Neurologic manifestations in the lower extremity in elderly persons.

According to the US Census Bureau, by the 21st century, approximately 20% of the US population will be over age 65. With the continued emphasis upon primary care, it is imperative that we devise a methodical approach in the assessment of patient problems as well as in the provision of optimal podiatric care in the geriatric community. The distinction between normal physiologic and pathologic neurologic aging processes was discussed in this article from both a diagnostic and prognostic standpoint. Degenerative and neurovascular causative conditions afflicting the lower extremity were discussed in greater detail with regard to clinical, diagnostic, pathologic, therapeutic, and prognostic aspects. It has been the authors' intent to enlighten the readers by providing measures that will secure more timely diagnoses and therapeutic regimens for age-related neuropathologic disorders affecting the foot.

Diabetic neuropathies.

An overview of the different forms of diabetic neuropathy, along with their presenting symptomatology, objective findings, pathophysiology, and sequelae have been discussed. Diagnostic methods used for the detection of this neuropathic entity have been outlined. Various treatment regimens have also been reviewed for each type. This article attempted to expand the knowledge of diabetic neuropathy and its effect on the lower neuropathy by highlighting the salient concept of these disorders. By accurately interpreting the clinical signs, symptoms, and supportive diagnostic studies, potential premature morbidity and mortality may ultimately be deterred, if not averted.

Nutritionally induced peripheral neuropathies.

The authors have presented a discussion of some of the more common nutritional deficiency syndromes. A discussion of the etiology, clinical manifestation, diagnosis, and prognosis has been provided. Special attention has been given to the relationship between nutritional deficiency and the development of peripheral neuropathies. When patients suffering from peripheral neuropathy present, the possibility of a nutritional deficiency should be considered. The diagnosis of a nutritional deficiency neuropathy is rarely established. This may not merely be the result of a low incidence of the problem. The prompt diagnosis and treatment may afford dramatic results. The more protracted the course for diagnosis, the less favorable the prognosis. It is often difficult to pinpoint the exact nutritional deficiency present. Various methods have been discussed in this article; however, often multiple deficiencies are present simultaneously. The treatment with pharmacologic supplementation is usually very innocuous. It often proves beneficial to administer pharmacologic supplementation for a short period. This will aid in the differential diagnosis. Often prescribing a patient large doses of the B-complex vitamins for a limited time will allow the physician to determine if a nutritional neuropathy is present. It should also be remembered that just because a patient is suffering from a peripheral neuropathy from a metabolic disease or secondary to medication, they may also be suffering from a nutritional deficiency simultaneously. We believe that the podiatric physician is well trained to extend comprehensive treatment of pedal manifestations of peripheral neuropathies. Podiatric physicians have a large armamentarium at their disposal to treat the pedal manifestations of the disease sufficiently. These treatments may be conservative or surgical in nature, as previously discussed. We hope that this discussion will increase the awareness of the physician to the various ramifications of nutritionally induced neuropathies as well as the provision of insight into the most efficacious means available for appropriate management.

Nerve conduction studies and their clinical applications.

Nerve conduction studies provide the most sensitive and accurate account of peripheral neuropathophysiology. Though nerve conduction studies should never be performed in lieu of a clinical examination, the electrodiagnostic evaluation provides an optimal adjuvant to the clinical examination. Indications for nerve conduction studies are many, including evaluation of the nature of the pathophysiology, quantification of the severity of involvement, detection of the level of a neurologic deficit, and determining prognosis. Among other indications, limitations of the study should also be acknowledged, such as its confined evaluation of large myelinated peripheral nerve fibers. It should be understood that nerve conduction studies are conventionally performed with EMG studies, typically performed consecutively in order to provide a comprehensive evaluation of suspected neuromuscular impairment. It is imperative to emphasize that utilization of nerve conduction findings is limited and potentially misdirected without a thorough knowledge of peripheral neuropathophysiology and related conditions. Parameters by which the studies are evaluated are outlined in detail within this article and discussed in terms of clinical and neurophysiological significance. Reference tables are provided on the normal values of individual peripheral nerves, as established by various investigators. Nerve conduction findings and their clinical significance relative to various pathophysiological conditions are reviewed. Radiculopathies, lesions of the lumbosacral plexus, polyneuropathies, as well as mononeuropathy multiplex and simplex, are also discussed relative to their various etiologies, and respective forms of pathogenesis. Finally, nerve conduction studies may be effectively used to select the most beneficial therapy. Appropriate consultative referral is addressed with regard to primary pathologic conditions requiring neurosurgical, neurologic, rheumatologic, and immunologic care, among other disciplines relative to the underlying pathologic process. Local therapy may invariably be gauged in terms of various modes of medical, orthopedic, and surgical intervention, depending on the degree, nature, and distribution of involvement of the neuropathy, as ultimately determined by the nerve conduction studies. In conclusion, nerve conduction studies provide a reliable index of measurement in the diagnosis, treatment, and prognosis of the patient.

Neuroanatomy and its clinical application.

In years prior, articles concerned with neuroanatomy have stressed just that, the anatomy. It is for this reason that this article was written. The primary intent addresses the clinical aspects of neuroanatomy, and as such, has stressed so-called "anatomic function." An overview of neuroanatomy as well as neural function and deficit is provided. The article is intended for both the student and practitioner in the hopes of taking the labor out of its study and replacing it with a logical approach to the neuroanatomy and its clinical applications.

A methodical approach to the evaluation of neurologic conditions affecting the lower extremity.

This article has attempted to demonstrate a methodical approach in identifying and evaluating neuropathy affecting the lower extremity. Patients with neurologic symptoms present in a multitude of ways, with a variety of possible etiologies. Logical progression through the history and physical examination, classification schemes, knowledge of etiology, reinforcement by diagnostic tests and differential diagnosis, is the only road the physician can follow that will lead to an effective treatment regimen, with optimum prognosis. The following articles discuss specific neurologic disease in more detail. A methodical approach to each pathology will hopefully enable the podiatric physician to extract the information from the pages and into everyday clinical practice.

The pathologic implications of vibration disease.

Vibration disease is a syndrome comprising a multitude of symptoms with ensuing pathologic alterations to the vasculature, nerves, and musculoskeletal system. There are various theories regarding the contributing factors involved in the etiology and pathogenesis of this disorder. This article reviews the pertinent theories and details the major aspects of vibration disease. It also introduces the potential synergistic role that the various affected systems have in influencing each other throughout the progression of this syndrome.