Welcome. If you happen to have come across this site because you’re newly diagnosed or an old veteran when it comes to Hereditary Neuropathy with Liability to Pressure Palsies (HNPP), I’m glad you’ve made it.
First of all, this is an introduction to what exactly it is to those who aren’t aware. And it’s also a quick chance for me to say how and why I’ve made this website. No, I’m not going to do a whole “Dear Diary” kind of blog. It’s going to be a compilation of tips and advice that I’ve gathered especially for those with HNPP who are struggling to stay afloat on the best of days.
So what is HNPP?
It is a genetic nerve disorder, similar to Multiple Sclerosis and Charcot Marie-Tooth Disorder in terms of symptoms, but it affects the peripheral nerves instead of the brain and the spine. It’s also hereditary, so there’s a big, fat chance someone in your near or distant family also has it.
It’s the defect and deletion of one of the PMP-22 genes, where everyone usually has two. So when you move or lean in certain ways, it can leave the nerve damaged for much longer than usual and can grow back incorrectly.
The symptoms can consist of tingling and numbness to loss of mobility of your hands and legs. It’s different for everyone, and given that only 2-5 out of 100,000 have been diagnosed with it, there’s very little resources and research out there.
And that’s where I come in.
Why have I made this blog?
Well, without stating the obvious, I’ve been diagnosed with HNPP – and only this year after going to a yoga retreat (yes, ridiculous I know). Both my sister and I have it so that’s a nice family bonding session we have right there. But mostly, I created this because I found a lot of people can end up feeling desperate and isolated with this condition, and there seems to be nothing to address the day-to-day issues – mental health, physical wellbeing and strategies in coping. So without further ado, I hope that I can help in some small way just to acknowledge WE DO EXIST.
“You’ve just got to make it work for you”, says award-winning American playwright Branden Jacob-Jenkins about living with the condition hereditary neuropathy with liability to pressure palsies.
Jacob-Jenkins, who hails from New York City, is no stranger to the public eye. The 35-year-old playwright is already a two-time finalist for the Pulitzer Prize, and a 2016 MacArthur fellow, having toured the world with his renowned adaptations. But less known is the fact that while achieving huge success in the theatre world, winning both the Windham–Campbell Literature Prize and PEN/Laura Pels Award in 2016, Jacob-Jenkins battles with migraines associated with HNPP.
“I think [HNPP] has influenced a lot about the way I think about my relationships with my body, which has only enhanced or runs alongside the way that being a black male already does that.”
“I live with visual auras pretty frequently, and that is a really significant issue”, says the writer, who has recently joined the faculty of the University of Texas’ MFA playwriting program.
The rare genetic nerve condition can present an array of symptoms ranging from chronic pain to fatigue, varying from one person to another.
Speaking to him in London last year, during his sellout run of An Octoroon at the National Theatre, Jacob-Jenkins mentioned that his frequent migraines began soon after being diagnosed with the condition at the age of 19.
He says: “It was crazy, there’s just a period of not-knowing that is so frightening. The worst part was that people thought it was a brain tumour, I had so many scans done.”
Jacob-Jenkins has subsequently had two surgeries on both his ulnar nerves to rectify some of the more extreme symptoms that he initially experienced.
“The first major symptom was I woke up one morning and I could not lift my left arm, which meant there was some sort of major palsy happening […] And in that original diagnosis, I realised that the numbness I had been feeling in my fingers [when younger] was due to this. I remember having no feeling in my pinky finger. And it wasn’t until that doctor said that this is probably related that I realised.”
The playwright, who was born in Washington DC, speaks about the uncertainty that came with his original diagnosis, and the fact that it took months to pinpoint. He says he was baffled by what this implied: “What do you mean I have HNPP, what does that mean? I couldn’t Google it. This did not tell me anything. All I know is that my arm can’t move and they would give me carpal tunnel exercises that would make it worse and it was just really difficult.”
“Here was a moment where a total lack of information about the disease was having an actual repercussion on me socially.”
While he describes his primary reaction as “traumatising”, Jacob-Jenkins, who has a major in Anthropology from Princeton University, says it may have inadvertently helped him develop his theatrical style. “I think it has influenced a lot about the way I think about my relationships with my body which has only enhanced or runs alongside the way that being a black male already does that […] Weirdly, almost every play of mine is obsessed with asking actors to use their bodies in different and stranger ways. They are either changing character over the course of the piece or they are negotiating it as an obstacle in terms of telling a story. I think that’s totally, weirdly related to my experience with this disease.”
This is certainly highlighted in An Octoroon, a radical adaptation of Dion Boucicault’s 1860’s play The Octoroon, in which the actors adopt blackface and whiteface in this version, while Jacob-Jenkins emphasises the politics of actual bodies onstage as conduits for meaning or emotional value that have changed over time.
“I’m always observing my body removed and I’m always thinking about the limitations in a way that I don’t think a lot of people do, so I do think that oddly it has some deep level that has affected my aesthetic impulses in a funny way.”
The writer first spoke about his condition publicly in a New York Times article, in which journalist Alex Witchel describes the “shocking news of his health”. However, Jacob-Jenkins appears to take it on the chin: “They think you’re dying of a degenerative disease […] So me in this article, appears as if I’m stoic in the face of impending doom. It was also the first time I realised that I manage it fine but suddenly everyone knew I had this thing.”
“It’s about self-education and the fact that my nerve health is going to degenerate, that’s the definition of the disease, but you can take preventative steps to try and slow the process down.”
He adds: “And here was a moment where a total lack of information about the disease was having an actual repercussion on me socially.”
Despite the impact of revealing his condition, he says he has the support of his partner who he married last year. “I have my partner. But it would be nice to know more people who have this. I like my neurologists a lot and I have my friends. Right now, I’m fortunate enough to be able to walk around by myself. In a way I know the hardest is yet to come so I’m trying to enjoy what I have today.”
Regularly seeing neurologist Bridget Carey at the Weill Cornell Medicine in New York has aided Jacob-Jenkins with managing the condition. “Having someone being able to monitor this thing and coming to a conclusion about that just feels so good. You just have to own it, and stay vigilant about it.”
“Right now, I’m fortunate enough to be able to walk around by myself. In a way I know the hardest is yet to come so I’m trying to enjoy what I have today.”
The playwright says he maintains a balanced lifestyle with his “low-impact job”: “Supplements are a huge part of my diet, so Vitamins D and K , Magnesium – these things are really important and I do think they help […] You don’t have to go to a gym and pull weights but actually you can work at flexibility and strength in small ways and it still makes in the long term a big difference. Just modify! Physically I don’t think of myself as ill. I have an illness, but I’m not an ill person […] But in terms of work, I’m a very lucky person.”
“Physically I don’t think of myself as ill. I have an illness, but I’m not an ill person.”
And fortune favours the bold and unstoppable, as Jacob-Jenkins’ outstanding play Gloria, receives its regional premiere at Curious Theatre in Denver, collecting glittering reviews.
“I’m never going to stop working in my life. And it could have been much worse. I still have to live my life, and the body is quite resilient in spite of itself so you’re going to bounce back.”
His final word on the matter? “It’s about self-education and the fact that my nerve health is going to degenerate, that’s the definition of the disease, but you can take preventative steps to try and slow the process down.”
Gloria, presented by Curious Theatre Company through February 16, 1080 Acoma Street, 303-623-0524, curioustheatre.org.
Results from an annual conference that took place late last year have revealed the extent of symptoms suffered by those with HNPP. Sufferers say that pain is the number one issue that plagues them.
On November 3rd, nearly 100 participants gathered at the Samberg Conference Center on the Massachusetts Institute of Technology (MIT) campus in Cambridge, MA, for the Hereditary Neuropathy Foundation (HNF) Patient-Centered Charcot Marie-Tooth (CMT) / Hereditary Neuropathy with Liability to Pressure Palsies (HNPP) Pain Summit. Ninety per cent of the 115 patients that took part in the study linked to the conference, indicated that their pain had a moderate to severe impact on their quality of life.
The meeting brought together people with hereditary neuropathies and their families, caregivers, clinicians, researchers, funding agencies, sponsors, leading pain experts, and the pharma industry to provide an in-depth look at chronic pain within the CMT/HNPP community, including its impact on quality of life.
The one day conference also offered expert sessions as well as breakout session, primarily led by sufferers, with a focus on identifying gaps that are hindering patient care in neuropathic and musculoskeletal pain, diagnosis and outcome measures to support development of therapies.
Consequently, HNF partnered with the voice-powered survey platform True Reply to record patient responses to a five-question survey in their own voice. A total of 621 responses were recorded by the participants over a 30-day period.
The questions asked included:
What type of Charcot Marie-Tooth or inherited neuropathy do you have?
Do you experience disease-related or other types of pain?
Please describe your pain symptoms as descriptively as possible.
Please describe how your pain impacts your daily quality of life.
How do you currently manage your pain?
HNF founder and CEO, Allison Moore, said that the results were “enlightening”.
Moore said: “Hearing about our patients’ experience with pain in their own words was both enlightening and heartbreaking at the same time.
“Our patients are hurting badly in so many ways, and they need guidance and protocols from their healthcare providers to help manage their pain so they can go about their daily lives as pain-free as possible.”
“The voice of the CMT patient can no longer be ignored when it comes to the protocols, treatments and therapeutics that are being developed to treat this disease.”
Allison Moore, Hereditary Neuropathy Foundation CEO
Other key takeaways from the study showed that 76 per cent of patients are managing their pain on their own, with a combination of over-the-counter medications and alternative therapies, while 63 per cent described their pain as numbness, sharp, burning or stabbing.
Jose Cotto, founder and CEO of True Reply, said: “The ability of True Reply to quantitatively analyse patient responses in real-time while also giving researchers and clinicians access to qualitative data such patient voice tone, cadence and stress levels is a real game changer for Patient Reported Outcome (PRO) studies”.
Moore said she hopes that as more sufferers speak out about their experiences, the better therapies may be: “We are looking forward to using technologies like True Reply to help us tell our patients’ stories in their own words so we can address their immediate quality of life issues while waiting for desperately needed therapeutics to move through the pipeline and be approved for commercial use.”
She adds: “The voice of the CMT patient can no longer be ignored when it comes to the protocols, treatments and therapeutics that are being developed to treat this disease”.
There have been some great developments in the world of HNPP, with the most recent being a website dedicated to all research papers related to the condition.
For those who want an easier way to explore scientific publications on HNPP, behold the website HNPP Research, compiled by a fellow sufferer, who happens to be a both a software developer with experience in the medical research field.
Speaking about the website, the creator has said: “It’s not for beginners, but if you are curious to dive deeper into the scientific side I hope this will be a helpful resource.
“There are over 500 studies and I learned a lot about the underlying causes by reading the articles. You can also search on topics of interest like “pain” to see what the latest studies say.”
Results from a study conducted this month by scientists at the Samsung Medical Center in South Korea, in collaboration with LabGenomics, have revealed that hereditary neuropathy with liability to pressure palsies (HNPP), is much more common than usually assumed.
Researchers estimate that one in every 5,943 Koreans have a deletion within the PMP22 gene, which is higher than worldwide estimates which stands at every 16 out of 100,000 person with the condition. It is generally believed across the board that 2-5 of 100,000 have HNPP, however, this latest research shows it is the equivalent to every 59th person out of 100,000, many of whom may present only mild symptoms. So are there more people with HNPP than we initially thought?
The team detected seven samples of those tested with deletions of genetic content affecting the 17p11.2 chromosome – which includes the PMP22 gene – and two cases of PMP22 gene duplication leading to CMT1A. They report that all samples were from unrelated families with six out of seven being female, and three (42.9%) had a family history of HNPP.
The exact prevalence of HNPP remains unclear, however, a prior study from the Republic of Ireland and in southwestern Finland reported a prevalence of 0.84 per 100,000 to 16 per 100,000. The major difference in this study is that patients with symptoms of HNPP were tested under the Irish and Finnish report, whilst South Korean researchers analysed data from newborns.
Previously reported prevalence of hereditary neuropathy with liability to pressure palsies:
Attributed to: Frequency of hereditary neuropathy with liability to pressure palsies (HNPP) due to 17p11.2 deletion in a Korean newborn population, 2018, Jong Eun Park et al.
While the study had limitations and the number of subjects may not be adequate enough to estimate the exact prevalence of the rare genetic disorder, it still provides insight regarding the baseline frequency of the chromosome deletion that commonly causes HNPP.
As the authors say: “[A] significant proportion of parents with PMP22 duplication already have CMT1A-related symptoms and may be more likely to request prenatal genetic diagnosis or preimplantation genetic diagnosis (PGD) rather than neonatal screening.
“Our data suggest that PMP22 deletion [associated with] HNPP might not be uncommon, at least in the Korean population,” they concluded.
You may have spotted the lack of posts for the past few months. This is solely blamed on that age-old issue of brain fog, as well as notoriously rebellious hands. Hence, while I was Google searching “How to get rid of brain fog with HNPP”, lo and behold, I find what appears to be one of the first official donation pages for HNPP! (I have definitely never come across this before, but I may be wrong).
As many with the condition know, money is scarce and not many health professionals are currently researching the condition, with only the exception of a few including the renown Dr. Jun Li, a professor of the Department of Neurology, Brain Institute and Center for Human Genetics Research at Vanderbilt University in Nashville, Tennessee. His research lab pages can be found here.
And HNF are very keen on people to get involved in fundraising:
For those who follow disability forum Team Inspire, you may have spotted Lainie from Trend-Able launching her new website with the tag line “where your disability is not an accessory”. Now this is a bit of a godsend for some women who struggle with buttons and even pulling up socks, but it seems that Lainie will be providing first-hand insight on what to use, and wear especially for those with orthotics and prosthetics.
After my work Christmas party, my legs had lost all feeling thanks to the stupidity of high heels and my own lack of commonsense. So it was only time that someone with the wits and the technological wisdom to create a wonderful site full of tips and tricks. And while it’s still a very new creation, it might be worth subscribing for any future information.
If you’re a fashionista, never fear, Lainie is here.
After several months of falling off the internet radar due to unruly fingers, I realised I may need some outside help. That’s where occupational therapists and vocational rehabilitation comes into play.
It’s easy to become confused over the role of an occupational therapist, given that it seems as if it is related solely to work-based activities. However, they cover a wide range of issues and activities that allow a person to operate relatively independently.
What is occupational therapy?
Occupational therapy is crucial in helping a person cope with the functional, vocational, and social impact of the condition. It helps a person in improving sensory motor skills through regular exercises related to it. It also teaches us to avoid exposure to certain environmental and industrial toxins that can be harmful.
The OTs also teach self care activities and patient safety issues. The therapist also teaches us to pay attention to issues which involve functions like learning how to change positions smoothly to avoid becoming numb and how to prevent falling. They can work with physiotherapists to ensure you get the best care possible.
There is a strong educational element in occupational therapy. Therapists typically teach people how to:
Prevent falls by watching out for uneven terrain and other hazards
Adjust habits, such as sitting correctly without injuring yourself
Find the best solutions to allow you to live independently.
Obviously, there are a lot of crossovers with vocational rehabilitation when it comes to learning to stabilise yourself. From avoiding falling at home and work, as well as correcting your posture, which can be applicable in any situation. Therefore an OT can be in charge of:
Environmental assessments – at school, work, home
OTs are people-centred and their goal is to promote and enable independence. They will assess how well you cope with activities of daily living (ADLs), listen to your needs concerning personal care, leisure, work, study, travel and household management and advise on options for you. Their assessment may involve breaking down the activities you find hard into their component parts.
For example, if you have neuropathy you may struggle with everyday activities like getting dressed, opening food packets or holding a pen to write. Your OT will work with you to find solutions to these problems to help you remain independent. Solutions may come in the form of trying some adaptive equipment to compensate for your difficulty, or by working on activities to help maintain strength in certain muscle groups.
OTs can also make referrals for making splints for hands. People with HNPP may develop problems holding and gripping and experience some muscle wasting in their hands. A hand splint can help to keep your hand in a good position in order to minimise pain and muscle contractures.
At various stages of the condition, an OT may be able to offer expertise in areas such as:
Individualised fatigue management programmes to understand the nature of your particular fatigue within your daily life
How to more effectively prioritise and manage your time to achieve the things you want to do
Strategies to improve sleep and good quality rest
Relaxation as a coping strategy – for example as a stress or pain management technique
Ergonomic information about effective joint protection and energy conservation strategies
Hand-care techniques including provision of hand exercise programmes, fabrication of custom made hand splints to aid daily tasks, pain management and hand positioning
Adaptive equipment from small aids to major adaptations for helping you at home or in your workplace
Signposting and referring on to agencies to help with the cost of purchasing daily living aids and adaptations
Information on employment legislation and your rights within the workplace
Graded return-to-work and remaining-in-work programmes
Care assessments for direct payments or home helps
Mental health-related referrals.
In the UK, OTs work in various settings including community teams, social services and hospitals. The health professionals involved in your care, including doctors, nurses and therapists, can refer you to an occupational therapist if this is required. You may also be able to self-refer to some therapy services – so it is always worth giving your local social services a call. They will explain the correct process for your area.
Some of the adapted changes in my own home include:
A wheelie tray to be able safely carry hot items from one place to another
A food workstation – which has adapted facilities such as a place to hold objects in order to be able to cut safely, a flat grater and slicer
Adapted knives – it has better grip and position to allow you to cut object safely
Special cutlery – a bevelled fork allows you to use one hand to both cut and eat
A bath board – to be able sit safely while in a bathtub
While you may feel helpless in the face of such an uphill battle, occupational therapists go a long way in assisting you to succeed.
Living Made Easy – (NHS and OT recommended) price comparison site for adaptive equipment
AbilityNet – help the lives of disabled people by helping them to use digital technology at work, at home or in education
Naidex – disability information shows like Naidex are excellent for giving you an idea of what is available, but be warned, these shows are huge. Take advantage of their Shopmobility scooters, or you’ll never last the distance
Expo Database – trade conferences around the world that showcase the latest disability equipment.
This is one of the more difficult subjects to tackle. It could partly be because some HNPP sufferers worry about coming forward due to the stigma of mental health, or feel they may be overreacting. But rest assured, it is absolutely natural and completely expected.
According to Scott Berman MD, Psychiatrist and neuropathy patient, there is a strong overlap between neuropathy pain, anxiety, and depression. In his book, Coping with Peripheral Neuropathy, Dr Berman says each of the components can raise the risk for having the other two. As much as 30 to 60 per cent of patients with chronic pain develop feelings of depression and anxiety, while pain and depression can co-occur 30 to 50 per cent of the time, and each can cause the other.
As a result, anxiety can cause several issues that may lead to the development of these neuropathic types of symptoms. Just a small sample includes:
Hyperventilation – common when you have anxiety, and when you hyperventilate your blood vessels constrict which takes away blood flow from some parts of your body. Without blood flow, these areas start to tingle, burn among others.
Nerve firings – anxiety could potentially cause the nerves to fire more, which can also lead to this feeling as though your nerves are always activated and cause “nerve damage-like symptoms” that can be hard to deal with.
Over-awareness – When you’re overly aware of your body, you can have trouble moving them leading to issues with gait (walking style) and how your body feels.
So it’s hardly any surprise that it becomes a vicious cycle, as you may have anxieties over fear of relapse or worsening, disability, isolation, stigma or even fear of further pain.
So how do you find ways of coping?
Everyone has different strategies in dealing with anxiety and stress, however, if you feel particularly stuck, these may be of benefit.
Speak to your medical practitioner or GP, and share your fears – don’t be alone with them
Speak to the groups and networks available. Please find them on the Resources page
Speak to friends and family if reasonably possible, they may not necessarily understand, but a listening ear is always useful
Mindfulness based stress reduction programs combines aspects of meditation and yoga. Many hospitals and complementary/alternative medicine centres use it
Spiritual and faith based help
Exercise, massage and yoga
Breathe better – make sure you slow your breathing down considerably if you’re hyperventilating. Take as long as 5 seconds to breathe in, hold for 2 seconds, and breathe out for 7. Slowing down your breathing is very important for controlling anxiety.
Distract your mind – you need to distract your mind from focusing too heavily on your body, because only by doing that can your body’s movements feel more natural again.
What about depression?
Depression in neuropathy is often confused with the condition. That is, continued problems in function are often attributed to “psychological” or “psychosomatic” issues. Bottom line: all pain is real, and physical symptoms most often have physical causes. The role of the psychiatrist/psychologist/counsellor is to help with the emotional issues that arise from the stress of a medical disease.
Depression and chronic pain share some of the same neurotransmitters – brain chemicals that act as messengers travelling between nerves – as well as some of the same nerve pathways, and depression and pain can interact in a vicious cycle. Depression magnifies pain, changing the brain’s sensitivity to painful stimuli and reducing a person’s coping skills. And the constant stress of experiencing chronic pain can lead to a cascade of other medical problems linked with depression, making it still more difficult to break the cycle.
There are also known side effects from some medication for HNPP that is said to cause severe depression. In the report Depression and Attempted Suicide under Pregabalin Therapy from 2014, the authors say one of the rare side effects include suicidal thoughts. Pregabalin is a compound originally developed for treating epilepsy. Meanwhile, it has shown positive effects on neuropathic pain as well as on general anxiety disorder and is therefore largely prescribed by neurologists, psychiatrists and, of course, general practitioners.
I also deal with depression, neuropathy, and am pre-diabetic. I have those days as well. *hugs*
An FDA warning concerning self-harm in patients taking antiepileptic drugs was released in 2008, yet a relevant risk for pregabalin is postulated to be less than 1 per cent. In the above report, a 20-year-old man was admitted to a psychiatric ward for severe depression and suicidal thoughts, although it was his first episode of a psychiatric disorder.
The authors add: “After the patient retrospectively clearly correlated the start of pregabalin therapy with the onset of his depressive symptoms during exploration on our ward, we immediately discontinued the drug. Consequently, he reported a rapid decline in depressive symptoms, his mood remained stable, and he was discharged.
“Taking into account that certain antiepileptic drugs have been shown to be protective for patients with bipolar disorder concerning suicidality, but hazardous for patients with monopolar depression, for example, there may be critical patient variables also for pregabalin which remain to be elucidated.”
So you may want to talk to your medical practitioner about changing your medications if this seems to be the case.
Some common signs of depression include:
How you might feel
How you might behave
down, upset or tearful
restless, agitated or irritable
guilty, worthless and down on yourself
empty and numb
isolated and unable to relate to other people
finding no pleasure in life or things you usually enjoy
a sense of unreality
no self-confidence or self-esteem
hopeless and despairing
avoiding social events and activities you usually enjoy
self-harming or suicidal behaviour
finding it difficult to speak or think clearly
losing interest in sex
difficulty in remembering or concentrating on things
using more tobacco, alcohol or other drugs than usual
difficulty sleeping, or sleeping too much
feeling tired all the time
no appetite and losing weight, or eating too much and gaining weight
physical aches and pains with no obvious physical cause
moving very slowly, or being restless and agitated
When it comes to neuropathy sleep changes, low energy, poor concentration is common. As the 2014 anxiety and depression study says: “Clinical observations and epidemiological studies show frequent association of chronic pain with psychiatric disorders, including a high prevalence of major depression among pain clinic patients and a high lifetime comorbidity between neuropathic pain and mood disorders.” Hence depression can be a major excess when dealing with chronic neuropathic pain and fatigue.
How to proactively deal with depression
Following are several steps to help proactively prevent or manage both the chronic pain and associated depression that may develop:
Early diagnosis of depression associated with pain – many physicians are not necessarily trained to assess for depression during the course of treating pain. Talking to a physician about symptoms of depression, while still in the acute pain phase of pain, can alert a physician to the need to consider treatment of both conditions. An informed physician can suggest a treatment plan early on that treats the patient’s depression as well as their physical pain, giving the patient the best chance at a positive outcome.
Communicate about depression – depression and an emotional reaction to chronic pain are to be expected; they are understandable. Many patients do not speak to their physicians about their depression because they believe that once the initial pain problem is resolved, the depression, anxiety, and stress they are feeling will go away. However, secondary losses from a chronic pain problem, such as the loss of the ability to do favourite activities, disrupted family relationships, financial stress, or the loss of a job, can continue to contribute to feelings of hopelessness and depression even beyond the resolution of the pain problem. Talking to a physician about feelings of depression will keep the physician better informed and better able to provide appropriate care. Depression can affect the frequency and intensity of pain symptoms, and the healing rate. Getting simultaneous back pain and depression treatment will give the patient a better chance of a full recovery.
Seek multi-disciplinary care for pain and depression – a multi-disciplinary course of treatment that involves involving both a physician and a mental health professional can often provide the best outcomes. With a team approach, both the pain problem and the depression are monitored simultaneously, and both doctors can communicate about how each area affects the other. It’s important for physicians to understand that changes in the physical symptoms of pain can also be related to changes in a patient’s mental state. In addition, it’s important to note that some common treatments for pain (e.g. opioid pain medication, activity restriction, bed rest), can actually make depression worse. This worsening depression can then affect the physical presentation of the pain. If both physical and mental well-being are being monitored closely by medical experts, treatment and medication recommendations, including antidepressants, can be made that take both the physical pain and the emotional health of the patient into account.
Depression and anxiety can be painful when you’re already dealing with a whole host of other symptoms. And it can spiral the more you feel the effects of HNPP. So it’s important to notice any changes and try to get help as soon as possible.
It can be difficult to pick up the phone, but reach out to somebody and let them know how you are feeling.
Samaritans (116 123) operates a 24-hour service available every day of the year. If you prefer to write down how you’re feeling, or if you’re worried about being overheard on the phone, you can email Samaritans at email@example.com.
Depression Alliance is a charity for people with depression. It doesn’t have a helpline, but offers a wide range of useful resources and links to other relevant information.
The National Suicide Prevention Lifeline is a 24-hour, toll-free, confidential suicide prevention hotline available to anyone in suicidal crisis or emotional distress. A 24-hour an Online Chat in partnership with Contact USA is also available.
Crisis Text Line is the only 24/7, nationwide crisis-intervention text-message hotline.
Samaritans is a registered charity aimed at providing emotional support to anyone in distress or at risk of suicide throughout the United States.
It’s a fact that most people with HNPP know, but there are suggestions that certain exercises can actually do more damage than good. From walking to some types of yoga, while most forms of physical activity are encouraged by gym instructors, our bodies tend to rebel from the norm. But can exercise actually induce HNPP, even though it’s generally thought to be an hereditary condition?
As HNPP is an autosomal dominant disorder in which the condition is inherited and there is a deletion of one of the genes associated with PMP22, a child of an affected individual is at a 50 per cent risk of being affected by the condition. This suggests that the likelihood of a person developing HNPP out of nowhere is relatively low.
What are ‘sporadic’ cases of HNPP?
There have been recent reports that state that a few types of muscle training has actually brought about sporadic symptoms of HNPP without any previous familial history of the condition. Sporadic cases due to de novo deletion accounted for 21 per cent of the investigated HNPP families, as reported by some studies. De novo mutation is an alteration in a gene that is present for the first time in one family member as a result of a mutation in a germ cell of one of the parents or in the fertilised egg itself.
According to a 2017 study carried out by researchers at the Department of Neurology and Rheumatology, Shinshu University School of Medicine, Matsumoto, Japan, this apparently was the case in a 15-year-old boy. The authors suggest that this is the first instance of an adolescent “that developed neurological symptoms during muscle training in a school baseball club activity”, the first signs in a sporadic case of HNPP. The teenager developed bilateral painless brachial plexopathy through short-term barbell training and plank exercises.
“Patients sometimes show an atypical clinical phenotype, and a diagnosis of HNPP can therefore be challenging, especially in sporadic cases as in our patient.”
“Muscle Training-induced Bilateral Brachial Plexopathy in an Adolescent with Sporadic HNPP” – Kodaira, M., et al – July 2017
While brachial plexopathy can be a common feature of HNPP, bilateral involvement is thought to be unusual because HNPP is usually associated as a mononeuropathic condition, where there is a focus in only one area of nerves.
The authors in this case say: “As his clinical and NCS [nerve conduction study] findings indicated muscle training-induced bilateral brachial plexopathy in HNPP, genetic analysis for this disorder was performed, which revealed deletion of the PMP22 gene. Patients sometimes show an atypical clinical phenotype, and a diagnosis of HNPP can therefore be challenging, especially in sporadic cases as in our patient.”
The major difference in this occasion is that not only did he suffer from a bilateral injury, he also developed a sporadic case of HNPP triggered by relatively straightforward exercises. This is unlike some of the other examples where those in military training are far more likely to develop symptoms linked to HNPP, due to the strenuous physical activity undertaken by soldiers. However, this is not the first time ‘push ups’ are seen to be the main culprit as a trigger.
In another 2017 report A Case of HNPP due to Push-up Exercise, a 17-year-old man with no familial history of the condition developed “motor and sensory disturbance of the left upper limb a few days after starting push-up exercise”. Scientists from the Department of Neurology, Hirosaki University Graduate School of Medicine, say that the patient also developed brachial plexopathy, similar to the case above.
In the abstract, they conclude that: “Genetic tests revealed a diagnosis of hereditary neuropathy with liability to pressure palsies (HNPP). HNPP should be included in the differential diagnosis for neuropathy due to slight exercise or nerve compression even when familial history is negative.”
Researchers from the Division of Neurology and the Department of Pathology, University of Missouri School of Medicine, Columbia, USA, found a case in 2004 akin to the above studies. A 21-year-old in good health began to develop symptoms of HNPP on her first day of military training. She began to show symptoms of severe pain, weakness, and atrophy in her right shoulder, foot and hands. Her mother and her family had no history of neuromuscular disease. She did not know her father or his family history.
They say: “While the presentation and severity of this patient’s condition may relate to a specific unknown genetic profile with very low PMP-22 mRNA levels, Schenone et al, in finding correlations between reduced PMP-22 mRNA levels and disease severity, also suggested that extrinsic factors—for example, level of physical activity, may be important in determining phenotypic features.
“This appears to be true of our patient—that she was neurologically normal, then developed symptoms on the first day of military physical training with progression as she continued the training over a three week period, suggests that disease severity and focal axonal damage were related to these intense activities.”
The authors add: “Additionally, as it has recently been recognised that sporadic cases of HNPP are common, either because of de novo mutations or asymptomatic carriers, her lack of family history did not preclude this diagnosis.”
How likely is it that a case of HNPP is sporadic?
It’s important to note that HNPP may not be easily traced in other family members, which means while it may appear sporadic, it could just have been overlooked. A 2013 case report reiterates this view, with authors saying that approximately one-third of deletion carriers are unambiguously detected on the basis of “electrophysiological criteria and confirmed by genetic analysis are asymptomatic and do not display significant signs at clinical examination.”
Researchers from Department of Paediatrics, Hospital de Guimarães, Portugal, say: “Thus, the family history is often uninformative, and a significant proportion of probands may be considered as apparently sporadic cases. However, a close questioning and examination of the relatives provided evidence for autosomal dominant inheritance in families that were originally stated by the probands to be normal. Therefore, HNPP can easily be overlooked in those cases in which familial involvement is not recognised unless intensive ascertainment techniques are used.”
Electrophysiologic studies are said to be “suggestive” and not “sufficient for diagnosis” which may be why it may be imperceptible to locate.
How exercise can trigger symptoms
The more frequent representations are in those who already have familial histories of HNPP, or in those who have already been diagnosed. In one such case in 2005, hiking and athletic training brought on the symptoms. A 10-year-old girl, who suffered from acute, recurrent monoplegic episodes affecting both the sciatic nerves and the left brachial
plexus since the age of 7, showed quite a lot extensive symptoms from relatively low impact exercise.
Authors from the Department of Paediatrics, Yokohama City University Medical Centre, Japan, say: “This school child having HNPP is considered to be susceptible to the influence of abundant physical training, rather than minor trauma or compression at sites of entrapment of peripheral nerves.” However, this is hardly surprising given the nature of the condition. What’s more unusual are the situations where HNPP is not present beforehand or without familial background.
It goes without saying, exercise can cause many types of injuries even for those without HNPP depending on how extreme it may be. And as we have seen above, there have been at least several cases of ‘sporadic’ HNPP, which develops without any prior history of symptoms or familial connection.
However, it may be worth noting that without the correct tests to detect hereditary links, these may be incorrectly termed as ‘sporadic’. That being said, there have been established reports that suggest at least 21 per cent of HNPP cases are de novo mutations, so it may not be out of the realms of possibility that certain types of exercise can induce symptoms of HNPP.