Peripheral Neuropathy and the Impact on Safety
Peripheral Neuropathy can impact safety for patients due to the symptoms it causes. Sarah Boyd, PT, DPT and Sarah Dahlhauser, OTR/L, OTD share with the Foundation for Peripheral Neuropathy tips and suggestions for improving safety and comfort of patients with peripheral neuropathy.
Why Peripheral Neuropathy can Impact Safety for Patients
Peripheral neuropathy is an umbrella term that reflects any condition that damages the peripheral nervous system. Our peripheral nervous system connects our brain and spine to our limbs and organs, thereby allowing us to walk, run, taste, digest, sweat, and more. The type of peripheral neuropathy a patient has is identified by the type of nerve that is damaged . There are three classifications of nerves in our body: motor, sensory, and autonomic. Below are symptoms that one may experience if that nerve type is damaged(1):
- Motor nerve damage – weakness, incoordination, cramping, fatigue, and muscle atrophy.
- Sensory nerve damage – impaired or loss of sensation, whether it is vibration, pressure, hot/cold, pain, or joint position sense. A common symptom is neuropathic pain, where nerves are firing at random.
- Autonomic nerve damage – impaired sweating, heat intolerance, and gastrointestinal symptoms. Another symptom is orthostatic hypotension, which is a sudden drop in blood pressure upon positional changes. This may cause lightheadedness and/or fainting, and reduce tolerance to upright positions for prolonged times.
Although each neuropathy has its own features that make it stand out against others, a common denominator between all neuropathies is the impact it has on one’s safety. The emphasis of this article is to broadly discuss safety considerations depending on what you may be experiencing in your peripheral neuropathy and providing simple strategies to assist in maximizing your safety, health, and day to day wellness.
Peripheral Neuropathy Impact on Safety: Methods to Enhance Safety for Weakness
Depending on the type and extent of the weakness you are experiencing, there are several aids that could significantly improve your comfort and safety:
- Hand/Finger Weakness: Recommend seeking a formal evaluation by an occupational therapist or certified hand specialist to assess the need for an hand orthosis to wear throughout the day or at night. A member of your care team may recommend an off-the-shelf model or customized orthosis depending on your needs and if sensation is impaired.
- Ankle/Foot Weakness: A common sign of leg weakness is “foot drop.” Foot drop occurs when the muscles that control lifting your foot are not strong enough to quickly and adequately lift up while moving. You may experience “foot slap,” “rolling an ankle,” or find that you are tripping over or catching your toe. Sometimes you may only experience this later in the day when you are fatigued. An ankle foot orthosis (AFO) can easily address this. An AFO can significantly improve your safety when walking, as well as optimize your ankle/foot positioning and protection. There are many styles, from a fabric-based AFO to a more rigid style made of plastic or carbon fiber. Bracing can be off-the-shelf or customized. Recommend seeking a formal evaluation with a local certified orthotist to specify the right brace for you. An orthotist is a healthcare specialist who fits and makes braces to address your specific needs. The orthotist will be there to address any modifications that may be needed if symptoms change. You will require a prescription from your primary care provider to assist in brace procurement and coverage.
Peripheral Neuropathy Impact on Safety: Methods to Enhance Safety for Sensory Impairments
Sensory impairments can significantly impact your safety, especially if you find it is too painful to walk on your feet or if you are unable to feel where you walk. The type of sensory impairments you are experiencing will dictate what recommendations are provided. Here are several general recommendations:
- Neuropathic Pain – Consult with your primary care physician or neurologist to identify possible medications that could assist in reducing nerve sensitivity. Conservative measures include physical therapy or cognitive behavioral therapy. Use of a transcutaneous electrical nerve stimulation (TENS) unit could be used but there is uncompelling evidence on the positive impact it has on neuropathic pain (2).
- Sensory Loss – Use a handheld mirror several times a day to assess skin around your toes, foot, heel and ankle to ensure skin is intact and there are no areas of redness, irritation, pressure, or wound development. You may benefit from customized shoe orthotics to assist in joint protection. As sensory loss has a significant impact on walking, there has been development of neuroprostheses to assist in providing much needed sensory input and has been found to be helpful in balance and walking stability.
Peripheral Neuropathy Impact on Safety: Methods to Enhance Safety for Orthostatic Hypotension
Orthostatic hypotension is a drop in blood pressure when changing positions. This can cause lightheadedness, fainting, weakness, visual changes, and reduce the ability to sit or stand for prolonged periods of time. General recommendations to reduce the severity of orthostatic hypotension are (3):
- Use of compression stockings and an abdominal binder.
- Sleeping with the head of your bed slightly elevated, approximately 4 inches.
- Avoiding heat.
- Eating small and frequent meals versus large meals.
- Take transitions slow and pause in each position before moving.
- Incorporating physical counter maneuvers prior to changing positions, such as wiggling foot up/down, straightening and bending the knee, squeezing thighs together, marching in place, and squeezing buttock together.
Falls Prevention and Safety
All of the symptoms above can increase your risk of falling and injury. Furthermore, you may experience a greater fear of falling, which could slowly reduce your participation in activities or leaving the home. Here are general recommendations to improve your safety and falls prevention:
- Use a gait aid, whether a single end cane, trekking pole (also known as a hiking stick), front or four wheeled walker. Before choosing one, seek a professional recommendation from a physical therapist to assess which is safest for you.
- Use bathroom safety equipment, such as a tub transfer bench, shower chair, and installation of grab bars. If you have a difficult time with standing or sitting from a toilet, recommend a toilet safety frame or pursuing a comfort height toilet.
- Remove all rugs and clutter from your home.
- Use night lights or install motion detector lights to ensure you have adequate lighting to safely navigate if needing to use the restroom or get a drink of water at night.
- Sit down when dressing or bathing.
- Organize your bathroom and kitchen to have frequently used items at shoulder or waist level.
Insurance Coverage
A healthcare provider may recommend a piece of durable medical equipment (DME), such as a cane, walker, or an arm/leg orthotic. The most common question asked by patients when this happens is: will my insurance cover this? Each insurance company is different so it is advised to consult with them for further clarification. In general, coverage is dependent on a piece of equipment that is deemed medically necessary the patient’s care team. The patient’s healthcare provider or rehabilitation specialist, specifically a physical and/or occupational therapist, will evaluate which device is the safest and most appropriate for the patient. The healthcare specialist will then provide a prescription for the DME.
If your DME needs change, insurance coverage may be impacted if you had prior DME equipment covered in the past five years. Furthermore, if you believe a wheelchair or powered scooter is needed, insurance coverage will be dictated as to where you will be using it. If you only require wheeled mobility for outdoors or community use, insurance generally will not provide coverage. If you require wheeled mobility inside of the home, insurance will assist in coverage if you have had a consultation by your primary care provider and a rehabilitation provider who specializes in wheelchair seating and assessment for best assessment of seating and cushioning needs (4).
Consult with Your Rehabilitation Team
If you are experiencing any of the aforementioned symptoms, recommend consulting with your local rehabilitation team, whether physical and/or occupational therapy, to find the best options for you. Request a provider that is neurologic-based versus orthopedic to ensure all needs are met. The American Physical Therapy Association (APTA) has developed a helpful resource to locate physical therapists near you with their “Find a PT” search engine. You can limit your search to only include providers who are neurologic-based. You can access this resource at: https://www.choosept.com. Unfortunately, there is not a search engine to locate an occupational therapist; however, you can ask your primary care provider or physical therapist for additional options.
References:
1. Peripheral Neuropathy Fact Sheet. National Institute of Neurological Disorders and Stroke. Modified March 16, 2020. Accessed October 22, 2020.
2. Gibson W, Wand BM, O’Connell NE. Transcutaneous electrical nerve stimulation (TENS) for neuropathic pain in adults. Cochrane Database Syst Rev. 2017;9(9):CD011976. doi:10.1002/14651858.CD011976.pub2.
3. Figueroa JJ, Basford JR, Low PA. Preventing and treating orthostatic hypotension: As easy as A, B, C. Cleveland Clinic J Med. 2020;77(5):298-306. doi:10.3949/ccjm.77a.09118.
4. Durable Medical Equipment (DME) Coverage. The Official U.S. Government Site for Medicare. Accessed October 22, 2020.