Painful PeripheralNeuropathy         Clinton Pong       Tufts/Cambridge        Health Alliance          December        20...
Objectives• By the end of this session, learners will be able to:• Develop and refine a differential diagnosis for  periph...
Definition                 Pain initiated or caused by a primary lesion                  or dysfunction in the peripheral ...
Symptoms       Neuralgias                 Neuropathies• Can be                     • Motor nerves may also  spontaneous, e...
Classifications• Location                            • Timing                                         o   Acute   o Axonal...
Epidemiology• Only 3 prevalence studies on peripheral neuropathy  o Italy: ~8% of Italians 55+ y/o with a PCP going for su...
Differential dx            Common                                Other interesting ones• Diabetes (30% of cases)          ...
http://www.aafp.org/afp/1998/0215/p755.html
http://www.aafp.org/afp/1998/0215/p755.html
Diagnosis (DynaMed)• Highest yield (AAN level C)                                   • Other tests     o    Blood glucose   ...
Case 1• 85 year old Caucasian male veteran who           • (these are all  complains of restless legs and progressive     ...
Idiopathic• ?age-related?• Clinical research focusing on impaired glucose  tolerance as a culprit   o Fasting >110 & <125 ...
Case 2• 48 yo Italian-American male with PMH of diabetes  comes in for routine diabetes exam   o Lives in the North End an...
Diabetes• 2/3 of all diabetes patients have a peripheral nervous disorder   o   (also includes dysautonomia, painless foot...
Diabetes syndromes• Painful diabetic                     • Diabetic neuropathic                                         ca...
Uremic neuropathy• 80% of pt with advanced renal failure have a  sensory motor axonal polyneuropathy• Characterized by cra...
http://ndep.nih.gov/publications/PublicationDetail.aspx?PubId=116
Upper panel: For performance of the 10-g monofilament test, the device is placed              perpendicular to the skin, w...
http://ndep.nih.gov/publications/PublicationDetail.aspx?PubId=116
http://ndep.nih.gov/publications/PublicationDetail.aspx?PubId=116
http://ndep.nih.gov/publications/PublicationDetail.aspx?PubId=116http://ndep.nih.gov/media/FootExamForm.pdf
Case 3 pt 1• 53 yo Caucasian male with PMH of Bipolar  disorder, EtOH abuse and seizure disorder (s/p  trigeminal neuralgi...
Case 3 pt 2• CPEX:  o   CN II-XII intact  o   Tone: normal without cogwheeling/spasticity  o   Normal 2+ reflexes in bicep...
Case 3 pt 3• EMG/NCS:   o Motor conduction studies of both ulnar and right median nerves are     nromal. Sensory conductio...
Cervical radiculopathy• Annual incidence 83 per 100,000   o   in Rochester NY (1976-1990) n=561   o   Higher in men than w...
Alcohol• Spanish study of Incidence: 1/3 of alcoholics in a  hospital clinic fulfilled EP criteria• Mainly the consequence...
Case 4 pt 1• L.R. 76 yo PMH of DM, COPD, chronic back pain presents  to the ED with leg weakness, numbness and gait  insta...
Case 4 pt 2• ―Bilateral Bell’s Palsy‖ resolved with a five-day  course of steroids• LP showed cytoalbuminologic dissociati...
Guillain-Barré Syndrome (GBS)• Epidemiology   o Annual incidence of 1-2 per 100,000 population   o 40-66% due to C. jejuni...
Case 5 pt 1• RI is a 84 yo male with PMH of HTN/zoster, home visit• A couple of years ago, he had a shingles outbreak  on ...
Case 5 pt 2• Old vesicular patch scar pattern on the left-medial  anterior thigh• Large inguinal hernia easily reducible, ...
VZV-Postherpetic neuralgia• Ganglionopathy• Acute phase  o Acute neuralgia at site of inflammation  o Lasts for several we...
Cancer              Drugs     (Large fiber neuropathy)• Paclitaxel                             • Paraneoplastic   o Ascend...
Treatment (1)• Opioids (level 2[mid-level])   o ―Timely and fearless use‖ for acute     ganglionopathy and plexopathy• Tra...
Treatment (2)• Anticonvulsants: unknown MOA• Gabapentin (Neurontin) (A-2)   o 300mg Qhs x2 nights, then 300mg BID x2 days,...
CAM treatment                                                         (evidence-harm)•   43% of pt with peripheral neuropa...
Objectives• By the end of this session, learners will be able to:• Develop and refine a differential diagnosis for  periph...
Take Home Points• Think systematically• High-yield actions:   o Drug review:     chemotx, INH, B6, Hydralazine, Metronidaz...
References•   DynaMed: Peripheral Neuropathy (Accessed December, 2012)•   AAN/AANEM National Guideline Clearinghouse 2009 ...
Questions?• Please comment on:• 1. What was the most important thing you learned  today?• 2. What question remains uppermo...
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Painful peripheral neuropathy

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By the end of this presentation, learners will be able to:
Develop and refine a differential diagnosis for peripheral neuropathy.
Discuss the workup for common & typical cases.
Perform a comprehensive diabetic foot exam by ADA/NDEP standards.
Treat painful peripheral neuropathy.

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Painful peripheral neuropathy

  1. 1. Painful PeripheralNeuropathy Clinton Pong Tufts/Cambridge Health Alliance December 2012, PGY-3 FM
  2. 2. Objectives• By the end of this session, learners will be able to:• Develop and refine a differential diagnosis for peripheral neuropathy• Discuss the workup for common & typical cases• Perform a comprehensive diabetic foot exam o by ADA/NDEP standards• Treat painful peripheral neuropathy
  3. 3. Definition Pain initiated or caused by a primary lesion or dysfunction in the peripheral nervous system (“Dysfunction” includes nociceptive and psychogenic conditions) Nociceptive = Response to tissue injury Neuropathic = Pathologic or maladaptive pain• International Association for the Study of Pain• [Classification of Chronic Pain: Descriptions of chronic pain syndromes and definitions of pain terms. 2nd ed. 2002. ]
  4. 4. Symptoms Neuralgias Neuropathies• Can be • Motor nerves may also spontaneous, episodic or cause painful cramps continuous• Abnormal tactile and thermal sensations Nociceptive aberrancy• Numbness • Dysesthesia, hyperalges• Tingling ia and allodynia• Pins and Needles • Painful percept evoked• Burning by stimuli below nociceptor threshold• Shooting• Electric shock-like sensation
  5. 5. Classifications• Location • Timing o Acute o Axonal vs Myelin o Sub-acute o Large vs Short-diameter fibers o Chronic • Large = vib/prop • Nerve Injury • Small = pain/temp o Neuropraxia • Both = light touch o Axonotmesis o Neuronotmesis o Nerve Trunk vs Nerve Root o Wallerian degeneration o Sensory vs Motor Nerves• Focal • Acquired o Metabolic o Mononeuropathy o Infectious• Multifocal o Inflammatory o Toxic o Mononeuropathy multiplex o Mechanical• Generalized o Traumatic o Polyneuropathy • Hereditary
  6. 6. Epidemiology• Only 3 prevalence studies on peripheral neuropathy o Italy: ~8% of Italians 55+ y/o with a PCP going for surgery have peripheral neuropathy o Bombay India: 2.4% of Indians surveyed door-to-door met criteria • Carpal tunnel syndrome and DM most common o Sicily: 7% of Sicilians surveyed door-to-door met criteria • DM neuropathy dx’ed in 0.3%• My best numbers are seen on the next slide o (x% of cases = overall percentage gathered from small studies on incidence for underlying dx of peripheral neuropathy) o (x% of [diagnosis] = overall percentage of patients with dx that have peripheral neuropathy) o Best study was in Oklahoma on elderly • n=795 Peripheral neuropathy Diagnosis • JABFP Sept-Oct 2004
  7. 7. Differential dx Common Other interesting ones• Diabetes (30% of cases) • Infectious o Hep B/C (1.3% of OK elderly) o 2/3 of DM o Lyme disease, HIV, CMV, Leprosy, Chagas• Idiopathic (30% of cases) • Drugs/Toxins/Chemotx o Isoniazid, Hydralazine, Lithium, Flagyl, Amit• Post herpetic neuralgia o riptyline, statins, retroviral, Dapsone Taxol, Vincristine• Mechanical o EtOH, arsenic, cyanide, Pb, Hg, thallium o Disc compression • Immune-mediated (6.3% of OK elderly) o Guillain-Barré o OA [(+) in 19.9% of OK elderly] o MGUS/MM, Sjogrens, Lupus, Vasculitic o Inflammation • Inflammatory o Carpal tunnel (5.8% of ♀, 0.6% of ♂) o Parsonage-Turner• GI/Malnutrition • Cancer-related o Paraproteinemic (discovered in 10% of (-) o Alcoholic (1/3 of Spanish alcoholics) workup cases) o B12 (5% of OK elderly) o Paraneoplastic syndrome o B6 • Hereditary (0.6% of OK elderly) o Charcot Marie Tooth, Fabry’s, famillial amyloid neuropathy, porphyria
  8. 8. http://www.aafp.org/afp/1998/0215/p755.html
  9. 9. http://www.aafp.org/afp/1998/0215/p755.html
  10. 10. Diagnosis (DynaMed)• Highest yield (AAN level C) • Other tests o Blood glucose o CBC, Lytes, BUN/Cr, BG, LFTs, Ca, • A1c (26% yield*) Mag Phos o Serum B12 with metabolities o HIV (methymalonic acid +/- o Lyme homocysteine) o CXR • 2% yield* o Heavy metals, lead, coproporphyrin o Serum protein immunofixation electrophoresis • If (+)Family history • 3% yield* o Initial genetic testing to consider (AAN level A)• If (-)diabetes (AAN level C) • CMT1A dupllication/HNPP o Consider test for impaired glucose deletion tolerance • Cx32 (GJB1) o 2hr GTT (61-62% yield*) • MFN2• 0% yield* • Specialist tests o TSH, ESR, Folate o Autonomic testing (AAN level B)• EMG/NCS (level 3[lacking-direct]) o Nerve biopsy (AAN level U) o Confirmed dx in 59% • Sural nerve bx may be useful but cause persistent pain o Changed dx in 14% o Affected management in 60% o Expanded dx in 18% o 33% reported increased pain at biopsy site 6 mo later*yield from a small study from a tertiary referral center in Utah o Skin biopsy (AAN level C)Arch Intern Med 2004 May 10;164(9):1021
  11. 11. Case 1• 85 year old Caucasian male veteran who • (these are all complains of restless legs and progressive risk factors for trouble with balance and walking bilateral sensory• PMH of HLD deficits)• Meds: statin, fibrate o 65-74 yo: 26% o 75-84 yo: 36% o 85+ yo: 54%• Routine CPEX notable for: • In addition to o Hx of DM• Increasing BMI from 30 to 35 o B12 deficiency• Absence of Achilles reflex and loss of fine o Rheumatoid arthritis touch o Absence of hx of HTN• Gait: normal, timed get-up-and-go is 10 o Income seconds <$15,000J Am Fam Pract 2004 Sep-Oct;17(5):309 n=795
  12. 12. Idiopathic• ?age-related?• Clinical research focusing on impaired glucose tolerance as a culprit o Fasting >110 & <125 or 2hr GTT >140 &<199 (75g load)• 35-50% of pt with idiopathic sensory neuropathy have IGT• Painful sensory neuropathy of small caliber afferent fibers in the lower limbs• In early stages, DTR, muscle strength and EMG/NCS are spared
  13. 13. Case 2• 48 yo Italian-American male with PMH of diabetes comes in for routine diabetes exam o Lives in the North End and works as a bank teller; walks to work every day for ~20 min/day. His 75 yo mother cooks ―pastas and calzones‖ for him but he has been trying to have smaller portions. o He saw the podiatrist once last year and was told he had ―elephantiasis.‖• Meds: metformin, ACEi, BB• PE significant for: o Morbid obesity (BMI 45) o Markedly swollen 3+ non-weeping lower extremities with leathery alligator like hyperkeratotic plaques by the heels and lower legs; unable to examine the entire leg. Onychomycosis, Xerosis. Nails are all long and dystrophic with discoloration and absent hair growth from the shins inferiorly. Left great toenail bleeding o Monofilament sensation absent bilaterally on 0/5 points detected• Labs: o A1c 6.5%, LDL 108, BUN/Cr 23/0.9, Albumin 3.9, Urine Alb/Cr 6,
  14. 14. Diabetes• 2/3 of all diabetes patients have a peripheral nervous disorder o (also includes dysautonomia, painless foot neuropathy) o Progressive • 5 years after diagnosis: 4% • 20 years after dx: 15%• Etiology (proposed pathways) o Persistent hyperglycemia activates polyol pathway for neural accumulation of fructose & sorbitol o Autoimmune damage o Endoneural vascular ischemic damage• Intensive treatment lowers incidence by 60% o Diabetes Control and Complications Trial (DCCT) • a ten-year clinical study that concluded in 1993 • ANY sustained lowering of the blood glucose helps, even if the person has a history of poor control • follow-up study shows reduction in microvascular changes persist for at least four years after, despite increasing blood glucose levels o United Kingdom Prospective Diabetes Study (UKPDS) • significantly lower prevalence of neuropathy at 9 and 15 years than patients randomized to conventional therapy
  15. 15. Diabetes syndromes• Painful diabetic • Diabetic neuropathic cachexia neuropathy o Acute onset: Severe diffuse o 11% of insulin-treated neuropathic pain in lower extremities population o Spreads to all the lower limbs/trunk o 25% of hospital diabetic clinic and hands, typically worsening at population night o Small fiber distal symmetric o Severe weight loss (up to 60%!) o Depression polyneuropathy o Lasts for several months and slowly • Long-lasting/unremitting, subsides over 8-12 months burning, shooting o Tx: aggressive insulin infusion • often with • Painful lumbosacral allodynia/hyperalgesia, radiculoplexus neuropathy alteration of thermal o Acute onset: severe asymmetric perception and autonomic deep aching pain localized dysfunction proximally in the lower limb • Cold/warm/painful o May have associated proximal weakness and wasting in the same hypesthesia area
  16. 16. Uremic neuropathy• 80% of pt with advanced renal failure have a sensory motor axonal polyneuropathy• Characterized by cramps and restlessness in legs, dysesthesia• Concomitant DM may cause a severe motor polyneuropathy with intense cramps
  17. 17. http://ndep.nih.gov/publications/PublicationDetail.aspx?PubId=116
  18. 18. Upper panel: For performance of the 10-g monofilament test, the device is placed perpendicular to the skin, with pressure applied until the monofilament buckles. Boulton A J et al. Dia Care 2008;31:1679-1685Copyright © 2011 American Diabetes Association, Inc.
  19. 19. http://ndep.nih.gov/publications/PublicationDetail.aspx?PubId=116
  20. 20. http://ndep.nih.gov/publications/PublicationDetail.aspx?PubId=116
  21. 21. http://ndep.nih.gov/publications/PublicationDetail.aspx?PubId=116http://ndep.nih.gov/media/FootExamForm.pdf
  22. 22. Case 3 pt 1• 53 yo Caucasian male with PMH of Bipolar disorder, EtOH abuse and seizure disorder (s/p trigeminal neuralgia ―surgery decompression) presents with shoulder pain o Two years ago, he broke his arm after a seizure + fall at home with progressively worse right neck, shoulder and arm pain o 8/10 Burning debilitating pain radiating down the right shoulder and arm to the elbow and encompasses the upper arm bicep/tricep o Denies clumsiness/dropping things in the right hand o Currently tried lidocaine patch, tylenol, tramadol and neurontin and flexeril without relief
  23. 23. Case 3 pt 2• CPEX: o CN II-XII intact o Tone: normal without cogwheeling/spasticity o Normal 2+ reflexes in biceps/triceps/brachioradialis bilaterally o Strength: 5/5 except right deltoid 4+/5, biceps 4+/5, due to pain o No atrophy, no tremor o Psych exam normal• MRI: o Cervical degenerative disc disease, uncoverterbral joint and facet arthritis, post operative changes at C5-6 with an anterior fusion o Cg-7 disc herniation and focal spinal stenosis with cord deformity o Mild cord atrophy and myelomalacia at C6-7
  24. 24. Case 3 pt 3• EMG/NCS: o Motor conduction studies of both ulnar and right median nerves are nromal. Sensory conduction studies of both ulnar and radial nervers demonstrate very reduced amplitudes. The right ulnar latency is mildly reduced. The right Median sensory response is moderately reduced o Concentric needle EMG studies of the right upper extremity demonstrate mild chronic denervative changes in the APB and FDI. The C5-7 paraspinal muscles are normal.• Impression: o Consistent with the presence of an axonal, predominantly sensory, peripheral neuropathy in the upper extremities. o There is no evidence for a right cervical radiculopathy
  25. 25. Cervical radiculopathy• Annual incidence 83 per 100,000 o in Rochester NY (1976-1990) n=561 o Higher in men than women o Highest in 50-54 years of age o C6-C7 affected in 64% of cases o Recurrence common 32% within 5 years o Luckily, 90% had few or no symptoms at follow up• (mild cases likely to be underrepresented)
  26. 26. Alcohol• Spanish study of Incidence: 1/3 of alcoholics in a hospital clinic fulfilled EP criteria• Mainly the consequence of nutritional deficiency o Thiamine o B6 o B12• Sensory motor axonal neuropathy affecting all fiber types• Severe burning/stabbing, associated w/ hyperalgesia/allodynia• Sensory ataxia
  27. 27. Case 4 pt 1• L.R. 76 yo PMH of DM, COPD, chronic back pain presents to the ED with leg weakness, numbness and gait instability.• 2 months ago, she had facial numbness around her lips with weakness with swallowing and an inability to tell if food was inside or outside her mouth. She also had numbness of her right hand.• 1 month ago, she had a whole body pain. Within two weeks, she developed numbness in her hands and feet and had difficulty walking with weakness in both legs.• She reports that this all started when she got ―bunch of shots.‖
  28. 28. Case 4 pt 2• ―Bilateral Bell’s Palsy‖ resolved with a five-day course of steroids• LP showed cytoalbuminologic dissociation with protein of 90 and 0 WBCs• EMG/NCS impression: mild chronic generalized sensory motor polyneuropathy, axonal in nature.• Diagnosed with Guillain-Barre and was given a course of IVIG that improved her gait mobility• She was not diagnosed with CIDP• 2 years later, she is able to stand up, but still has chronic pain in her lower legs and can only ambulate for about 10-20 steps.
  29. 29. Guillain-Barré Syndrome (GBS)• Epidemiology o Annual incidence of 1-2 per 100,000 population o 40-66% due to C. jejuni, also linked to Shigella, CMV o Very rarely linked to vaccines (except for vaccinia old-rabies w/ myelin and 1976 US Swine flu vaccine) • England: n=200+ cases, imm vs nonimm, OR of 1.8 [95% CI 0.7-4.4]• HPI o Preceding URI or GI infection o 85% of pts repots moderate/severe pain at onset• S/sx: o 1) stabbing, deep dorsal LBP radiating into the limbs o 2) Dysesthetic extremity pain with burning/tingling o 3) Joint/muscle pain o Characteristic: Weakness of limb and respiratory muscles • Mortality previously ~1/3 of pts; down to 5-10% with vent support
  30. 30. Case 5 pt 1• RI is a 84 yo male with PMH of HTN/zoster, home visit• A couple of years ago, he had a shingles outbreak on his leg and the pain was so bad that he lost nearly fifty pounds (down to 170#) and feels that the loss of appetite was secondary to the pain.• His kidneys were ―blocked up‖ around the same time and was on HD for a few months and was given a ―bladder bag‖ and has Q6 week visits at SH for foley changes after declining suprapubic surgery• He still has some residual pain from the zoster and lives independently. Otherwise well, no back pain
  31. 31. Case 5 pt 2• Old vesicular patch scar pattern on the left-medial anterior thigh• Large inguinal hernia easily reducible, foley draining clear yellow urine• Neuro exam intact. No sensory changes to light touch or sensitivity over the zoster scar• BUN/Cr 38/2.1, Alk phos 1301, SPEP/UPEP negative except total protein high at 59.6• PSA: 88.3• MRI chest: multiple bone through the thoracic and lumbar spine concerning for ossesous neoplastic disease
  32. 32. VZV-Postherpetic neuralgia• Ganglionopathy• Acute phase o Acute neuralgia at site of inflammation o Lasts for several weeks• Long-lasting neuropathic pain o 3+ months after healing of the skin lesion o Major or complete sensory loss o Hyperalgesia/allodynia (light stroking or warming)
  33. 33. Cancer Drugs (Large fiber neuropathy)• Paclitaxel • Paraneoplastic o Ascending distal polyneuropathies paraesthesiae/dysesthesia with burning pain/allodynia to cold or • Acute sensory mechanical stimulation ganglionopathy o Vibration/pin/cold sensation are o 90% of the time, it precedes other impaired symptoms of cancer o Stocking-glove distribution o Anti-Hu neuronal antibody (+)• Cisplatin o Most commonly SCLC o Painless ataxia o More rarely: ovarian, breast or lymphoma• Vincristine o Large fiber sensory/motor • Paraproteinemic neuropathy neuropathy o Muscle aches o SPEP(+) in 10% of unexplained neuropathies
  34. 34. Treatment (1)• Opioids (level 2[mid-level]) o ―Timely and fearless use‖ for acute ganglionopathy and plexopathy• Tramadol o 50-100mg Q6hr prn pain, max dose 400mg/day o Antagonize nociceptive nerve trunk injury• Steroids o In cases of acute inflammatory component to nerve injury• Capsaicin (Zostrix) 0.025% (A-1) o Up to 3-4x/day x 4-6 weeks, apply with gloves and don’t rub eyes o Chili pepper extract depleting substance P/VIP/CCK/somatostatin stores• TCAs (Amitrip/Nortrip/Desip) (level 2[mid-level], A-2) o Start at 10mg Qhs and increased up to 25mg Qhs and by 25mg increments as tolerated o May experience relief in 2 weeks
  35. 35. Treatment (2)• Anticonvulsants: unknown MOA• Gabapentin (Neurontin) (A-2) o 300mg Qhs x2 nights, then 300mg BID x2 days, increase to 300mg TID and additional 300mg doses as tolerated o ADR: leukopenia, somnolence/dizziness/ataxia/fatigue• Pregabalin (Lyrica) (A-2) o 100mg Qhs o Titrated over 2 weeks to max of 600mg Qhs o ADR: somnolence/dizziness, headache, dry mouth, peripheral edem• Botulinum toxin (Botox) (Level 2[mid-level])• Clonazepam (no RCTs)• Phenytoin (no RCTs)
  36. 36. CAM treatment (evidence-harm)• 43% of pt with peripheral neuropathy use CAM• Megavitamins (35%) o Vitamin B complex (B-100) (B-2) one tab BID • for deficiency syndromes • Caution: High dose B6 (1000mg/d) can cause toxic neuropathy! o Acetyl-L-carnitine 500 BID-1000TID (A-1) • For chemo-induced and DM neuropathy o Alpha-lipoic acid 600-1800 PO Daily (A-1) o Benfotiamine-B1 50-100 TID (B-1) • For DM neuropathy o Vitamin E 400-800 IU Daily (B-2)• Magnets (30%) o Magnetic insoles (A-1)• Acupuncture (30%) (B-1) o Beta-endorphin release• Herbals (22%) o Geranium oil (Neutragen PN) topically several times a day (level 1[likely-reliable])C-1) • Reduces neuropathic foot pain for up to 4 hours o Evening Primrose Oil 360mg PO daily of GLA from EPO (A-1)• Chiropractor (21%)
  37. 37. Objectives• By the end of this session, learners will be able to:• Develop and refine a differential diagnosis for peripheral neuropathy• Discuss the workup for common & typical cases• Perform a comprehensive diabetic foot exam o by ADA/NDEP standards• Treat painful peripheral neuropathy
  38. 38. Take Home Points• Think systematically• High-yield actions: o Drug review: chemotx, INH, B6, Hydralazine, Metronidazole, Lithium, Amitriptyline o Labs: fasting glucose, A1c, BUN/Cr, CBC, ESR, UA, B12 and TSH o Order for EMG/NCS o Refer to Neuro (if considering: autonomic eval, LP, CXR, EKG, PFT: FVC)• By prevalence, think about: o Diabetes (30% of cases) o Idiopathic (30% of cases) o Consider • Post herpetic neuralgia, Mechanical (Disc compression, OA, Inflammation, Carpal tunnel), Alcoholic, B12
  39. 39. References• DynaMed: Peripheral Neuropathy (Accessed December, 2012)• AAN/AANEM National Guideline Clearinghouse 2009 Jun1:13615• Arch Intern Med 2004 May 10;164(9):1021• Boulton et al. Comprehensive Foot Examination and Risk Assessment. Diabetes Care August 2008 vol. 31 no. 8 1679-1685 o http://care.diabetesjournals.org/content/31/8/1679.long• Martyn C et al. Epidemiology of peripheral neuropathies. Neuroepidemiology. J. Neuro/Neurosurg/Psych. 1997; 62:310-318• Marchettini, P. et al., Painful Peripheral Neuropathies. Current Neuropharmacology. 2006. 4 175- 181. o http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2430688/pdf/CN-4-3-175.pdf• Mold J et al. Prevalence, Predictors and Consequences of Peripheral Sensory Neuropathy in Older Patients. JABFP Sept-Oct 2004. 17;5: 309-318• PONCELET, AN. An Algorithm for the Evaluation of Peripheral Neuropathy. Am Fam Physician. 1998 Feb 15;57(4):755-764. o http://www.aafp.org/afp/1998/0215/p755.html• Schaumberg H., et al. Sensory Neuropathy from Pyridoxine Abuse — A New Megavitamin Syndrome. N Engl J Med 1983; 309:445–8. o http://www.nejm.org/doi/pdf/10.1056/NEJM198308253090801• Rakel. Integrative Medicine. 2nd edition. Chapter 15: Peripheral Neuropathy pp 157-168• Feet Can Last a Lifetime – A Health Care Provider’s Guide to Preventing Diabetes Foot Problems o http://ndep.nih.gov/publications/PublicationDetail.aspx?PubId=116 o http://ndep.nih.gov/media/FootExamForm.pdf
  40. 40. Questions?• Please comment on:• 1. What was the most important thing you learned today?• 2. What question remains uppermost in your mind afterward?• 3. What is the muddiest point in todays lecture?
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