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Diabetic Neuropathy

Overview

Diabetic neuropathy refers to the damage to the nerves of the body in people with diabetes mellitus. Nerves carry signals in the form of electric current to various parts of your body to enable you to feel something or do the desired actions. In diabetic neuropathy, your nerves get damaged, resulting in the symptoms of weakness, numbing, pain in the legs or hands, or problems with the involuntary vital functions such as heart rate, urinary and gut symptoms, etc. The most common complication people with diabetes suffer is diabetic neuropathy, affecting around 50% of patients with DM.

 

Uncontrolled blood sugar levels are the chief factor contributing to neuropathy and involve the changes in the small blood vessels supplying the nerves. It adversely affects the quality of life and predisposes to complications like foot ulcers, fractures, amputations, and even death. However, by taking care of your blood sugar levels and adopting a healthy lifestyle, you can easily manage your symptoms and even slow the progression of the process. 

Causes

Just like the wires present in the electrical system of your home, your body has nerves that carry electrical signals to various organs, enabling them to feel and respond. Although the precise etiology behind diabetic neuropathy is still under research, it is proposed that in diabetes mellitus, the small blood vessels supplying blood and nutrition to these nerves undergo some structural changes affecting their function. The nerves can also be affected directly by high levels of glucose and its other products. Various factors combined alter these nerves' structure and function, resulting in multiple symptoms. 

Types

Diabetic neuropathy can be classified into different types according to the manner in which nerves are affected;

·         Mononeuropathy: Only one nerve is affected, for example, the third cranial nerve controlling eye movements.

·         Proximal radiculopathy: It involves a specific pattern of nerves, particularly the proximal muscles. (buttocks, thighs, shoulder)

·         Mononeuritis multiplex: It affects multiple nerves without any pattern.

·         Autonomic: It affects nerves of the autonomic organs like the heart, gut, urinary tract, etc.

 

·         Distal symmetrical polyneuropathy: This is the most prevalent type. It is also known as diabetic peripheral neuropathy (numbness or weakness in both feet and legs).

Risk Factors

The main risk factor is poorly controlled sugar levels. Other factors that can predispose you to diabetic neuropathy include;

·         Older age

·         Increased lipid and cholesterol levels(hyperlipidemia)

·         High blood pressure (Hypertension)

·         Long-standing DM

·         Smoking

·         Excessive alcohol intake

 

·         Tall height

Epidemiology

Around 132 million people are affected by diabetic neuropathy globally( 2010). It remains the most common complication of diabetes affecting approximately 50% of people with DM.

Signs And Symptoms

You can experience the following symptoms in different types of diabetic neuropathy.

Peripheral neuropathy: It symmetrically affects feet and legs first, then hands and arms.

·         Decreased sensations related to pain or temperature

·         Numbness

·         Sharp, sudden pains

·         Weakness of the muscles

·         Foot complications: Foot ulcers, infections, etc.

Autonomic neuropathy: It affects the autonomic system that controls blood pressure, heart, urinary tract, bowel, sex organs, etc.

·         Orthostatic hypotension: It is the drop in blood pressure when you suddenly move up from the sitting position.

·         Urinary bladder control and emptying problems

·         Bowel or gut problems: Slowed movement, nausea, vomiting, early satiety.

·         Increased or decreased sweating

·         Sexual dysfunction

Proximal neuropathy: This type affects the proximal muscles in the hip and shoulder regions. The symptoms usually appear on one side of the body but may also cross to the other.

·         Pain in the hip or thigh

·         Weakness and thinning of the thigh muscles

·         Feeling difficulty in raising from a chair or bed

Mononeuropathy: The only nerve affected may belong to the face, arm, or leg. The following symptoms may result.

·         Double vision

·         Weakness on one side of the face

·         Tingling or numbness in hands or fingers

·         Pain in the front of the thigh, shin, or foot.

 

·         Foot drop; inability to lift the foot.

Diagnosis

Diabetic neuropathy is diagnosed on the basis of clinical manifestations of pain, weakness, numbness, or loss of balance in a person having long-term diabetes. If you are diabetic and experiencing the above symptoms, you must contact your healthcare provider. He will assess you for the symptoms and will examine you for the signs like muscle wasting, ulcers or ankle reflex, etc. Along with some other physical tests, your doctor may use a tuning fork to check for the presence of vibration sensations. Your doctor may advise you to undergo the following lab tests.

Blood tests: Your blood sample may be taken to check for fasting glucose levels, Hemoglobin A1c, Complete blood count, complete metabolic panel (electrolytes and liver function tests), Vitamin B-12 and folate levels, Thyroid function tests, etc.

Electromyography and nerve conduction velocity testing: Some electrodes are connected to your body during this test, and you will be asked to perform actions like lifting your leg. During this movement, some waves are recorded on a device that can tell if you have nerve injury or not.

 

Imaging: For a clearer picture, in the presence of localized symptoms, you may be asked to have an imaging test like an MRI or CT scan of that region to rule out other causes and make an efficient diagnosis.

Differential Diagnosis

Several conditions may result in nerve diseases, for example;

·         Vitamin B-12 deficiency

·         Alcohol-Related Neuropathy

·         Amyloid polyneuropathy

·         Neurosarcoidosis

·         Nutritional Neuropathy

·         Spinal Cord Tumors

·         Toxic Neuropathy

·         Uremic Neuropathy

 

·         Vasculitic Neuropathy

Treatment

Diabetic neuropathy can not be reversed. The goals of treatment are to relieve the symptoms, prevent and manage the development of complications and slow the progression of the disease.

The chief components that are included in the management of diabetic neuropathy include;

 

·         Regulated and controlled blood sugar levels are of utmost importance to slow the progression.

·         Appropriate foot care, including self-examination, follow-ups, and urgent care in case of ulcer development.

·         Medications for neuropathic pain include gabapentin, pregabalin, sodium valproate, dextromethorphan, tramadol, duloxetine, and transdermal lidocaine.

·         Diabetic gastroparesis can be managed by eating smaller frequent meals, changes in the diet, and a medicine called metachlopromide.

·         A urinating timetable can be established for urinary symptoms to avoid retention and infections.

·         To improve sexual dysfunction, some medications can be prescribed, but all of them are not safe for everyone. Mechanical devices can be used for the penis, and lubricating creams can be used for the vagina.

 

Surgical interventions may be required for the following;

 

·         Necrosis of lesion on foot may require aggressive debridement.

·         Some surgery (Jejunostomy) of the intestine may be needed for intractable gastroparesis.

·         A penile prosthesis can be implanted for sexual dysfunction.

 

·         Special boots, Bracing, or surgery may be needed for Charcot's foot.

Prognosis

Diabetic neuropathy is a progressive disease. However, by sticking to appropriate treatment and lifestyle, one can slow the progression and enjoy life to the fullest. 

Prevention

Diabetic neuropathy can be prevented by taking the following measures;

·         Maintain good control of blood sugar levels by taking your medications and controlling your diet.

·         Take regular treatment and follow-ups for diseases like hypertension and hyperlipidemia.

·         Bodyweight should be maintained according to BMI by taking a balanced diet and regular exercise.

·         Consuming a healthy diet rich in vitamins, minerals, omega-3 fatty acids, and antioxidants and avoiding sugary, fatty, and fried food.

·         Employ regular exercises or a brisk walk for at least 30 minutes every day to improve muscular activity and overall functions of the body.

·         Learn to manage stress using different strategies like meditation, yoga, or breathing exercises.

·         Get to know your disease and adopt healthy lifestyle changes from the beginning.

·         Avoid drinking alcohol

·         Avoid smoking

 

·         Take good care of your feet by regularly examining your legs and feet for injuries, ulcers, etc. 

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