Physical Therapist's Guide to Peripheral Neuropathy
Peripheral neuropathy (PN) is a condition affecting the nerves of the body that results in a variety of symptoms including pain, changes in sensation, and alterations in muscle activity. PN may be associated with other disease processes such as diabetes, bodily injury, and overuse conditions. It also can occur as a side effect of medications, such as chemotherapy. Although the symptoms of some types of PN have been shown to improve over time, many do not. Treatment by a physical therapist can help reduce symptoms of PN in some cases, and reduce the effect the symptoms have on movements and activities to improve an individual's quality of life.
What is Peripheal Neuropathy?
Peripheral neuropathy (PN) is a condition that affects the nerves of your body. It is generally classified by the number of nerves affected, the type of nerve cells affected, or the process affecting the nerves. Depending on these factors, the symptoms of PN vary widely, and can include sensory (eg, touch), motor (eg, movement), and/or autonomic (ie, nervous system) issues (see the “How Does It Feel” section below for more details).
Common classifications of PN include:
- Mononeuropathy. This is a condition only affecting 1 nerve. It is often a result of the compression of a nerve, which creates an onset of symptoms. Carpal tunnel syndrome is an example of a mononeuropathy, in which compression of the median nerve in the arm results in altered sensation, pain, and weakness of the hand.
- Polyneuropathy. This is a condition affecting 2 or more nerves and is generally a result of a disease process that affects the entire body. This type of PN can result in an individual experiencing symptoms in various body parts, on both sides of the body.
- Neuritis. This is a condition that results from inflammation of a nerve. There are many causes of this type of PN including infection, injury, or exposure to chemicals.
How Does it Feel?
To understand symptoms of PN, we must first understand that nerves have influence over 3 primary functions, all of which may be altered by PN:
- Motor function (movement)
- Autonomic (nervous system) function
Depending on the location and type of nerve(s) involved, people with PN may experience:
- Numbness and tingling, most commonly starting in the feet and hands, and possibly spreading up the limbs
- Loss or absence of sensation (the ability to sense contact with outside objects)
- Pain, often described as burning, sharp, or "electric-like"
- Increased sensitivity to light touch
- Clumsiness or decreased coordination in the affected limb(s)
- Weakness or paralysis in the muscles or parts of the body affected by the nerve or nerves
- Bowel or bladder changes; nerves controlling these functions may be affected
- Temperature intolerances
- Decreased balance
- Poor wound healing
- Excessive sweating or skin dryness
- Flushed or pale skin
- Abnormal nail growth
- Decreased ability to participate in normal functional activities
CAUTION: If you or a loved one are experiencing any of the above symptoms, consult a medical professional.
How Is It Diagnosed?
A thorough examination by a medical professional will help determine if you have symptoms of PN. There are several methods and tests a clinician may use to make a diagnosis, such as testing your reflexes, sensation, and muscle strength.
If you have suspected symptoms, your physician may also order blood work, diagnostic imaging (such as an MRI), or nerve-conduction testing. These tests are generally ordered based on the suspected origin of symptoms.
How Can a Physical Therapist Help?
Physical therapists play a vital role in helping individuals improve and maintain functions that may be limited by PN. Your physical therapist will work with you to develop a treatment plan to help address your specific needs and goals.
Because the cause, type, and symptoms of PN can all vary, the approach to care will also vary. Your physical therapist may provide the following recommendations and care:
Nerve gliding activities. To function well, nerves require 3 things: movement, blood, and space. Exercises that move and “glide” your nerves are often effective at helping to manage symptoms of PN, as well as promote nourishment and healing of the nerve. Your physical therapist can show you effective exercises that move and glide your nerves.
Moderate-intensity exercise. Your physical therapist may recommend moderate-intensity exercises to help improve your strength and physical function.
Balance and coordination activities. Your physical therapist may work on strategies to improve your balance and coordination, both of which may be altered by PN. Improving balance and coordination can help decrease your risk of falling.
Bracing. Your physical therapist may prescribe bracing for your nerve injury. Braces can be used to protect injured nerves or to help you move safely.
Education. Your physical therapist will educate you on how to safely manage PN. Your education will vary based on your individual needs, and may focus on improving your safety, preventing further complications, and finding alternative ways to perform certain tasks.
Can this Injury or Condition be Prevented?
Because there are many conditions associated with PN, some basic lifestyle modifications can help reduce the risk of its development. Examples of lifestyle modification include avoidance of specific activities that put nerves at risk for injury, avoidance of specific environmental chemicals that may aggravate a preexisting nerve injury, and incorporating daily exercise into one’s lifestyle to better control diseases that may aggravate nerve injuries.
Maintaining an active, healthy lifestyle with routine checkups by your physical therapist may help reduce your risk of developing certain types of PN and the complications associated with it. Your physical therapist is trained to notice any changes in factors, such as your strength, sensation, and functional ability, which could suggest development of PN—and to work with you to help prevent its further development.
Real Life Experiences
Tom is a 66-year-old retiree who enjoys playing golf at his local course every week. Recently, Tom began to notice that his feet were feeling numb and "tingly" throughout the day. When walking on the golf course, he noticed that he had bouts of clumsiness, stumbling a few times. During his last golf game, he fell. He decided it was time to see his physical therapist.
During his examination, Tom reports that he felt like his feet "just gave out" on the golf course, and he’s worried it might happen again. He describes the numbness and tingling in his feet and his recent bouts of stumbling.
Tom’s physical therapist asks him about his medical history. Tom admits he was recently diagnosed with type 2 diabetes and is on medication for high blood pressure. He reports that he had suspected he was diabetic for the past year or two, but was hesitant to find out for sure.
Upon examination, Tom’s physical therapist notes a decrease in strength and sensation in both of Tom's feet and ankles. Using further tests, he detects that Tom also has decreased coordination in his legs, and poor balance when standing.
Tom's physical therapist explains that these symptoms may be related to a nerve condition called peripheral neuropathy, which is often associated with diabetes. He contacts Tom's doctor, and recommends that Tom receive physical therapy treatment for a few weeks to work on his balance and coordination.
On his next visit, Tom reports that his doctor has indeed diagnosed peripheral neuropathy, has prescribed medicine for the condition, and has concurred that physical therapy is necessary. His physical therapist works with him over the next few weeks to strengthen his muscles and improve his balance.
After several weeks of physical therapy, Tom's physical therapist determines that he has improved strength in both of his legs as well as improved balance. Tom says he feels much more confident about walking outdoors, and is ready to return to the golf course.
Just this week, Tom reports that his renewed strength and confidence are improving his golf game—and making his retirement much more enjoyable!
This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat conditions, such as PN. However, when seeking a provider you may want to consider:
A physical therapist who is a board-certified clinical specialist, such as a board-certified geriatric clinical specialist (GCS), board-certified neurologic clinical specialist (NCS), or board-certified orthopaedic clinical specialist (OCS), or who has advanced knowledge, experience, and skills that may apply to your condition. You want to seek a physical therapist who is well-versed in the treatment of PN or other neuropathic disorders.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with peripheral neuropathy.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and keeping a journal highlighting when you experience pain will help the physical therapist identify the best way of approaching care.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions, and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence for the treatment of PN. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Gilchrist LS, Tanner LR. Short-term recovery of balance control: association with chemotherapy-induced peripheral neuropathy in pediatric oncology. Pediatr Phys Ther. 2018;30(2):119–124. Article Summary on PubMed.
Amato Nesbit S, Sharma R, Waldfogel JM, et al. Non-pharmacologic treatments for symptoms of diabetic peripheral neuropathy: a systematic review. Curr Med Res Opin. August 17, 2018 [Epub ahead of print]. doi: 10.1080/03007995.2018.1497958. Article Summary on PubMed.
Fernández-de-Las-Peñas C, Plaza-Manzano G. Carpal tunnel syndrome: just a peripheral neuropathy? Pain Manag. June 5, 2018 [Epub ahead of print]. doi: 10.2217/pmt-2017-0063. Article Summary on PubMed.
Oh PJ, Kim YL. Effectiveness of non-pharmacologic interventions in chemotherapy induced peripheral neuropathy: a systematic review and meta-analysis [article in Korean]. J Korean Acad Nurs. 2018;48(2):123–142. Article Summary in PubMed.
Wolny T. The use of neurodynamic techniques in the conservative treatment of carpal tunnel syndrome: a critical appraisal of the literature. Ortop Traumatol Rehabil. 2017;19(5):427–440. Article Summary on PubMed.
Stubblefield MD. The underutilization of rehabilitation to treat physical impairments in breast cancer survivors. PM R. 2017;9(9S2):S317–S323. Article Summary on PubMed.
Childress MA, Becker BA. Nonoperative management of cervical radiculopathy. Am Fam Physician. 2016;93(9):746–754. Free Article.
Jones RC III, Lawson E, Backonja M. Managing neuropathic pain. Med Clin North Am. 2016;100(1):151–167. Article Summary in PubMed.
Tuttle LJ, Hastings MK, Mueller MJ. A moderate-intensity weight-bearing exercise program for a person with type 2 diabetes and peripheral neuropathy. Phys Ther. 2012:92(1):133–141. Free Article.
Kluding PM, Pasnoor M, Singh R, et al. The effect of exercise on neuropathic symptoms, nerve function, and cutaneous innervation in people with diabetic peripheral neuropathy. J Diabetes Complications. 2012;26(5):424–429. Free Article.
Uusitupa M, Tuomilehto J, Puska P. Are we really active in the prevention of obesity and type 2 diabetes at the community level? Nutr Metab Cardiovasc Dis. 2011:21;380–389. Article Summary on PubMed.
Coppieters MW, Butler DS. Do “sliders” slide and “tensioners” tension: an analysis of neurodynamic techniques and considerations regarding their application. Man Ther. 2008;13(3);213–221. Article Summary on PubMed.
* PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Revised by Stephen Carp PT, PhD, a board-certified geriatric specialist. Authored by Joseph Brence, PT, DPT. He is a certified orthopedic manual therapist and a Fellow of the American Academy of Orthopedic Manual Physical Therapists. Reviewed by the MoveForwardPT.com editorial board.
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