Numbness and tingling

Definition

Numbness and tingling are decreased or abnormal sensations caused by altered sensory nerve function.

Description

The feeling of having a foot "fall asleep" is a familiar one. This same combination of numbness and tingling can occur in any region of the body and may be caused by a wide variety of disorders. Sensations such as these, which occur without any associated stimulus, are called paresthesias. Other types of paresthesias include feelings of cold, warmth, burning, itching , and skin crawling.

Demographics

People of all ages experience episodes of numbness and tingling. These generally become more common as people age. Episodes of numbness and tingling are more common among people with diabetes, hypothyroidism , alcoholism , malnutrition , or who experience mechanical trauma, especially to their limbs, neck or spine.

Causes and symptoms

Causes

Sensation is carried to the brain by neurons (nerve cells) running from the outer parts of the body to the spinal cord in bundles called nerves. In the spinal cord, these neurons make connections with other neurons that run up to the brain. Paresthesias are caused by disturbances in the function of neurons in the sensory pathway. This disturbance can occur in the central nervous system (the brain and spinal cord), the nerve roots that are attached to the spinal cord, or the peripheral nervous system (nerves outside the brain and spinal cord).

Peripheral disturbances are the most common cause of paresthesias. "Falling asleep" occurs when the blood supply to a nerve is cut off—a condition called ischemia. Ischemia usually occurs when an artery is compressed as it passes through a tightly flexed joint. Sleeping with the arms above the head or sitting with the legs tightly crossed frequently cause numbness and tingling.

Direct compression of the nerve also causes paresthesias. Compression can be short-lived, as when a heavy backpack compresses the nerves passing across the shoulders. Compression may also be chronic. Chronic nerve compression occurs in entrapment syndromes. The most common example is carpal tunnel syndrome, which occurs when the median nerve is compressed as it passes through a narrow channel in the wrist. Repetitive motion or prolonged vibration can cause the lining of the channel to swell and press on the nerve. Chronic nerve root compression, or radiculopathy, can occur in disk disease or spinal arthritis.

Other causes of paresthesias related to disorders of the peripheral nerves include the following:

• metabolic or nutritional disturbances, including diabetes, hypothyroidism (a condition caused by too little activity of the thyroid gland), alcoholism, malnutrition, and vitamin B₁₂ deficiency
• trauma, including injuries that crush, sever, or pull on nerves
• inflammation
• connective tissue disease, including arthritis, systemic lupus erythematosus (a chronic inflammatory disease that affects many systems of the body, including the nervous system), polyarteritis nodosa (a vascular disease that causes widespread inflammation and ischemia of small and medium-size arteries), and Sjögren's syndrome (a disorder marked by insufficient moisture in the tear ducts, salivary glands, and other glands)
• toxins, including heavy metals (metallic elements such as arsenic, lead, and mercury which can, in large amounts, cause poisoning ), certain medications antibiotics and chemotherapy agents, solvents, and overdose of pyridoxine (vitamin B₆)
• malignancy
• infections, including Lyme disease , human immunodeficiency virus (HIV), and leprosy
• hereditary disease, including Charcot-Marie-Tooth disease (a disorder that causes wasting of the leg muscles, resulting in malformation of the foot), porphyria (a group of disorders in which there is abnormally increased production of substances called porphyrins), and Denny-Brown's syndrome (a disorder of the nerve root)

Paresthesias can also be caused by central nervous system disturbances, including stroke , transient ischemic attack (TIA), tumor, trauma, multiple sclerosis, or infection.

Symptoms

Sensory nerves supply or innervate particular regions of the body. Determining the distribution of symptoms is an important way to identify the nerves involved. For instance, the median nerve innervates the thumb, the first two fingers, half of the ring finger, and the part of the hand to which they connect. The ulnar nerve innervates the other half of the ring finger, the little finger, and the remainder of the hand. Distribution of symptoms may also aid diagnosis of the underlying disease. Diabetes usually causes a symmetrical glove-and-stocking distribution in the hands and feet. Multiple sclerosis may cause symptoms in several, widely separated areas.

Other symptoms may accompany paresthesias, depending on the type and severity of the nerve disturbance. For instance, weakness may accompany damage to nerves that carry both sensory and motor neurons. (Motor neurons are those that carry messages outward from the brain.)

When to call the doctor

A healthcare professional should be consulted when instances of numbness or tingling last for more than a few hours.

Diagnosis

A careful history of the affected individual is needed for a diagnosis of paresthesias. The medical history should focus on the onset, duration, and location of symptoms. The history may also reveal current related medical problems and recent or past exposure to drugs, toxins, infection, or trauma. The family medical history may suggest a familial disorder. A work history may reveal repetitive motion, chronic vibration, or industrial chemical exposure.

The physical and neurological examination tests for distribution of symptoms and alterations in reflexes, sensation, or strength. The distribution of symptoms may be mapped by successive stimulation over the affected area of the body.

Lab tests for paresthesia may include blood tests and urinalysis to detect metabolic or nutritional abnormalities. Other tests are used to look for specific suspected causes. Nerve conduction velocity tests, electromyography, and imaging studies of the affected area may be employed. Nerve biopsy may be indicated in selected cases.

Treatment

Treatment of paresthesias depends on the underlying cause. For limbs that have "fallen asleep," restoring circulation by stretching, exercising, or massaging the affected limb can quickly dissipate the numbness and tingling. Physical therapy can also be helpful. If the paresthesia is caused by a chronic disease such as diabetes or occurs as a complication of treatments such as chemotherapy, most treatments are aimed at relieving symptoms. Anti-inflammatory drugs such as aspirin or ibuprofen are recommended if symptoms are mild. In more difficult cases, antidepressant drugs such as amitriptyline (Elavil) are sometimes prescribed. These drugs are given at a much lower dosage for this purpose than for relief of depression. They are thought to help because they alter the body's perception of pain . In severe cases, opium derivatives such as codeine can be prescribed. In the early 2000s trials are being done to determine whether treatment with human nerve growth factor will be effective in regenerating the damaged nerves.

Several alternative treatments are available to help relieve symptoms of paresthesia. Nutritional therapy includes supplementation with B complex vitamins , especially vitamin B ₁₂ (intramuscular injection of vitamin B ₁₂ is most effective). Vitamin supplements should be used cautiously, however. Overdose of Vitamin B ₆ is one of the causes of paresthesias. People experiencing paresthesia should also avoid alcohol. Acupuncture and massage are said to relieve symptoms. Self-massage with aromatic oils is sometimes helpful. The application of topical ointments containing capsaicin, the substance that makes hot peppers hot, provides relief for some. It may also be helpful to wear loosely fitting shoes and clothing. None of these alternatives should be used in place of traditional therapy for the underlying condition.

Prognosis

Treating the underlying disorder may reduce the occurrence of paresthesias. However, paresthesias resulting from damaged nerves may persist throughout or even beyond the recovery period. The overall prognosis depends on the cause.

Prevention

Preventing the underlying disorder may reduce the incidence of paresthesias. For those with frequent paresthesias caused by ischemia, changes in posture may help.

Nutritional concerns

Vitamin supplements should be used with caution as an overdose of vitamin B ₆ is one of the causes of paresthesias. People experiencing paresthesia should avoid alcohol.

Parental concerns

Parents should monitor children who complain of numbness or tingling that lasts for more than a few minutes and fails to improve. They should recommend stretching and exercise and if relief does not come quickly, investigate other causes, such as clothing that is too tight.

KEY TERMS

Electrooculography (EOG) —A diagnostic test that records the electrical activity of the muscles that control eye movement.

Motor nerve —Motor or efferent nerve cells carry impulses from the brain to muscle or organ tissue.

Nerve condition velocity (NCV) —Technique for studying nerve or muscle disorders, measuring the speed at which nerves transmit signals.

Nerve growth factor —A protein resembling insulin that affects the growth and maintenance of nerve cells

Peripheral nervous system —The part of the nervous system that is outside the brain and spinal cord. Sensory, motor, and autonomic nerves are included.

Sensory nerves —Sensory or afferent nerves carry impulses of sensation from the periphery or outward parts of the body to the brain and spinal cord.

Resources

BOOKS

Asbury, Arthur K. "Approach to the patient with peripheral neuropathy." In Harrison's Principles of Internal Medicine, 15th ed. Edited by Eugene Braunwald, et al., New York: McGraw Hill, 2001, pp. 2498–2506.

Dyck, Patrick. Peripheral Neuropathy, 4th ed. New York: Elsevier, 2004.

Greenberg, David A., et al. Clinical Neurology, 5th ed. New York: McGraw Hill, 2002.

Griffin, John W. "Peripheral Neuropathies." In Cecil Textbook of Medicine, 22nd ed. Edited by Lee Goldman, et al. Philadelphia: Saunders, 2003, pp. 2379–86.

Nobak, C. R., et al. Human Nervous System: Structure and Function, 6th ed. Totawa, NJ: Humana Press, 2004.

PERIODICALS

Aldridge, T. "Diagnosing heel pain in adults." American Family Physician 70, no. 2 (2004): 332–8.

Carrero, G. "Paresthesia: what causes this sensory phenomenon?" Regional Anesthesia and Pain Medicine 29, no. 1 (2004): 69–70.

Hogan, Q. "Finding nerves is not simple." Regional Anesthesia and Pain Medicine 28, no. 5 (2004): 367–71.

Karaca, P., et al. "Painful paresthesiae are infrequent during brachial plexus localization using low-current peripheral nerve stimulation." Regional Anesthesia and Pain Medicine 28, no. 5 (2004): 380–3.

Nandi, D., and T. Z. Aziz. "Deep brain stimulation in the management of neuropathic pain and multiple sclerosis tremor." Journal of Clinical Neurophysiology 21, no. 1 (2004): 31–9.

Tuzun, E. H., et al. "A comparison study of quality of life in women with fibromyalgia and myofascial pain syndrome." Disability Rehabilitation 26, no. 4 (2004): 198–202.

ORGANIZATIONS

American Academy of Family Physicians. 11400 Tomahawk Creek Parkway, Leawood, KS 66211–2672. Web site: <www.aafp.org/>.

American Academy of Neurology. 1080 Montreal Avenue, St. Paul, Minnesota 55116. Web site: <www.aan.com/>.

American Academy of Pediatrics. 141 Northwest Point Boulevard, Elk Grove Village, IL 60007–1098. Web site: <www.aap.org/default.htm>.

American Academy of Physical Medicine and Rehabilitation. One IBM Plaza, Suite 2500, Chicago, IL 60611–3604. Web site: <www.aapmr.org/>.

American College of Occupational and Environmental Medicine. 55 West Seegers Road, Arlington Heights, IL 60005. Web site: <www.acoem.org/>.

American College of Physicians. 190 N Independence Mall West, Philadelphia, PA 19106–1572. Web site: <www.acponline.org/>.

American College of Sports Medicine. 401 W. Michigan St., Indianapolis, IN 46202–3233. Web site: <www.acsm.org/>.

WEB SITES

"Numbness and Tingling." Medline Plus. Available online at <www.nlm.nih.gov/medlineplus/ency/article/003206.htm> (accessed November 13, 2004).

"Numbness and Tingling." University of Michigan Health System. Available online at <www.med.umich.edu/obgyn/smartmoms/discomforts/numbness.htm> (accessed November 13, 2004).

"Paresthesia." Family Practice Notebook. Available online at <www.fpnotebook.com/NEU242.htm> (accessed November 13, 2004).

"Paresthesia Information Page." National Institute of Neurological Disorders and Stroke. Available online at <www.ninds.nih.gov/health_and_medical/disorders/paresthesia.htm> (accessed November 13, 2004).

L. Fleming Fallon, Jr., MD, DrPH

Numbness and Tingling

Definition

Numbness and tingling are decreased or abnormal sensations caused by altered sensory nerve function.

Description

The feeling of having a foot "fall asleep" is a familiar one. This same combination of numbness and tingling can occur in any region of the body and may be caused by a wide variety of disorders. Sensations such as these, which occur without any associated stimulus, are called paresthesias. Other types of paresthesias include feelings of cold, warmth, burning, itching, and skin crawling.

Causes and symptoms

Causes

Sensation is carried to the brain by neurons (nerve cells) running from the outer parts of the body to the spinal cord in bundles called nerves. In the spinal cord, these neurons make connections with other neurons that run up to the brain. Paresthesias are caused by disturbances in the function of neurons in the sensory pathway. This disturbance can occur in the central nervous system (the brain and spinal cord), the nerve roots that are attached to the spinal cord, or the peripheral nervous system (nerves outside the brain and spinal cord).

Peripheral disturbances are the most common cause of paresthesias. "Falling asleep" occurs when the blood supply to a nerve is cut off—a condition called ischemia. Ischemia usually occurs when an artery is compressed as it passes through a tightly flexed joint. Sleeping with the arms above the head or sitting with the legs tightly crossed frequently cause numbness and tingling.

Direct compression of the nerve also causes paresthesias. Compression can be short-lived, as when a heavy backpack compresses the nerves passing across the shoulders. Compression may also be chronic. Chronic nerve compression occurs in entrapment syndromes. The most common example is carpal tunnel syndrome. Carpal tunnel syndrome occurs when the median nerve is compressed as it passes through a narrow channel in the wrist. Repetitive motion or prolonged vibration can cause the lining of the channel to swell and press on the nerve. Chronic nerve root compression, or radiculopathy, can occur in disk disease or spinal arthritis.

Other causes of paresthesias related to disorders of the peripheral nerves include:

• Metabolic or nutritional disturbances. These disturbances include diabetes, hypothyroidism (a condition caused by too little activity of the thyroid gland), alcoholism, malnutrition, and vitamin B₁₂ deficiency.
• Trauma. Trauma includes injuries that crush, sever, or pull on nerves.
• Inflammation.
• Connective tissue disease. These diseases include arthritis, systemic lupus erythematosus (a chronic inflammatory disease that affects many systems of the body, including the nervous system), polyarteritis nodosa (a vascular disease that causes widespread inflammation and ischemia of small and mediumsize arteries), and Sjögren's syndrome (a disorder marked by insufficient moisture in the tear ducts, salivary glands, and other glands).
• Toxins. Toxins include heavy metals (metallic elements such as arsenic, lead, and mercury which can, in large amounts, cause poisoning ), certain antibiotics and chemotherapy agents, solvents, and overdose of pyridoxine (vitamin B₆).
• Malignancy.
• Infections. Infections include Lyme disease, human immunodeficiency virus (HIV), and leprosy.
• Hereditary disease. These diseases include Charcot-Marie-Tooth disease (a hereditary disorder that causes wasting of the leg muscles, resulting in malformation of the foot), porphyria (a group of inherited disorders in which there is abnormally increased production of substances called porphyrins), and Denny-Brown's syndrome (a hereditary disorder of the nerve root).

Paresthesias can also be caused by central nervous system disturbances, including stroke, TIA (transient ischemic attack), tumor, trauma, multiple sclerosis, or infection.

Symptoms

Sensory nerves supply or innervate particular regions of the body. Determining the distribution of symptoms is an important way to identify the nerves involved. For instance, the median nerve innervates the thumb, the first two fingers, half of the ring finger, and the part of the hand to which they connect. The ulnar nerve innervates the other half of the ring finger, the little finger, and the remainder of the hand. Distribution of symptoms may also aid diagnosis of the underlying disease. Diabetes usually causes a symmetrical "glove and stocking" distribution in the hands and feet. Multiple sclerosis may cause symptoms in several, widely separated areas.

Other symptoms may accompany paresthesias, depending on the type and severity of the nerve disturbance. For instance, weakness may accompany damage to nerves that carry both sensory and motor neurons. (Motor neurons are those that carry messages outward from the brain.)

Diagnosis

A careful history of the patient is needed for a diagnosis of paresthesias. The medical history should focus on the onset, duration, and location of symptoms. The history may also reveal current related medical problems and recent or past exposure to drugs, toxins, infection, or trauma. The family medical history may suggest a familial disorder. A work history may reveal repetitive motion, chronic vibration, or industrial chemical exposure.

The physical and neurological examination tests for distribution of symptoms and alterations in reflexes, sensation, or strength. The distribution of symptoms may be mapped by successive stimulation over the affected area of the body.

Lab tests for paresthesia may include blood tests and urinalysis to detect metabolic or nutritional abnormalities. Other tests are used to look for specific suspected causes. Nerve conduction velocity tests, electromyography, and imaging studies of the affected area may be employed. Nerve biopsy may be indicated in selected cases.

Treatment

Treatment of paresthesias depends on the underlying cause. For limbs that have "fallen asleep," restoring circulation by stretching, exercising, or massaging the affected limb can quickly dissipate the numbness and tingling. If the paresthesia is caused by a chronic disease such as diabetes or occurs as a complication of treatments such as chemotherapy, most treatments are aimed at relieving symptoms. Anti-inflammatory drugs such as aspirin or ibuprofen are recommended if symptoms are mild. In more difficult cases, antidepressant drugs such as amitriptyline (Elavil) are sometimes prescribed. These drugs are given at a much lower dosage for this purpose than for relief of depression. They are thought to help because they alter the body's perception of pain. In severe cases, opium derivatives such as codeine can be prescribed. Currently trials are being done to determine whether treatment with human nerve growth factor will be effective in regenerating the damaged nerves.

Alternative treatment

Several alternative treatments are available to help relieve symptoms of paresthesia. Nutritional therapy includes supplementation with B complex vitamins, especially vitamin B₁₂ (intramuscular injection of vitamin B₁₂ is most effective). Vitamin supplements should be used cautiously however. Overdose of Vitamin B₆ is one of the causes of paresthesias. People experiencing paresthesia should also avoid alcohol. Acupuncture and massage are said to relieve symptoms. Self-massage with aromatic oils is sometimes helpful. The application of topical ointments containing capsaicin, the substance that makes hot peppers hot, provides relief for some. It may also be helpful to wear loosely fitting shoes and clothing. None of these alternatives should be used in place of traditional therapy for the underlying condition.

Prognosis

Treating the underlying disorder may reduce the occurrence of paresthesias. Paresthesias resulting from damaged nerves may persist throughout or even beyond the recovery period. The overall prognosis depends on the cause.

Prevention

Preventing the underlying disorder may reduce the incidence of paresthesias. For those with frequent paresthesias caused by ischemia, changes in posture may help.

Resources

PERIODICALS

McKnight, Jerry T., and Bobbi B. Adcock. "Paresthesias: A Practical Diagnostic Approach." American Family Physician 56 (December 1997): 2253-2260.

KEY TERMS

Electromyography— A test that uses electrodes to record the electrical activity of muscle. The information gathered is used to diagnose neuromuscular disorders.

Motor nerve— Motor or efferent nerve cells carry impulses from the brain to muscle or organ tissue.

Nerve conduction velocity test— A test that measures the time it takes a nerve impulse to travel a specific distance over the nerve after electronic stimulation.

Nerve growth factor— A protein resembling insulin that affects growth and maintenance of nerve cells

Peripheral nervous system— The part of the nervous system that is outside the brain and spinal cord. Sensory, motor, and autonomic nerves are included.

Sensory nerves— Sensory or afferent nerves carry impulses of sensation from the periphery or outward parts of the body to the brain. Sensations include feelings, impressions, and awareness of the state of the body.