplex = multiple mono or multifocual neurop
polyneuropathy = diffuse symmetrical dz usu begins peripherally
radiculopathy
acute/chronic
static/progressive
relapsing/recovering
MONONEUROP
etio: trauma, pinched nerve root, tumor, dibetes, immuno
mc mononeuropathy: carpal tunnel, involves single nerve, electro dx studies indispensible
tx: ala 300-600, CoQ10, B's esp B6/PLP, hydro: alt to both hands
immune support in acute: lomatia, ech, rhus-t, ranunculus
give PLP not B6, less toxicity, high doses, if giving non-PLP then must give B complex same day
hypericum for n damage,
POLYNEUROPATHY
mc etio: idiopathic, DM, B12 def
other etio: post-chemo esp cisplatin, infx, neoplasm, vasc
chemo still influences body 10yrs post tx if not detoxed, pts often have repeat sx on detox: N/D, neuropathies
conventional tx: antiepileptics, antidep, tramadol, tx for DM, renal insuff, hypothyroid, B12 def, vasculitis
pts will come in major pain, using buckets of ice at night to kill pain
not easy to injx B12 in these pts
pain management: paracetamol/codeine, anticonvuls: gabapentin, pregabalin, lamotrigine, carbamazepine, oxcarbazepine, topicals: lidocaine patch, capsaicin patch, opiates: tramadol, oxycodone, antidep: amytriptyline, nortriptyline, desipramine, duloxetine
tx: B12 1000mcg/day, B6 50mg qd, folic 1-2mg, vit E 400 IU
avoid vit C, may interfere with Bortezomib-mediated proteasome inhibition
other: tonic water, Mg, acetyle L carnitine 400-500mg, ALA 300mg bid, EPO
exercise, stop smoking, weight reduction,
self care esp diligent foot care, good shoes, ankle orthotics, assistive devices
Cochrane: inconsistent evidence for vit B
no evidence for most complimentary tx but he suggests try it anyway, there's nothing better
GUILLAIN-BARRE SYNDROME
the only peripheral neuropathy that is potentially lethal, demyelinating
ascending paralysis, up to neck
etio: post-viral, vaccine (post H1N1, post swine flu vaccine), campylobacter infx
tx: ventilator support
plasmapheresis in first 2 weeks of onset washes out inflam particles, reduces time to recovery
risks: sig heart strain
tx in first 2 wks reduces morbiditiy, after 3 wks plasmapharesis no benefit
IV IgG immunglobulin only works early, increases clotting risk
nutrit: TF, TPN, diet
tx infx
in his practice all pts with this are type A, burning candle at both ends
prog: some heal--slow, some have permanent disabilities, some die
tx: heat, sine, PT for ROM and strength
whirlpool therapy, active exercise
flax, EPO, he esp likes borage oil, fish oil
Cromium
immune support, viral immune stim, acupx
he also likes magnets
restoratives: lithospermum
research shows corticosteroids don't work, amantadine doesn't reduce fatigue
anti-viral: vit A protocol, licorice, lomatium, zinc, lots more
ddx: tick paralysis per Jody, better when remove tick
COMPLEX REGIONAL PAIN SYNDROME TYPE I
aka reflex sympathetic dystrophy
very challenging to tx, even morphine can't touch the pain
pts feel like the scream, very painful, frustrating, may start with minor trauma
not limited to 1 nerve distrib, discomfort disproportionate
sx: unrelenting pain, skin color and temp changes, edema, vasomotor, sudomotor, allodynia, hyperalesia
sx: weak and stiff, muscle spasms, difficulty with mvt, easily triggered for years in future
interaction of immune, sympathetic, motor, CNS and sensory
stages: II = dystrophic, III = atrophic
tx: try anything
elevat, compress, heat/cold, tens/US, stretch/AROM/PROM, stressl oading, exercise
go past the point of pain per PTs, don't shy away from pain when going for ROM, decreases future pain
PT is critical
conventional: nerve blocks, max 3-6 done, NSAIDS, predinisone, opioids, TCAs, anticonvulsants
sympathectomy? mb not such a good idea-->sympathalgia
gabapentin may reduce pain but has mega SEs
quigong-->transient pain redx and long term anxiety redx
**active mirror therapy mb assoc w reduced pain severity
vit C
MYOPATHIES
proximal mm weak, waddling gait, can't climb stairs, lift arms over head, etc
DYSTROPHIES
Duchenne's muscular dystrophy
myotonic dystrophy
congenital: glycogenoses, mitochondrial
acquired: polymyositis, dermatosmyositis, inclusion body myositis, drug related
MUSCULAR
motor weakness
23% duchenne
10% Becker
12% hered
12% spinal
3% congen
13% myotonic
7% congen
10% limb girdle MD
13% facio-musc
DUCEHNNE MUSCULAR DYSTROPHY
Gower's sign: uses hands to stand up, hands walk up legs
ends up swaybacked, weak ankles need bracing
large limbs: mm replaced by fat
tx: resp probs: o2 therapy, ventilator esp nocturnal, surgery for scoliosis, tracheotomy
tx: PT, bracing, crutches, prednisone, NSAIDS, wheelchair
tx: kayaking because upper body may stay functional longer
glutamine to help GI for absorption
MYOSITIS
allo tx: steroids if sxm methotrexate/immunosupp, H2 blockers, etc tx for sx
Gottron's sign
rash
sx: weakness, can't gt in and out of tub
tx: assisted living
tx: anti-inflam, food allergies, EPO, flax
PT/rehab
normalization of CK not necc
exercise is not cause of high CK
passive ROM exercises to prevent joint contractures
isometric and resistive exercises
NMJ DISORDERS
persynaptic: Lambert-Eaton synd, botulism
Post: myasthenia gravis
MYASTHENIA GRAVIS
Disney character of sleepy, eyes droop, upper body
etio: AI
face, swallowing tires, can't eat, can involve other areas
eat ev 20 mins 1-2 bites, lots of liquid foods to avoid chewing
tx: thymectomy, steroids x1yr usu 60mg pred qd, IV immunoglobulin
anticholinesterase inhibitors, keep ACh to improve neurotransmission, monitor dose!
mestinon 60mg ev 3 yr, withdraw asap, leads to half the complications, prostigmine
supps: B, E 2000IU, C 10g, Ca 500mg, lecithin, B5 200mg, glycine 5-30mg
what will help one pt won't touch the next
herbs: ephedra, 7 forest chinese herb combo
**don't give Mg+, CI with mm weakness