Radiculopathy Vs Neuropathy Vs Myopathy Compilation.pptx

Radiculopathy, Neuropathy and Myopathy are common neurological clinical presentations. However the clinical differential diagnosis is challenging. This presentation demonstrates the differentiating features along with the Electrodiagnostic findings. It also highlights the management variations in all three conditions.

1. Radiculopathy vs. Neuropathy v s. Myopathy -Diagnosis and Prognosis Gaurav Toshniwal , 2 nd yr MPT Simran Jetahni , 2 nd yr MPT Sumeet Chikkale , 2 nd yr MPT Prof Suvarna Ganvir , DVVPF’s College of Physiotherapy Ahmednagar Maharashtra.

2. By clinical Features R, N & M Radiculopathy (R), Neuropathy (N) & Myopathy (M) Interpretation for R,N & M Strategies and outcomes of treatment 01 04 02 03 Based Electrophysiological Findings Understand by definition Differential diagnosis Differentiate Objectives Clinical Tests Prognosis & Management 05

3. Clinical Features Radiculopathy - a range of symptoms produced by the pinching of a nerve root in the spinal column – Cervical, Thoracic or Lumbar. Radiculopathy symptoms include: Tingling or numbness in the fingers or hand Weakness in arm, shoulder or hand Decreased motor skills Loss of sensation Pain associated with neck/Back movement or straining Steven J. Jones Spurling Test: Aug. 2023

4. Shoulder Abduction (Relief) sign:   Active abduction of symptomatic arm by patient placing their ipsilateral hand on their head- relief (or reduction) of cervical radicular symptoms. Neck Distraction test:   Active distractive force applied by examiner while grasping patient’s head under the occiput and chin- relief (or reduction) of cervical radicular symptoms. L’hermitte’s sign : P assive flexion of patient’s cervical spine- electric shock-like sensation down spine or extremities. Adson’s test(For differentiation from TOS):   instructed to inspire with chin elevated, and head rotated to the affected side- results in obliteration of radial pulse . Steven J. Jones Spurling Test: Aug. 2023

5. Lumbar lateral bending - Antalgic postures assumed to obtain relief. The relationship between the direction of the patient's antalgia (lateral bending) and the side of leg pain provides significant diagnostic information. Kemp test - lateral bending with extension or rotation of the thoracolumbar spine into and away from the direction of antalgia - determining if a lateral or medial disk protrusion is present. Lasegue test - Hip flexion and knee extension achieved in sequence, hip flexion followed by knee extension - . S traight leg raising (SLR) - knee extension followed by hip flexion. Straight leg raising - symptomatic leg - reproduces pain in the symptomatic leg - lateral disk lesion. Straight leg raising - asymptomatic leg (CSLR)- reproduces pain in the symptomatic leg - medial disk lesion. Kenneth Jeffrey Miller Physical assessment of lower extremity radiculopathy and sciatica: 2007

6. Neuropathy A nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body . Symptoms of peripheral neuropathy include: Gradual onset of numbness, prickling, or tingling in your feet or hands. These sensations can spread upward into your legs and arms. Sharp, jabbing, throbbing or burning pain. Extreme sensitivity to touch. Allodynia - such as pain in your feet when putting weight on them or when they're under a blanket. Lack of coordination and falling. Muscle weakness. Feeling as - wearing gloves or socks when not. Inability to move if motor nerves are affected. Martyn CN, Hughes RA. Epidemiology of peripheral neuropathy.  J Neurol Neurosurg Psychiatry. 1997;62(4):310-318.

7. Causes Martyn CN, Hughes RA. Epidemiology of peripheral neuropathy.  J Neurol Neurosurg Psychiatry. 1997;62(4):310-318 .

8. Martyn CN, Hughes RA. Epidemiology of peripheral neuropathy.  J Neurol Neurosurg Psychiatry.  1997;62(4):310-318.

9. Myopathy - Heterogeneous group of disorders primarily affecting the skeletal symptoms with myopathy include : Muscle weakness, most commonly in the upper arms, shoulders, and thighs. Muscle cramps and stiffness Muscle spasms Low energy Being easily fatigued, especially with activity Emery AE. The muscular dystrophies. Lancet. 2002;359:687.

10. Types of Myopathies INHERITED MYOPATHIES INCLUDE: Emery AE. The muscular dystrophies. Lancet. 2002;359:687.

11. ACQUIRED MYOPATHIES Emery AE. The muscular dystrophies. Lancet. 2002;359:687.

12. Emery AE. The muscular dystrophies. Lancet. 2002;359:687. Hani Almoallim et. al. Diagnostic Approach to Proximal Myopathy Jan 2021

13. Proximal > Distal Radiculopathy Proximal/ Distal Symptoms Distal >Proximal Myopathy Neuropathy Positive Provocative Tests Positive Systematic Features – Rashes, Generalised Weakness Positive Distal Provocative tests Tinel’s Sign, Phalen’s test.

14. Case Examples 1. 58 Y/O Female, Farmer by occupation with right hand numbness & weakness. No Neck/Arm Pain. (Excluding Radiculopathy) Weakness in the opponens Pollicis Numbness in First 3 digits + Phalen’s Test (Compressive Type – Compressive Neuropathy) Single Peripheral Nerve Involved

15. 2. 32 year old woman, Reported with the complaints of Bilateral Leg weakness since past 2 days. Progressive Symmetrical Ascending Limb Weakness . Proximal > Distal Recent Fever Spikes (During Travel) Paraesthesia in Hands & feet. Confirmatory Diagnosis on Spinal Tap Test

16. 3. A 5 y/ o Male reported with Progressive difficulty in walking, Increased fatigue & Increase in No. of falls. Progressive Weakness Proximal> Distal Pseudo hypertrophy of calf muscles. Reduced Endurance – Systemic Involvement. Positive Gower’s Sign

17. 4. 45 y/o Male with Neck pain since 1 month, Now experiencing Weakness in the right hand. Numbness in the thumb & Index finger . Sensory disturbance in the C6 Dermatome . Motor Weakness in Biceps & Deltoid – C6 Nerve root but different peripheral nerve Branches. Spurling’s Test Positive on Rt. Side. MRI - Confirmatory Diagnosis.

18. Radiculopathy vs. Neuropathy Vs. Myopathy Electrophysiological findings

19. Radiculopathy - NCV SNAP amplitude is reduced. CMAP is reduced . Sensory and motor nerve conduction velocity are normal.

20. Radiculopathy - EMG Electrodiagnosis of radiculopathy JOHN-MICHAEL LI AND JINNY TAVEE, Handbook of Clinical Neurology, Vol. 161 Abnormalities encountered include spontaneous activity in the form of fibrillation potentials, neurogenic recruitment patterns, and MUP morphology changes such as enlarged or polyphasic motor units , indicating reinnervation. The presence of myotonal fibrillation potentials is a key finding that provides objective evidence of active denervation, and is seen even with mild nerve root lesions. Fibrillation potentials are more likely to be found in distal rather than proximal muscles , likely due to the proximal-to-distal pattern of reinnervation

21. Demyelinating polyneuropathy Prolong latency. Slow conduction velocity. Conduction block. Temporal dispersion. Kalita Misra . Clinical neurophysiology. 3 rd edition

22. Uniform demyelinating sensory motor polyneuropathy NCV Conduction velocity < 25m/sec. Prolong latency. SNAP Amplitude reduced. EMG Reduced MUAP Increased duration and amplitude. Abnormal spontaneous activity seen. Kalita Misra . Clinical neurophysiology. 3 rd edition

23. Segmental demyelinating sensory motor polyneuropathy . NCV Conduction block. Temporal dispersion During initial 3 week. 14% normal conduction velocity. 68% reduced conduction velocity upto 70%. 25% distal prolong latency with slow conduction velocity. Kalita Misra . Clinical neurophysiology. 3 rd edition

24. EMG 2 nd - 4 th week fibrillation seen 4 th – 5 th week increased polophasia and amplitude. Kalita Misra . Clinical neurophysiology. 3 rd edition

25. Axonal polyneuropathy Reduced conduction velocity and amplitude. No conduction block or temporal dispersion seen. Kalita Misra . Clinical neurophysiology. 3 rd edition

26. Axonal motor > sensory polyneuropathy NCV CMAP reduced. 50% reduction in SNAP. Conduction velocity spared. EMG Fibrillation seen. Kalita Misra . Clinical neurophysiology. 3 rd edition

27. Axonal sensory polyneuropathy NCV SNAP reduced. CMAP normal Conduction velocity normal. In severe stage reduced conduction velocity. Kalita Misra . Clinical neurophysiology. 3 rd edition

28. Axonal mixed sensorimotor polyneuropathy . NCV Early stage Reduced SNAP. CMAP normal Normal conduction velocity Late stage SNAP, CMAP CV reduced. EMG Fibrillation and positive sharp wave. Kalita Misra . Clinical neurophysiology. 3 rd edition

29. Myopathy NCV Prolonged Sensory nerve action potentials (SNAPs) are usually normal in disorders of muscles unless there is a superimposed sensory polyneuropathy or disorder affecting muscle and nerve simultaneously (critical illness neuropathy/myopathy, amyloidosis). Compound muscle action potentials (CMAPs) are normal in proximal myopathies but can be abnormal in distal myopathies when significant muscle atrophy is present. Nagy H, Veerapaneni KD. Myopathy. StatPearls . 2020 Sep Jun Kimura. Electrodiagnosis in disease of nerve and muscle. 3 rd edition

30. EMG Jun Kimura. Electrodiagnosis in disease of nerve and muscle. 3 rd edition It has been shown that fibrillation potentials, positive sharp waves, complex repetitive discharges are more typical for myopathies with intramuscular structural changes, including protein accumulation, vacuoles, inflammatory infiltrates, fiber necrosis, and fiber splitting.

31. In myopathies, the number of motor units remains the same. However, the number of normally functioning muscle fibers is reduced, causing MUAPs to become small in duration and amplitude. The asynchronous firing of affected fibers creates a polyphasic appearance. To generate force with minimal volitional contraction, many motor units are getting activated earlier than expected. This is described as an early or rapid recruitment pattern and is typical for myopathic . Kalita Misra . Clinical neurophysiology. 3 rd edition

32. Radiculopathy vs. Neuropathy Vs. Myopathy Prognosis & Management

33. Cervical Radiculopathy Management Education and advice Manual Therapy - Passive Assessory Intervertebral Movements) / Passive Physiological Intervertebral Movements) / NAGs (Natural Apophyseal Glides) / SNAGs (Sustained Natural Apophyseal Glides) Exercise Therapy - AROM, stretching and strengthening Postural re-education Hassan F, Osama M, Ghafoor A, Yaqoob MF. Effects of oscillatory mobilization as compared to sustained stretch mobilization in the management of cervical radiculopathy: A randomized controlled trial. Journal of Back and Musculoskeletal Rehabilitation. 2020 Jan 1;33(1):153-8.

34. Boyles et al  (2011)  - thrust mobilisations of the cervical or thoracic spine and cervical non-thrust mobilisations (PA glides/Lateral Glides in ULTT1 position /Rotations /Retractions) – effective in reducing pain levels, improving function and increasing joint ROM. Ragonese  (2009)  -   neurodynamics   sliding and tensioning techniques - upper limb tension positions described by  Magee conducted in a slow and oscillatory manner. Improvement in symptoms - progressed to a ‘tension’ technique - to pain and function- treatment duration was not recorded. Fritz JM et al examined the effectiveness of cervical traction - resulted in lower disability and pain - long-term follow-ups. Hassan F, Osama M, Ghafoor A, Yaqoob MF. Effects of oscillatory mobilization as compared to sustained stretch mobilization in the management of cervical radiculopathy: A randomized controlled trial. Journal of Back and Musculoskeletal Rehabilitation. 2020 Jan 1;33(1):153-8.

35. Lumbar Radiculopathy Management In an acute phase, there is moderate evidence for spinal manipulation for symptomatic relief . For chronic lumbar radiculopathy , only low-level evidence was found for manipulations, Because the pain is due to a narrowing of the intervertebral foramen normal traction of the lower spine will also relieve the pain Pilates exercises McKen zie exercises Mild stretching Pain relief modalities Lumbosacral Radiculopathy Andrew W. Tarulli , MDa,b , Elizabeth M. Raynor, MDa,b

36. Prognosis Following clinical features were found to be most predictive of a positive short-term outcome:  Age <54 Dominant arm not affected Looking down does not worsen symptoms Treatment involves manual therapy, cervical traction, and deep neck flexor strengthening for at least 50% of visits If 3 of these features are present, the probability of success is 85%, and increases to 90% if all 4 are present. Cleland JA, Fritz JM, Whitman JM, et al. Predictors of short-term outcomes in people with a clinical diagnosis of cervical radiculopathy . Phys Ther . 2007;87(12):1619-1632.

37. Chemotherapy induced peripheral neuropathy Sensorimotor Training 3 –5 exercises: 20–40 s > 40 s rest between each repetition 1 min rest between each exercise Improved peripheral deep sensitivity and balance control (static, dynamic and perturbed) Improves QOL Streckmann F, Kneis S, Leifert JA, et al. Exercise program improves therapy-related side-effects and quality of life in lym p homa patients undergoing therapy. Ann Oncol . 2014;25(2): 493–9. doi:10.1093 / annonc / mdt568 . Symptoms: Decreased sensation Pins/needles/itching sensation Painful paresthesia or numbness Cold-induced dysesthesia Reduced or absent reflexes (Achilles and patellar) Loss of balance control Gait instability More falls and injuries Weakness Endurance training For 10-30 min Improves aerobic performance level & QOL Strength training 4 exercises, 1 min max. force Improves QOL INTERVENTION for 36 weeks, 2 */week

38. Diabetic neuropathy SYMPTOMS: Hypoesthesia , Pin sensation, pain, Diminished or absent reflexes(Achilles and patellar) Loss of balance control Autonomic dysfunction Endurance training 60 min (brisk walking at 50–85 % heart rate reserve) Preventive: 4 years, 4*/ week Better vibration, perception threshold,Improved nerve conduction velocity Progressive: nerve conduction velocity, distal and sural sensory Combination (balance + strength) (balance + strength + endurance) 4 exercises, 1 min max. force Improves balance, gait, BBS score & reduced postural sway Balance training 30 min for 8 weeks 2*/week Improves balance & gait Dixit S, Maiya AG, Shastry BA. Effect of aerobic exercise on peripheral nerve functions of population with diabetic peripheral neuropathy in type 2 diabetes: a single blind, parallel group randomized controlled trial. J Diabet Complicat . 2013;28(3): 332–9. doi:10.1016 / j.jdiacomp.2013.12.006 . Mueller MJ, Tuttle LJ, Lemaster JW, et al. Weight-bearing versus nonweight-bearing exercise for persons with diabetes and peripheral neuropathy: a randomized controlled trial. Arch Phys Med Rehabil . 2013;94(5):829–38. doi:10.1016 / j.apmr.2012.12 . 015.

39. Neuropathy of other causes (Hereditary mutation of axonal or myelin proteins) Mo tor and sensory symptoms (depending on the subtype), no pain, chronic progressive Autonomic dysfunction, pain, hypoesthesia , paresis Balance training 30 min for 10 sessions 2*/daily Improves balance Strength training 24 weeks 3*/week Improved knee muscles strength and rotation Combination (balance + strength) (strength + endurance) 60 min unsupervised workout 12 weeks 3*/weeks Improves Knee extensors strength & Total work load Ruhland JL, Shields RK. The effects of a home exercise program on impairment and health-related quality of life in persons with chronic peripheral neuropathies. Phys Ther . 1997;77(10): 1026–39 . Graham RC, Hughes RA, White CM. A prospective study of physiotherapist prescribed community based exercise in inflam - matory peripheral neuropathy. J Neurol . 2007;254(2):228–35. doi:10.1007 /s00415-006-0335-4.

40. Prognosis GBS: 40% patients  Respiratory paralysis (Early recovery at younger age) 35% patients long term disability 38% patients change lifestyle CIDP: 70% good efficacy of medications & physical therapy in acute phase Slowly progressive / remitting relapsing course  secondary progressive deterioration Critical illness polyneuropathy Complete recovery in 42 months

41. Myopathy Classification (more useful for rehabilitation) Ambulatory stage Wheelchair- dependent stage Stage of prolonged survival Bach & Lieberman 1993 Selzer ME, Clarke S, Cohen LG, Kwakkel G, Miller RH, editors. Textbook of neural repair and rehabilitation. Cambridge University Press; 2014.

42. The Rehabilitation approach Strength & endurance Muscle weakness more pronounced in proximal musculature Endurance required to complete a given task A) still possible independently B) possible but only with more time given to complete it C) possible, but only with assistance D) not possible at all Orthopaedic deformity Muscle imbalance  joint contracture  reduced PROM  orthopaedic deformity Cardiopulmonary dysfunction Cognitive dysfunction Disease progression Non progressive/ Slow progressive/ rapidly progressive Selzer ME, Clarke S, Cohen LG, Kwakkel G, Miller RH, editors. Textbook of neural repair and rehabilitation. Cambridge University Press; 2014.

43. Goals of the Rehabilitation program Preserve strength & Endurance Improve strength & Endurance Minimise & prevent joint contractures Permit weight bearing Prolong standing / Walking Maximise functional mobility Maximise independence for ADL’s Minimise deleterious effects of deconditioning Selzer ME, Clarke S, Cohen LG, Kwakkel G, Miller RH, editors. Textbook of neural repair and rehabilitation. Cambridge University Press; 2014.

44. REHABILITATION INTERVENTIONS Exercise Strengthening ROM Balance Assistive devices Proper footwear Orthoses Standing devices Gait aids Wheelchairs/scooters ADL’s Assistive devices Selzer ME, Clarke S, Cohen LG, Kwakkel G, Miller RH, editors. Textbook of neural repair and rehabilitation. Cambridge University Press; 2014.

45. Strengthening Sub maximal resistive exercises program  Increase overall strength without causing overwork weakness Moderate intensity aerobic exercises  Improve cardiovascular performance High resistive weight training  Significant increase in muscle performance Electrical stimulation with voluntary contractions  Useful for strengthning Selzer ME, Clarke S, Cohen LG, Kwakkel G, Miller RH, editors. Textbook of neural repair and rehabilitation. Cambridge University Press; 2014.

46. ROM Exercises P ROM A-A ROM AROM Stretching  Prevents contractures Botulinum toxin type A (Medial & Lateral Hamstrings)  Improve knee contractures  Increase knee ROM Selzer ME, Clarke S, Cohen LG, Kwakkel G, Miller RH, editors. Textbook of neural repair and rehabilitation. Cambridge University Press; 2014.

47. Balance Use of arm swing while walking to place arms in position that aids to shift COG to avoid falling. Practicing balance in uneven terrains Challenging dynamic standing balance Selzer ME, Clarke S, Cohen LG, Kwakkel G, Miller RH, editors. Textbook of neural repair and rehabilitation. Cambridge University Press; 2014.

48. Assistive devices Proper footwear Lightweight Ability to facilitate sensory feedback Desirable co-efficient of friction Orthosis Lightweight Providing proper joint alignment Cosmetically unappealing Standing devices Gait aids Wheelchairs/ Scooters Aids for ADL’s Selzer ME, Clarke S, Cohen LG, Kwakkel G, Miller RH, editors. Textbook of neural repair and rehabilitation. Cambridge University Press; 2014.

49. Ageing with Myopathy Debilitating strength in addition to Neuro-musculoskeletal effects of ageing Degenerative joint diseases & overuse injuries because of bio mechanical abnormalities Osteoporosis because of reduced muscle force on bone. Worsening gait because of Spinal stenosis or hip arthritis Selzer ME, Clarke S, Cohen LG, Kwakkel G, Miller RH, editors. Textbook of neural repair and rehabilitation. Cambridge University Press; 2014.

50. SUMMARY Radiculopathy Neuropathy Myopathy CLINICAL FEATURES Injury/ damage to nerve root. Pain/Tingling/ numbness in fingers of hand (Proximal  distal) Nerve problem which causes tingling and pain in different parts of body. (distal) Changes in muscle fibre / interstitial tissue Proximal muscle weakness MANAGEMENT Manual therapy Mobilisation Traction Exercise therapy Postural reeducation Sensory training Balance training Strength training Endurance training Improve strength & Endurance Minimise & prevent joint contractures Maximise functional mobility PROGNOSIS Depending upon the severity. Good prognosis post rehabilitation Leads to long term disability provoking lifestyle changes. Most of the myopathies are slowly progressive with high mortality rate

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