Preface

Sadly, and for a multitude of reasons, the incidence and prevalence of peripheral neuropathy in the United States and around the world continue to increase. We are all well aware of the number of Americans affected by diabetes mellitus and one of its most common complications, peripheral neuropathy. Another complication of diabetes mellitus is chronic kidney disease. Kidney disease, separate from diabetes, is in itself an indirect cause of peripheral neuropathy. As the number of HIV infections continues to increase worldwide, we are seeing an increasing number of patients with HIV-related neuropathic complications. Peripheral neuropathy is a common side effect of scores of prescribed (and illegal) drugs. Cancers and their sequelae—paraneoplastic syndrome, complications of chemotherapy and surgeries, and space-occupying tumors—often lead to peripheral neuropathy. Nerve injuries may result from low-force, high-repetition activities such as keyboard typing, overhead work, and musical instrument playing. Exposure to environmental toxins such as lead, mercury, and arsenic, prevalent in some areas of the United States and the world, may cause nerve injury. A common risk factor for falls is lower extremity neuropathy. The list goes on and on. Peripheral neuropathy is becoming a very common presenting and comorbid diagnosis for rehabilitation professionals.

Peripheral neuropathy may affect motor neurons, sensory neurons, and regulatory (autonomic) neurons. The functional impact may range from minimal to severe. The spectrum of motor neuropathy may range from weakness of muscles within the myotomal distribution of one nerve (mononeuropathy) to weakness of many muscles innervated by many nerves (systemic polyneuropathy). The severity of weakness may range from subclinical to flaccid paralysis. The spectrum of sensory loss is even greater than that of motor neuropathy. There may be positive (additive) signs such as paresthesia, radicular pain, and multisegmental pain. There may be negative signs such as loss of tactile, temperature, pain, somatosensory (proprioception and kinesthesia), vestibular, and vibratory senses. Lastly, pathology of the regulatory neurons may lead to aberrant and inappropriate blood pressure and cardiac responses to positional change and exercise. There may be delayed healing, loss of toenails and fingernails, and trophic skin changes.

Peripheral Nerve Injury: An Anatomical and Physiological Approach to Pathology and Intervention is the first comprehensive textbook written for rehabilitation professionals—physical therapists, occupational therapists, physical therapy assistants, occupational therapy assistants, physician assistants, nurse practitioners, athletic trainers, and orthotists/prosthetists—with content related to the etiology and intervention of diagnoses of peripheral neuropathy. In addition, primary care physicians, nurses, vocational rehabilitation specialists, and insurance providers may find the text helpful with their practices.

The textbook is divided into five content areas:

1. Overview of the peripheral nervous system and biomechanics of peripheral nerve: This section includes chapters related to the anatomy and physiology of the peripheral nerve, the biomechanics of healthy and damaged nerve, and the pathophysiology of the peripheral nervous system. This section contains a focused blueprint of the impact of the inflammatory cascade on peripheral nerves associated with injury and illness.

2. Etiologies of peripheral nerve injury: This section examines common pathologies that either directly or indirectly injure peripheral nerves. Pathologies examined include vasculitic, connective tissue, and seronegative spondyloarthropathies; environmental toxins; critical illness myopathy/polyneuropathy; diabetes mellitus; infection; nutritional deficiencies; chronic kidney disease; and neuropathic complications of common medications.

3. Evaluation of a patient with suspected peripheral nerve injury: This section includes chapters on the physical examination of individuals with suspected peripheral neuropathy, the use of laboratory tests and measures in the investigation of suspected neuropathy, and an overview of electroneurodiagnostic testing.

4. Evidenced-based interventions for individuals with peripheral nerve injury: These chapters provide a clear summary of the rehabilitative modalities and interventions that may be used to treat patients. In addition, chapters describe manual therapy techniques, the role of physical agents, and orthotic fabrication for use with these patients. This section ends with a chapter on behavioral modification techniques used by health care practitioners to address functional loss and chronic pain syndromes.

5. Current “hot topics” related to peripheral nerve injury: The topics addressed in this section include brachial plexus syndromes, Guillain-Barré syndrome, neuropathies associated with athletics, entrapment neuropathies in the upper and lower extremity, and neuropathic processes associated with HIV disease.

I authored half the chapters. The other half were authored by many who are national and international experts in their unique content areas.

Mary F. Barbe, PhD, Professor of Anatomy and Cell Biology at Temple University School of Medicine, Philadelphia, Pennsylvania, is one of the leading researchers in the growing field of repetitive strain injury. For the past 10 years, she has been involved in neurobiological, cell, and molecular biological studies examining the effects of repetition and force on musculoskeletal and neural systems and on sensorimotor function with a research colleague, Ann E. Barr, PT, PhD (now at Pacific University, Portland, Oregon). Drs. Barbe and Barr developed a unique voluntary rat model of work-related musculoskeletal disorders (also known as repetitive strain injury and overuse injury) with varying levels of repetition and force and have been working to characterize the short-term effects. They have now expanded to examining the long-term effects of repetitive and forceful tasks on musculoskeletal and nervous system pathophysiology, focusing on injury and inflammation and how these processes induce degenerative tissue changes and sensorimotor dysfunction. Dr. Barbe is currently exploring inflammation-induced catabolic tissue changes versus mechanical overload–induced tissue disruption using pharmaceutical methods to block inflammatory processes. This work is currently funded by the National Institute for Occupational Safety and Health and National Institute of Arthritis and Musculoskeletal and Skin Diseases.

Susan Bray, MD, Clinical and Associate Professor in the Division of Nephrology at Drexel University College of Medicine, Philadelphia, is a much honored clinical nephrologist, internist, author, and palliative care specialist. She currently maintains a clinical practice in Philadelphia.

Stephan Whitenack, MD, PhD, a graduate of Thomas Jefferson Medical College, Thomas Jefferson University, Philadelphia, is board certified in general surgery, thoracic surgery, and vascular surgery and is a preeminent researcher, writer, lecturer, diagnostician, and surgeon in the field of brachial plexopathies.

Emily A. Keshner, PT, EdD, received her Certificate in Physical Therapy at the College of Physicians and Surgeons, Columbia University, New York, New York. She received her doctoral degree in Movement Science at Teachers College, Columbia University. She then pursued postdoctoral fellowships at the University of Oregon, Eugene, Oregon, and the University Hospital in Basel, Switzerland, both in the area of postural control in healthy and vestibular-deficient adults. Subsequently she was a Research Associate in the Department of Physiology, Northwestern University, Chicago, Illinois, where she performed animal and human research. She then worked as a research scientist in the Sensory Motor Performance Program at the Rehabilitation Institute of Chicago with a faculty position in the Department of Physical Medicine and Rehabilitation at Northwestern University until she came to Temple University in 2006. Dr. Keshner has been continuously funded from the National Institutes of Health since 1989. She currently teaches in the PhD program in the Department of Physical Therapy. In addition to her appointment at Temple University, Dr. Keshner is Adjunct Professor, Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University and Director of the Virtual Environment and Postural Orientation Laboratory at Temple Univeristy. Dr. Keshner has authored more than 100 peer-reviewed publications. Jill Slaboda, PhD, at the time this article was written, was a post-doctoral research fellow in Dr. Keshner's laboratory. Currently, she is with the Geneva Foundation.

James W. Bellew, PT, PhD, is an associate professor at the Kranert School of Physical Therapy at the University of Indianapolis, Indianapolis, Indiana. Dr. Bellew has published more than 50 peer-reviewed scientific articles and abstracts in the areas of exercise training, balance, and muscle physiology and is the co-author of the textbook Modalities for Therapeutic Intervention, 5th ed., published by FA Davis Company. Edward Mahoney, PT, DPT, CWS, is currently Assistant Professor at Louisiana State University Health in Shreveport Louisiana. He obtained his Doctorate of Physical Therapy from Louisiana State University Health Sciences Center in Shreveport and his Master's in Science of Physical Therapy from Sacred Heart University. He has published extensively in the areas of wound healing and therapeutic modalities for tissue healing. He is a member of the American Board of Wound Management as well as a site reviewer for the American Board of Physical Therapy Residency and Fellowship Education.

Roberta A. Newton, PT, PhD, FGSA, an internationally recognized expert in fall prevention programming for older adults and the author of 53 peer-reviewed publications, 5 books, and 16 book chapters. At the time of the authorship of this chapter, Dr. Newton was professor of Physical Therapy and Clinical Professor of Medicine at Temple University. Past posts at Temple have included director for the Institute on Aging, and regional coordinator and director of education of the Gerontology Education Center. Newton was also a tenured associate professor at the Department of Physical Therapy, School of Allied Health Professions, Medical College of Virginia of Virginia Commonwealth University. Newton earned a PhD in neurophysiology and a BS in physical therapy from the Medical College of Virginia, Virginia Commonwealth University, and a BS in biology from Mary Washington College. She is the recipient of the American Physical Therapy's Catherine Worthingham Fellow Award. Dr. Newton has written, along with Dennis W. Klima, PT, PhD, GCS, NCS, formerly Dr. Newton's doctoral student and now assistant professor in the Department of Physical Therapy at University of Maryland Eastern Shore, Princess Anne, Maryland, a wonderful chapter on fall risk identification, prevention, and management. Dennis Klima joined the faculty at University of Maryland, Eastern Shore, in the fall of 2002. Prior to his UMES appointment, Dennis served as Program Director of the Physical Therapist Assistant Program at the Baltimore City Community College for thirteen years. He received his Bachelor of Science degree in Physical Therapy from the Medical College of Virginia. He completed a PhD in Physical Therapy from Temple University where his dissertation focused on physical performance and fear of falling in older men. Dr. Klima received his geriatric and neurologic clinical specializations from the American Board of Physical Therapy Specialties. His APTA experience also includes serving as an on-site reviewer for both PT and PTA programs with the Department of Accreditation since 1990. He has presented geriatric and neurological continuing education courses both nationally and internationally. Areas of research include both management of adults with TBI and fall prevention in older adults.

Robert B. Raffa, PhD, is Professor of Pharmacology and Chair of the Department of Pharmaceutical Sciences at Temple University School of Pharmacy and Research Professor at Temple University School of Medicine. Dr. Raffa holds bachelor's degrees in Chemical Engineering and in Physiological Psychology, master's degrees in Biomedical Engineering and in Toxicology, and a doctorate in Pharmacology. Dr. Raffa was a Research Fellow and Team Leader for an analgesics discovery group at Johnson & Johnson and was involved in the elucidation of the mechanism of action of tramadol. He is co-holder of several patents, including the combination of tramadol with acetaminophen. Dr. Raffa is the co-author or editor of several books on pharmacology, including Netter's Illustrated Pharmacology and Principles in General Pharmacology and Drug-Receptor Thermodynamics, and has published more than 150 articles in refereed journals and more than 70 abstracts and symposia presentations. He is co-founder and editor of the journal Reviews in Analgesia and was an associate editor of the Journal of Pharmacology and Experimental Therapeutics. Dr. Raffa is active in several professional societies and is a past president of the Mid-Atlantic Pharmacology Society. He is the recipient of the Hofmann Research Award, Lindback Teaching Award, and other honors.

John P. Scanlon, DPM, is a graduate of the Temple University School of Podiatric Medicine and maintains a podiatric clinical practice in Philadelphia. Dr. Scanlon is also the Chief Medical Officer at Chestnut Hill Hospital in Philadelphia and directs the Chestnut Hill Hospital Podiatric Residency Program. Crystal N. Gonzalez, DPM, Benjamin R. Denenberg, DPM, and Krupa J. Triveda, DPM, were residents in Podiatry under Dr. John Scanlon at Chestnut Hill Hospital and are now all in private practice.

Joseph I. Boullata, PharmD, RPh, BCNSP, is a clinician-educator on the standing faculty of the University of Pennsylvania School of Nursing in Philadelphia. He received his Doctorate in Pharmacy from the University of Maryland in Baltimore after completing undergraduate degrees in Nutrition Science (Pennsylvania State University), State College, Pennsylvania, and in Pharmacy (Philadelphia College of Pharmacy & Science, Philadelphia). He completed a residency at the Johns Hopkins Hospital in Balfimore and a nutrition support fellowship at the University of Maryland Medical System. His teaching experiences have spanned well over a dozen years mostly in pharmacy education through didactic, small group, and bedside teaching. Outside the classroom, Dr. Boullata is involved with student mentoring and professional organizations as well as his clinical practice and scholarship. Dr. Boullata's research agenda generated from questions that arise during clinical practice and then developed further through interdisciplinary collaboration. His research areas have included pharmacotherapeutic issues within the intensive care unit setting, pharmacotherapeutic implications of nutrition regimens, and drug-nutrient interactions. The pharmacology and therapeutics of individual nutrients and natural health products in disease management as well as their interaction with medication require further exploration. Dr. Boullata has achieved and maintained board certification in nutrition support. He has also received recognition for his active membership in several multidisciplinary, national professional organizations including the American Society for Parenteral and Enteral Nutrition. He has also served on the editorial boards for Nutrition in Clinical Practice and Current Topics in Nutraceutical Research.

David M. Kietrys, PT, PhD, OCS, received his entry-level physical therapy degree from Hahnemann University in Philadelphia and his doctorate from Temple University. Dr. Kietrys is currently Associate Professor of Rehabilitation and Movement Sciences at the Rutgers School of Health Related Professions (formerly known as UMDNJ–School of Health Related Professions) in Stratford, New Jersey. Dr. Kietrys has published extensively in the field of HIV and exercise and repetitive strain injury. Mary Lou Galantino, PT, PhD, MS, MSCE, has a dual appointment: Adjunct Associate Professor of Family Medicine and Community Health at the Perelman School of Medicine, University of Pennsylvania, and Professor of Physical Therapy at Richard Stockton College. An accomplished funded researcher, Dr. Galantino has published extensively in the areas of HIV-related neuropathy, holistic medicine, and women's health.

Bill Egan, DPT, OCS, FAAOMPT, received a BA in psychology from Rutgers University, New Brunswick, New Jersey, in 1997, and an MPT from the US Army–Baylor University in San Antonio, Texas, in 1999. He served as an active duty Army physical therapist for 6 years. Dr. Egan completed the tDPT and Manual Therapy Fellowship program through Regis University in Denver, Colorado, in 2006, and he now serves as affiliate faculty for these programs. Currently, Dr. Egan is an associate professor in the Doctor of Physical Therapy program at Temple University. He is a board-certified Orthopedic Clinical Specialist and a Fellow of the American Academy of Orthopedic Manual Therapists. Dr. Egan serves as an adjunct instructor for various local physical therapy programs teaching manual therapy and thrust manipulation. He is also an instructor for Evidence In Motion. Dr. Egan maintains a part-time clinical practice at the Sports Physical Therapy Institute in Princeton, New Jersey. Scott Burns, PT, DPT, OCS, FAAOMPT, received his Master of Physical Therapy and transitional Doctor of Physical Therapy from the University of Colorado-Denver. He is currently Associate Professor and Assistant Chair in the Doctor of Physical Therapy Program at Temple University. Dr. Burns's teaching responsibilities include the Musculoskeletal Management course series, Orthopaedic Residency Coursework and Advanced Musculoskeletal Elective, and Clinical Decision Making. In addition to his teaching responsibilities, he maintains an active clinical schedule including research and patient care. His main research interests revolve around clinical decision making, clinical education strategies/models, patient outcomes, chronic pain management and manual physical therapy interventions for various musculoskeletal conditions. His work, entitled “Short-term response of hip mobilizations and exercise in individuals with chronic low back pain: a case series” was awarded the Dick Erhard Award for Best Platform Presentation at AAOMPT Conference in 2010. In 2014, Dr. Burns was selected as the recipient for the College of Public Health Excellence in Teaching Award.

Amy Heath, PT, PhD, OCS, is Chair and Assistant Professor of Physical Therapy at Simmons College. She received her BS in Health Studies and DPT from Simmons College, and her PhD in Educational Psychology from Temple University. Dr. Heath is credentialed by the American Physical Therapy Association as a Clinical Instructor.

Teri O'Hearn, DPT, CHT received a bachelor's degree in Health Science from the University of North Florida, Jacksonville, Florida, a master's of science degree in Physical Therapy from the University of North Florida, and a Doctor of Physical Therapy degree from Boston University, Boston. She became a Certified Hand Therapist in 2007. She is currently employed at Ministry Door County Medical Center in Sturgeon Bay, Wisconsin.

Megan Mulderig McAndrew, DPT, MS, is employed in the Drucker Brain Injury Center at Moss Rehabilitation Hospital in Elkins Park, Pennsylvania. Ms. McAndrew has presented and written extensively in the field of neurotrauma and neurorehabilitation. She is a graduate of the Moss Rehabilitation Neurological Physical Therapy Residency.

Elizabeth Spencer Steffa, OTR/L, CHT, is an occupational therapist, certified hand therapist, partner of Highline Hand Therapy, and a clinical faculty member at the University of Washington, Seattle, Washington, her alma mater. Ms. Steffa treats hand and upper extremity injuries, performs physical capacity evaluations, and participates in splinting/orthosis fabrication.

Each chapter begins with a title, germane quotation, objectives, key terms, and an introduction. The text is supplemented liberally with photographs, tables, and diagrams. Each chapter includes a case study and sample questions. A comprehensive list of references also is included with each chapter. At the end of the text is a comprehensive glossary of definitions of all key terms in the chapters. An index is also provided for ease of locating subject matter.