Diabetic Neuropathy

by Dr. Virgil Thomas

Diabetic Neuropathy
About 60-70% of people with diabetes have mild to severe forms of nervous system damage, including:
Impaired sensation or pain in the feet or hands. Slowed digestion of food in the stomach. Carpal Tunnel Syndrome.

Other nerve problems.

More than 60% of non-traumatic lower-limb amputations in the Sri Lanka occur among people with diabetes.

Risk Factors
Glucose control. Duration of diabetes. Damage to blood vessels. Mechanical injury to nerves. Autoimmune factors. Genetic susceptibility. Lifestyle factors : Smoking. Diet.

Pathogenesis of Diabetic Neuropathy

Metabolic factors : High blood glucose. Advanced Glycation end products. Sorbitol (Glucitol). Abnormal blood fat levels. Ischemia. Nerve fiber repair mechanisms.

Diagnostic Tests
Assess symptoms - Muscle weakness, Muscle cramps, Pin & needle prickling, Numbness or Pain, Vomiting, Diarrhea, Poor bladder control and Sexual dysfunction. Comprehensive foot exam Skin sensation and skin integrity. Quantitative Sensory Testing (QST). X-ray. Nerve conduction studies. Electromyographic Examination (EMG). Ultrasound.

Classification of Diabetic Neuropathy

Symmetric Polyneuropathy Autonomic Neuropathy Polyradiculopathy Mononeuropathy

Symmetric Polyneuropathy
Most common form of diabetic neuropathy. Affects distal lower extremities and hands (stockingglove sensory loss). Symptoms/Signs
Pain. Paresthesia (Tingling-pricking-numbness like sensation). Loss of vibratory sensation.

Complications of Polyneuropathy
Ulcers. Charcot Arthropathy ( Progressive degeneration of a weight bearing joint marked by bony destruction, bone resorption, and eventual deformity). Dislocation and Stress Fractures. Amputation - Risk factors include: Peripheral Neuropathy with loss of protective sensation. Altered Biomechanics. Evidence of increased pressure (Callus). Peripheral Vascular Disease. History of Ulcers or Amputation. Severe nail pathology.

Treatment of Symmetric Polyneuropathy

Glucose Control. Pain Control.
Tricyclic Antidepressants. Topical Creams. Anticonvulsants.

Foot Care.

Essentials of Foot Care

Examination.
Annually for all patients. Patients with neuropathy - visual inspection of feet at every visit with a health care professional.

Advise patients to:

Use lotion to prevent dryness and cracking. File calluses with a pumice stone. Cut toenails weekly or as needed. Always wear socks and well-fitting shoes. Notify their health care provider immediately if any foot problems occur.

Autonomic Neuropathy
Affects the autonomic nerves controlling internal organs. Peripheral. Genitourinary. Gastrointestinal. Cardiovascular.

Is classified as Clinical / Subclinical based on the presence or absence of symptoms.

Peripheral Autonomic Dysfunction

Contributes to the following Symptoms/Signs: Neuropathic Arthropathy (Charcot Foot). Aching, pulsation, tightness, cramping, dry skin, pruritus, edema, sweating abnormalities. Weakening of the bones in the foot leading to fractures.

Testing Direct Microelectrode recording of Postglanglionic fibers. Galvanic Skin Responses. Measurement of vascular responses.

Peripheral Autonomic Dysfunction

Treatment Foot Care/Elevate feet when sitting. Eliminate aggravating drugs. ( Vincristine, Cisplastin,
Amiodarone )

Reduce edema: Midodrine. Diuretics. Support stockings. Screen for CVD.

Genitourinary Autonomic Neuropathy

Sign/Symptom
Bladder dysfunction Retrograde ejaculation Erectile dysfunction Dyspareunia

Treatment
Voluntary Urination; Catheterization Antihistamine Sildenafil, Tadalafil Lubricants; Estrogen creams

Gastrointestinal Autonomic Neuropathy

Symptoms/Signs
Gastroparesis resulting in anorexia, nausea & vomiting. Diabetic Enteropathy resulting in Diarrhea and Constipation.

Treatment
Other causes of Gastroparesis or Enteropathy should first be ruled out. Gastroparesis - Small, Frequent meals, Metoclopramide, Erythromycin. Enteropathy - Loperamide, Antibiotics, Stool softeners & Dietary fiber.

Cardiovascular Autonomic Neuropathy

Symptoms/Signs
Exercise Intolerance. Postural Hypotension.

Treatment
Discontinue aggravating drugs Change Posture (Make postural changes slowly, Elevate bed) Increase plasma volume.

Polyradiculopathy
Lumbar Polyradiculopathy (Diabetic Amyotrophy)
Lower back & Thigh pain followed by muscle weakness and atrophy.

Thoracic Polyradiculopathy
Severe pain on one or both sides of the abdomen, possibly in a band-like pattern.

Diabetic neuropathic cachexia

Polyradiculopathy + Peripheral Neuropathy. Associated with weight loss and depression.

Polyradiculopathy,...
Polyradiculopathies are diagnosed by Electromyographic (EMG) studies. Treatment :
Foot Care. Glucose Control. Pain Control.

Mononeuropathy
Peripheral Mononeuropathy Single nerve damage due to compression or ischemia. Occurs in wrist (Carpal Tunnel Syndrome), elbow, or foot (Unilateral Foot Drop). Symptoms/Signs : Numbness. Edema. Pain. Pin-Prickling.

Mononeuropathy,...
Cranial mononeuropathy Affects the 12 pairs of nerves that are connected with the brain and control sight, eye movement, hearing, and taste. Symptoms/Signs : Unilateral pain near the affected eye. Paralysis of the eye muscle. Double vision. Mononeuropathy Multiplex.

Mononeuropathy,...
Treatment Foot care. Glucose control. Pain control. Other options :
Aldose Reductase Inhibitors. ACE Inhibitors. Weight Control. Exercise.