Richard DeFalco, DPT, OCS, CSCS

Numbness and tingling in the lower legs, decreased balance, inability to sense where your body is in space……if these are symptoms that you experience, you may be suffering from peripheral neuropathy. More and more, there are patients being referred for physical therapy for treatment of their neuropathy.

Neuropathy is a diagnosis that is classified by an inability of nerves to transmit information to and from the brain. It commonly affects the ability of those nerves to transmit information regarding sensation as well as appropriate muscle control and sometimes autonomic control (the automatic control of visceral functions such as sweating, heart rate, and blood pressure.) There may be only one nerve that is affected such as in a mononeuropathy or several nerves as in a polyneuropathy. A classic pattern of nerve involvement is one that exists in peripheral neuropathy.

Some of the causes of peripheral neuropathy are diabetes, alcoholism, inherited disorders, autoimmune disorders, an entrapped peripheral nerve, medication side effects, exposure to toxins, infection, and physical injury.

With peripheral neuropathy the longer nerves in the body are most often affected first and speak to the reason as to why symptoms are often felt first in the feet and/or hands and progressing towards the trunk. Some of the initial symptoms are burning, tingling, and numbness starting in the feet. Patients will often report a “sort of stocking glove” distribution of neurological deficit. In other words, the initial report of symptoms (numbness, burning, and tingling) they may feel resemble the pattern of wearing an invisible glove or pair of stockings. This is because the condition will affect multiple nerves in the affected extremities.

Just as sensation can be affected, so can motor function, leading to the inability to coordinate muscle movement. One may start to notice a loss of muscle size and abnormalities of muscle tone. Again, usually starting in the extremities first, one may notice a decreased ability to control their ankle dorsiflexors (the muscles on the front of the lower leg responsible for lifting your toes and foot towards your shin) which will ultimately result in impaired ambulation. The resultant loss of sensation and motor function can lead to a decreased ability to maintain balance with a subsequent increased risk for falls.

This leads to the reasoning of a referral for physical therapy. Between pharmacological management and physical therapy interventions, an appropriate treatment plan can be devised to help manage the symptoms that lead to further complications including falls, fractures as a result of falls, and head injuries as a result of falls.

There have been multiple controlled studies that demonstrate that a moderate-intensity exercise program can be successful in improving measures of muscle strength, physical function, activities of daily living, and other quality of life measures in individuals living with peripheral neuropathy as well as other neuromuscular disorders. Moreover, when individuals are educated on the risk factors leading to falls and implement strategies to thwart them, there is a resultant decrease in the frequency of falls.

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Vertigo or dizziness refers to the sensation of spinning or disorientation that occurs as a result of a disturbance in a person's balance or equilibrium. It also may be used to describe feelings of dizziness, lightheadedness, faintness, and unsteadiness. Vertigo usually occurs as a result of a disorder in the vestibular system. The vestibular system as a whole is a system of peripheral organs and central based neurons that your body uses to maintain its upright positioning and orientation in space. It is comprised of structures of the inner ear, the vestibular nerve, brainstem, and cerebellum. The vestibular system is responsible for integrating sensory information as the body or its surroundings move keeping objects in visual focus.

When the head moves, signals are transmitted to the labyrinth in the inner ear which is structure that is made up of three semicircular canals surrounded by fluid. The labyrinth then transmits movement information to the vestibular nerve which carries the information to the brainstem and cerebellum. The brainstem and cerebellum are areas of the brain that control balance, posture, and motor coordination. Disorders of the vestibular system can cause dizziness, vertigo, imbalance, hearing changes, nausea, fatigue, anxiety, and difficulty concentrating. These symptoms can potentially have devastating effects on a person's day-to-day functioning.

Vertigo is one of the most common health problems in adults. According to the National Institutes of Health (NIH), about 40% of people in the United States experience a feeling of dizziness at least once during their lifetime. There are two types of vestibular disorders, peripheral vestibular disorders and central vestibular disorders. The sudden onset of vertigo usually indicates a peripheral vestibular disorder. Benign paroxysmal positional vertigo (BPPV) is the most common form of peripheral vertigo. It usually lasts a few seconds to a few minutes and is intermittent, or comes and goes. It may include lightheadedness, imbalance, and nausea, and is usually the result of a change in position, such as rolling over in bed or getting out of bed. Benign Paroxysmal Positional Vertigo (BPPV) occurs when debris made up of calcium carbonate and protein, called otoliths or ear crystals, becomes displaced in the labyrinth portion of the inner ear. This displacement causes abnormal sensations when the head is moved in relation to gravity and is perceived by your brain as confusion or "Vertigo." Statistically BBPV accounts for 50% of the dizziness in individuals over the age of 65.

Vertigo caused by a central vestibular disorder usually develops gradually and may include symptoms such as; double vision, headache, lack of coordination, nausea and vomiting, and weakness. This is due to damage in the central or brain portion of the vestibular system. There are many causes of vertigo due to central vestibular disorders that may include; cardiovascular disorders, stroke, head trauma, migraine, multiple sclerosis, and tumors that may affect the central vestibular system.

It is important to diagnose the cause of vertigo, or dizziness, as quickly as possible to rule out serious conditions such as cardiovascular disease, stroke, hemorrhage, or tumor. Following a thorough examination your medical practitioner can make the appropriate diagnosis. Some important considerations to keep track of for your physician to assist with the proper diagnosis are; what triggers the vertigo, what symptoms occur, how long does the dizziness last, and what improves or worsens symptoms.

If your physician determines that your vertigo is peripheral and positional based you may be referred to a physical therapist that is trained in a canalith repositioning maneuver. This is a maneuver in which a Physical Therapist trained in performing canalith repositioning techniques through changing your head position and orientation in space can reposition your displaced canaliths or ear stones helping to resolve your vertigo. With the correct diagnosis and the correct canalith repositioning technique positional based vertigo can be corrected in just a few treatments.

If your physician determines that you may be suffering from central vestibular dysfunction or if following a treatment for BPPV you still are suffering from residual imbalances, you may be referred by your physician to a Physical Therapist trained in vestibular rehabilitation therapy (VRT). Vestibular rehabilitation therapy is a type of physical therapy used to treat vertigo and imbalance. The goal of treatment is to minimize dizziness, improve balance, and prevent falls by restoring normal function of the vestibular system. In VRT, the patient performs exercises designed to allow the brain to adapt to and compensate for whatever is causing the vertigo. In most cases, patients visit the therapist and are instructed in custom-designed exercises to be performed at home, several times a day. As the patient progresses, difficulty of the exercises increases until the highest level of balance is attained, or until the vertigo resolves. Often, VRT is so successful that no other treatment is required.