PERIPHERAL NEUROPATHY

PRESENTED BY:
HASNA DIYANI SALAMAH, DR

SUPERVISED BY:
DR. VITRIANA., DR., SP.KFR (K)
• Patofisiologi
• Assessmen KFR dan interpretasi
• Penegakan diagnosis fungsional
• Prognosis fungsional
• Faktor yang mempengaruhi proses pemulihan
• Tujuan penanganan rehabilitasi
• Komplikasi, penyulit
NEUROPATHY
• Neuropathies can be generalized or localized, proximal or distal
• Etiology :
• Compression
• Metabolic derangements
• Toxic exposure
• Autoimmune inflammation
• Hereditary causes
• Infection
• Neoplasm
TERMINOLOGI

• Polyneuropathy : bilaterally symmetric affliction of the peripheral nerves,

usually involving legs more than arms, segmen distal lebih awal dan berat
daripada proksimal
• Radiculopathy : involvement of the roots
• Mononeuropathy : involvement of a single nerve
• Mononeuropathy multiplex : involvement of multiple nerves in an asymmetric
and random distribution
• Plexopathy denotes involvement limited to the brachial or lumbar plexus.
• Sensory ganglionopathy and sensory neuropathy are self-explanatory.
• The term axonal or demyelinative specifies the site of principal structure
change.
DIAGNOSIS OF PERIPHERAL NEUROPATHY
TREATMENT STRATEGIES FOR PERIPHERAL
NEUROPATHY

include treatment of
underlying disease,
splinting,
medication,
therapeutic
modalities, stem cell
therapies, and
surgery
Stem cell = evidence in both rats and humans that myelinating Schwann cells can
be obtained by seeding with marrow stem cells (recovery from pain and sensory
nerve function) or mesenchymal stem cell seeding (animal model).

Treatment of underlying disease also addresses conditions that lead to fluid

retention or thickening of tissues sur rounding a nerve.

Splinting is useful for restricting joint or tendon motion and reducing intermittent
pressure on the nerve

mobilize tissues and reduce adhesions (massage, ultrasound, exercise) are useful in
entrapment neuropathies before considering surgical release.
ENTRAPMENT PERIPHERAL
ENTRAPMENT PERIPHERAL
• Patofisiologi
= external compression, swelling of the nerve or compression of vascular supply, and
ischemia

Risk factor:
1. a rise pressure within a contained site (tendon thickening/edema from overuse)
2. rigid containment (carpal tunnel border)
3. pathologic increase in nerve caliber (edema / hypertropic remyelination)
4. stretching or tethering the nerve with a related increase in resting tension
5. presence of anomalous muscle or bone in a common confined space
• Patofisiologi:
Segmental demyelination  Neuropraxia*  pressure and
rigidity in fascial compartement  (1) changes in
intraneurial microcirculation, (2) impairment axonal
transport (3) changes in vascular permeability  edema
formation , block conduction
THORACIC OUTLET SYNDROME
• Definition : compression of the neurovascular structures as they exit through the
thoracic outlet (cervicothoracobrachial region). The thoracic outlet is marked by the
anterior scalene muscle anteriorly, the middle scalene posteriorly, and the first rib
inferiorly.
(1) brachial plexus typically travels posterior and superior to the subclavian vein,
passing over the rib, between the medial and anterior scalene muscles, referred to as
the interscalene triangle
(2) midcourse the plexus runs between the first rib and the clavicle. Distally, as it enters
the axilla,
(3) it passes beneath the pectoralis muscle close to its insertion on the coracoid process.
• Sign symptom :
symptoms in median and/or ulnar nerve distributions.
specifically intrinsic hand muscle weakness. Sensory impairment can be seen
in a C8 to T1 distribution
• Etiology:
the presence of a cervical rib, with fibrous bands, accessory and
hypertrophied scalene muscles, anatomic variations in the course of the
muscle, and postural factors
• Rehabilitation Prescription: shoulder and neck range of motion, posture,
and strengthening of the shoulder girdle
ASSESSMEN IKFR

• Adson test
The patient is asked to rotate the head and elevate the chin toward the affected side. If the
radial pulse on the side is absent or decreased then the test is positive, showing the vascular
component of the neurovascular bundle is compressed by the scalene muscle or cervical rib
• Wright test
the patient’s arm is hyperabducted. If there is a decrease or absence of a pulse on one side
then the test is positive, showing the axillary artery is compressed by the pectoralis minor
muscle or coracoid process due to stretching of the neurovascular bundle
• Roos test
he patient has arms at 90° abduction and puts downwards pressure on the scapula as the
patient opens and closes the fingers. If the TOS symptoms are reproduced within 90 seconds,
the test is positive
MEDIAN NERVE
CTS
CARPAL TUNNEL

• Dibentuk oleh tulang2 karpal dan fleksor • Isi utama carpal tunnel
retinakulum - N medianus
• Komponen tulang ; membentuk suatu arkus - 4 tendon fleksor dig superfisialis
yang terbentuk dari 4 penonjolan tulang
- 4 tendon fleksor profundus
- Bgn proksimal
- Tendon fleksor pol longus
: pisiformis dan tuberkel dari skaphoid
- Bgn distal: hook dari hamate dan tuberkel
dari trapezium
• Contents of carpal tunnel include • Nocturnal worsening of symptoms is
median nerve, flexor pollicis longus common
tendon, four tendons from flexor dig • Awakening with hand paresthesis,
superf and profundus muscles. which relieved by shaking the
• Paresthesis (numness, tingling, burning) involved hand (flick sign).
1st 3,5 digits, along with deep aching • Advanced cases ; sensory symptom
pain in hand and wrist. last longer/persistent, thenar
• Pain radiate into forearm, rarely to weakness
the shoulder • Dropping object frequently
• Most common in women, bilaterally • Weakness and atropy of abd pol
in about 50% brevis and opponens pol muscles
• Often assoc. Repetitive hand and • Tinel sign, phalen sign, median nerve
wrist movements or the use vibrating compression test
machines • Flick sign
• Great majority idiopathic
• Can predispose to CTS: DM,
amyloidosis, hypothyroidism, RA,
obesity,pregnancy
• Phalen's sign.
Hold your hands back-to-back
as shown with your wrist bent at
90 degrees. If you develop pain,
numbness, or tingling within 60
seconds, you may have carpal
tunnel syndrome
• Tinel sign.
Have someone hold your hand with your
wrist bent slightly back.
With the other hand, your assistant should
tap on your wrist as shown.
If you experience pain, numbness, or
tingling while they are tapping, you may
have carpal tunnel syndrome.
You can also perform this on yourself by
tapping on your wrist as shown in the
picture. Having someone else bend your
wrist back slightly is a little more
effective.
TREATMENT

1. Penggunaan volar wrist splint untuk • Bidai digunakan sesegera mungkin (dlm 3
membatasi pergerakan pergelangan bln pertama)
tangan, dan diposisikan secara netral • Sepanjang hari
Tujuan pengunaan volar wrist spint: • Selama 4-6 minggu
• menahan secara statis • Penelitian :Bidai waktu malam 6 minggu
• mengurangi pergerakan pergelangan  mengurangi gejala
tangan agar tetap dalam keadaan • Tekanan plg rendah : posisi 0-5◦
netral atau ekstensi 0-5◦
• Posisi sendi metakarpophalangeal
posisi netral juga
2. Modifikasi aktifitas 3. Medikasi
-hindari gerakan berulang - NSAID
-hindari memaksakan wrist dlm kondisi - Kortikosteroid oral
hiperekstensi atau hiperfleksi - Vitamin B6 (hasil masih kontradiksi)
-perhatikan gerakan mengangkat, - Penyuntikan lokal kortikosteroid
mendorong, menarik, gerakan
4. Modalitas:
berulang, dsb
US : 1.5 watt/cm, frek 3 MHz,
diameter probe 3 cm, lama terapi 5
menit, 3X/minggu selama 3 minggu
5. Latihan gliding nervus dan gliding • The purpose of nerve glide exercises is
tendon to maintain flexibility of the nerves and
- Teknik yang berdasar pada ligaments.
pergerakan gliding sehingga nervus
medianus dapat bergerak sesuai
jangkauan gerakannya • Setiap posisi ditahan selama 5 detik,
sebanyak 5 sesi sehari selama 4
- Mengurangi adhesi dan mengurangi
minggu, setiap sesi dilakukan 10
gejala karena saraf dapat
bergerak bebas serta mengirimkan gerakan
02 ke saraf dan mengurangi nyeri
karena iskemi
masih blm banyak penelitian
TREATMENT

Conservative treatment options for entrapment/compression

syndromes relieve pressure and nerve compression
Strategies: splinting, massage and tendon mobilization, treat
underlying disease, medication
ULNAR NERVE
ENTRAPMENT
CUBITAL TUNNEL SYNDROME

• = ulnar nerve neuropathy at the • N.ulnaris memasuki cubital tunnel

elbow (UNE) antara medial epicondyle dan
• 2nd most common neuropathy olecranon, dan di bawah
humeroulnar aponeurotic arcade
• Keluar melalui deep flexor pronator
aponeurosis
CUBITAL TUNNEL SYNDROME

• Paresthesia pada jari ke 4-5, di daerah aspek • Untuk deteksi weakness dilakukan side to side
ulnaris di dorsum manus confrontatial strength testing
• Weakness & atrophy muncul kemudian, • Tinel sign at the elbow
kebanyakan mengenai otot-otot intrinsik hand
gejala akan muncul pada beberapa pasien
dengan elbow flexion atau kompresi ulnar groove
• Bisa terjadi penurunan ROM elbow atau deformitas
berupa elbow varus
CUBITAL TUNNEL SYNDROME

• Ulnar neuropathy pada elbow akan • Pasien dapat memperlihatkan gejala

memperlihatkan gejala berupa kelemahan berupa peningkatan paresthesia dan
pada otot-otot intrinsik tangan tingling pada distribusi nervus ulnaris ketika
• Dapat dites dengan aduksi little finger ke diminta untuk fleksi elbow selama 5 menit.
arah jari manis Tes ini disebut elbow flexion test.

• Ketidakmampuan untuk melakukan hal tsb

disebut Wartenberg’s sign.
• Atrophy bisa ditemukan di otot-otot intrinsik
tangan
TINEL’S TEST • Tinel’s sign dapat muncul di elbow
antara processus olecranon dan
epicondylus medial
• Hal ini didapatkan dengan
tapping nervus ulnaris pada
groovenya dengan jari pemeriksa
• Hasil tes positif ketika ada
tingling sensation pada forearm
dan aspek medial pada hand
• Seiring dengan regenerasi saraf,
Tinel’s sign dirasakan lebih ke
distal oleh pasien
• False-positive Tinel’s signs biasa
CUBITAL TUNNEL SYNDROME
PENYEBAB • Bila cubital tunnel kecil
kongenital,fleksi dan ekstensi
• Kompresi eksternal kronis dapat
berulang dapat menyebabkan
muncul dengan posisi tnt seperti
timbulnya lesi
routinely resting at the elbow on
a hard surface • Elbow joint derangement
secondary to trauma or arthritis,
• Lesi akut dapat muncul sekunder
intraarticular loose bodies,
akibat posisi arm berada
ligamentous thickening, soft
dalam posisi tdk nyaman dlm
tissue calsification & ganglion
jangka waktu panjang, seperti
cyst
pronasi atau fleksi seperti saat
operasi atau koma • UNE after trauma = tardy ulnar
palsy
 CUBITAL TUNNEL SYNDROME
TREATMENT • Obat antiinflamasi
• Konservatifmenghilangkan faktor • Jika dalam 3-6 bulan terapi
pencetus : splint kmdn tahan konservatif gagal atau muncul
elbow dalam posisi mild flexion kelemahan berat, dibutuhkan
utk elbow fleksi yang ekstrim evaluasi surgical
malam hari dan jangka waktu • Surgical option include ;
lama • Dekompresi pada saraf di bawah
• Tekanan eksternal pada humeroulnar aponeurotic arcade
saraf dpt dikurangi dengan • Transposisi pada saraf di anterior
epicondylus medial
penggunaan elbow pad
• Medial epicondylectomy
• Edukasi utk menghindari
elbow dan ekstensi fleksi
SATURDAY NIGHT PALSY

• = radial neuropathy at the spiral • The radial nerve is the largest nerve in
groove the upper limb
• The most common radial neuropathy • It is involved in entrapment syndromes
less frequently than the median and
ulnar nerve
• More commonly injured from trauma,
such as humeral shaft fracture affecting
the radial nerve near the radial groove
SATURDAY NIGHT PALSY
SATURDAY NIGHT PALSY
SIGNS & SYMPTOMS
• Wrist drop
• Strength testing reveals weakness of wrist & finger extensors
• Weakness with elbow flexion, apparently due to weakness of the
brachioradialis
• Weakness of thumb abduction and forearm supination secondary to
involvement of the brachioradialis, abd. pollicis longus and supinator
muscles
• Elbow extension (triceps) is spared in most cases, as the majority of
the triceps muscle is inervated above the site of radial injury
• Sensory disturbance over the posterolateral hand
SATURDAY NIGHT PALSY
RECOVERY recovery
• Spontaneous TREATMENT
• During the recovery phase, wrist splint
usually occur over a time can be used to help assist with wrist &
frame of several weeks to a fingers extension
few months, as long as
• Upper extremity ROM exercise should
underlying source of injury is
be instituted to avoid contacture
eliminated or does not recur
• Serial electrodiagnostic studies can
• Neuropraxic lesion can follow nerve recover
recover in days, axonal
• If sign of reinnervation are absent
lesions require months after 4 months, surgical exploration.
• Radial nerve transection is • Tendon transfer : if nerve injury is
uncommon and is usually irreparable or nerve repair has failed
ANTERIOR INTEROSSEUS NERVE ENTRAPMENT

• This nerve is a motor nerve to the long • Examination of a patient with anterior
flexors of the thumb and index and middle interosseous nerve syndrome
fingers, and the pronator quadratus muscle. characteristically reveals weakness of the
• There are no cutaneous sensory fibers, but long flexor muscles.
this nerve does provide some sensation to • This can be tested for by asking the patient
the joints of the wrist. to make the “OK” sign. An inability to do
tip-to-tip pinch of the thumb and index
finger results from damage to the anterior
interosseous nerve
ANTERIOR INTEROSSEUS NERVE ENTRAPMENT
ANTERIOR INTEROSSEUS NERVE ENTRAPMENT
• Etiology • Sign Symptom :
(1) can be compressed at the fibrous (1) purely motor syndrome resulting in
arch formed by the flexor digitorum weakness of flexion of the
superficialis and the pronator teres interphalangeal joint of the thumb and
(2) repetitive forearm flexion or distal interphalangeal joints of the index
pronation and middle fingers

(3) elbow or forearm fracture (2) aching pain in the forearm, but there
is no sensory loss
(4) association with brachial neuritis.
POSTERIOR INTEROSSEUS NERVE ENTRAPMENT
POSTERIOR INTEROSSEUS NERVE ENTRAPMENT

• The posterior interosseus nerve (PIN) is a deep branch of the radial nerve, which
pierces the interosseus membrane between the radius and the ulna
• Supplies :
• Extensor carpi ulnaris
• Fingers and thumb extensors
• Abductor pollicis

• It does not contain any cutaneous sensory fibers, as the superficial radial sensory
nerve comes off the radial nerve proximal to the PIN
POSTERIOR INTEROSSEUS NERVE ENTRAPMENT
• The posterior interosseus neuropathy is most often caused by
entrapment in the radial tunnel or at the arcade of frohse
(supinator syndrome)
• Other report causes of PIN lesion include Monteggia #
(proximal ulna and radial head posterior dislocation), elbow
joint #, rheumatoid elbow synovitis, lipomas, hematomas,
ganglion cyst and fibromas
POSTERIOR INTEROSSEUS NERVE ENTRAPMENT
• Kaplan found that 80% patient with
electrophysiologically confirmed PIN
lesion treated conservatively had
resolution of symptoms at 5 years
TREATMENT & RECOVERY
• In cases with progressive weakness or
• Aluminium forearm orthosis (canadian failed conservative treatment after 3-
crutches) 6 months, surgery should be
• Conservative treatment includes : considered
• NSAIDs • Underlying mass : surgical exploration
• Splinting & resection
• Upper limb ROM exercise
• Repetitive pronation and supination should be
• Persistent weakness : tendon transfer
avoided • In complete lesions, an extensor
tenodhesis splint can aid in
developing pinch force
RADICULOPATHY
RADICULOPATHY

• Definition: pathologic
process affecting the
nerves at the root
level
In descending order, it
most commonly presents
as pure sensory
complaints, sensorimotor
complaints, or pure
motor complaints
ETIOLOGY
• Herniatednucleuspulposus(HNP): Mostcommon. Typically seen in adults
below50yearsofage
• Spinal stenosis: Typically seen more commonly in adults above 50 years of
age

Uncommon: “Hi Madam”

H—Herpes zoster
I—Inflammatory: TB, Lyme disease, HIV, syphilis, cryptococcus, and sarcoidosis
M—Metastasis
A—Arachnoiditis: Myelogram, surgery, steroids, and anesthesia
D—Diabetes mellitus
A—Abscess
M—Mass: Meningioma, neurofibroma, leukemia, lipoma, cysts, and hematoma
CLINICAL PRESENTATION
ELECTRODIAGNOSTIC FINDINGS
• Nerve Conduction Studies
SNAP: Normal if the lesion is located proximal to the dorsal root ganglion.
CMAP: Normal or reduced amplitude. The lesion is distal to the motor neuron cell body. It can be
normal if the injury is purely demyelinating, incomplete, or reinnervation has occurred.
• Late Responses
H-reflex: Possibly abnormal in an S1 radiculopathy
F-waves: This is not overly sensitive or specific for a radiculopathy. Muscles have more than one root
innervation, which can result in a normal latency.
• Somatosensory Evoked Potentials
Advantage: It monitors sensory pathways and proximal demyelinating injuries. Disadvantage: The
long pathway monitored can mask focal lesions between the recording sites.
• EMG
Classically, FIBs or PSWs should be found in two different muscles innervated by
• two different peripheral nerves originating from the same root. They may not be found if the lesion
is demyelinating, purely sensory, post-reinnervation, or missed by random sampling.
CERVICAL MYOTOMES
LUMBOSACRAL MYOTOMES
DUAL INNERVATED MUSCLE
MYASTHENIA GRAVIS
MYASTHENIA GRAVIS
 ALS
(AMYOTROPHIC LATERAL SCLEROSIS)
 ALS

• Definition: involves both

the upper and lower
neurons, but some variants
may be restricted to only
UMNs or LMNs, or certain
body regions. Such
variants include primary
lateral sclerosis (PLS) and
progressive muscular
atrophy (PMA) where
neuron loss is restricted to
the UMNs or LMNs,
respectively
PRIMARY LATERAL SCLEROSIS

• progressive spasticity and weakness of limb and bulbar muscles related to

degeneration of UMNs