Diabetic neuropathy

Diabetic neuropathy can be defined as a chronic complication of diabetes that affects the peripheral nervous system. According to the American Diabetes Association, the chances of developing diabetes neuropathy are about 50% for the rest of the diabetic’s life. However, these chances can increase or decrease substantially depending on the diabetes management. Although it is ideal to be prevented, neuropathy is treatable nowadays.

Neuropathy is a chronic complication because it takes at least five years of exposure to hyperglycemia to occur. This is obvious, where the exact onset of the disease is known. Sometimes the presence of diabetic neuropathy is found right from the time of diagnosis of diabetes. This can happen in type 2 diabetes. The reason is that the onset of type 2 diabetes took place over five years ago. Type 2 diabetes can develop without symptoms for a long time. For this reason, the diagnosis can be very delayed, even with decades.

Symptoms of diabetic neuropathy

The main symptoms of diabetic neuropathy are those of the affected nerves of the feet and later of the hands. Sometimes the symptoms of diabetic neuropathy are the reason for going to the doctor, where a high blood sugar is also accidentally detected. The doctor checks for the symptoms of neuropathy and usually finds one that triggers a chain of investigations, which can lead to the diagnosis of diabetes.

The main signs and symptoms of diabetic neuropathy are the following:

  • numbness in the toes; 
  • numbness in the feet;
  • tingling in the toes;
  • burning sensation in the feet;
  • foot pain, especially from the knees down;
  • numbness of the hands (palms, burning sensation on the palm);
  • tingling in the body;
  • sensation of burning on the skin all over the body;
  • muscle weakness;
  • lack of balance.

Most are symptoms of sensory polyneuropathies, in addition to those caused by vegetative neuropathy.

Diabetic neuropathy affects the nerves that collect information from the whole body and then returns specific commands to various devices and systems in the body. Each time we touch an object, the information about this contact is transmitted through various nerves to a control center (eg brain). The nerve fibers that transmit this information are called the sensory nerve fibers. This decision is then transmitted back to various devices or systems in the body. This can quickly control the withdrawal of the hand from the fire or the heart rate to a strong emotion. Nerve fibers that carry information about the control center decision to the organs of the control are called motor nerve fibers. 

Diabetic neuropathy does not affect the control center. The control center belongs to the central nervous system. It is connected to the rest of the body through the nerves, ie the peripheral nervous system.

Classification of diabetic neuropathy

Diabetic neuropathy is classified according to the location and number of nerves. affected:

Peripheral diabetic neuropathy with multiple, diffuse nerve damage – Poly means more, that is, more nerves are affected. Peripheral means to affect the nerves at a great distance from their origin (spinal cord).

Symmetrical peripheral diabetic polyneuropathy – The term symmetrical shows that the intensity of the lesions, but also of the symptoms is similar on the left and on the right. This symmetry should not be perfect, but there should be no obvious discrepancies.   Symmetrical peripheral diabetic polyneuropathy is the most common form of neuropathy. The causes of this diabetic neuropathy are metabolic and vascular. For this reason, its symptoms are generally similar on both the left and right.   Unlike vegetative neuropathy, the nerve fibers damaged here are those that come from the skin and tendons. According to  WebMD , up to 70% of patients with diabetes will develop diabetic neuropathy at some point. The diagnosis of peripheral diabetic polyneuropathy is purely clinical. There is no need for electrophysiological tests, such as nerve conduction velocity, to make this diagnosis. The mere presence of a combination of signs and symptoms suggestive of neuropathy will make the diagnosis in the presence of diabetes.   Difficulties in determining the diagnosis may occur when the presentation is atypical. Only these patients should be referred to a neurologist for a diagnosis.

Vegetative neuropathy – Autonomic (vegetative) neuropathy  means the damage to the nerves that control the activity of the internal organs. This control is performed automatically, without us realising its activity. For this reason, vegetative neuropathy is sometimes referred to as autonomous. The main categories of vegetative neuropathy are as follows: cardiovascular, gastrointestinal, urogenital, sudomotor, hypoglycemia non-recognition syndrome, pupillary autonomic neuropathy.

Mononeuropathy – is a form of diabetic neuropathy in which only one nerve in a particular region of the body is affected. This can be single nerve neuropathy or multiplex mononeuropathy.

Neuropathy with nerve damage at or near the root of the nerve – this can be lumbar polyradiculopathy or thoracic polyradiculopathy. Diabetic polyradiculopathy refers to the damage to the nerve roots in the immediate vicinity of the spinal cord. The term root it refers precisely to this aspect of the nerve root damage, in the vicinity of the spinal cord. The spinal cord is located in the spine. From it, nerves are formed, which then go all the way to the periphery, including the palms and feet.

What are the diabetic neuropathy causes?

The causes of diabetic neuropathy  are complex and therefore are dealt with separately. In short, the main risk factor for the onset of diabetic neuropathy is the duration of the disease. In second place is the degree of metabolic imbalance as assessed by glycosylated hemoglobin. Total exposure to hyperglycemia is the result of the level of hyperglycemia and its duration of action in years.   For the same total exposure to hyperglycemia, the risk of developing diabetic neuropathy is further increased by glycemic variability. For the same  glycosylated hemoglobin , nerve damage occurs at a significantly higher rate in those with rapid alternations of hyperglycemia and  hypoglycemia.  

The difference between pain from diabetic neuropathy and arthritis 

diabetic neuropathy and arthritis 

Both diabetic neuropathy and  peripheral arterial disease  (arthritis) may be responsible for the appearance of pain in the lower limbs. Correct diagnosis of the source of pain is important because it changes treatment options. The main differences are the location, the qualitative features, pain while resting, the walking effect and lying in bed.

  • Location:  Pain in neuropathy is located mainly in the foot. Pain of vascular (ischaemic) origin tends to appear in the legs, thighs and less often in the buttocks. with numbness and sometimes burning sensations. In contrast, the pain in the arthritis is persistent, deep, with an apparently deep origin. 
  • Pain while resting:  Neuropathic pain is frequently present at rest. Pain of ischaemic origin, due to poor arterial circulation, appears rather when walking and disappears at rest.
  • The walking effect:  Walking relieves neuropathic pain, but increases or even triggers vascular pain. However, walking is recommended for those with vascular pain, but it is recommended to stop before it occurs.
  • Lying in bed, especially in the evening and at night. Arterial pain is relieved by sitting in bed, with your feet level or lower than the rest of your body. . Instead, this worsens vascular perfusion in areas affected by arterial ischaemia (arthritis).  

Prevention of diabetic neuropathy  

Studies have shown that good blood sugar control may significantly decrease the risk of developing diabetic neuropathy. Although treatable, prevention is the most important weapon against neuropathy. The effect is greater when blood glucose levels are kept at the individual target near the clinical onset of diabetes. The first ten years of diabetes have a tenfold greater impact on the risk of neuropathy than in subsequent years. Intensified diabetes treatment has a greater beneficial effect in type 1 diabetes than in type 2. 

Good metabolic control means a glycosylated hemoglobin below 7% (53 mmol / mol) for the vast majority of patients. adults, outside pregnancy in women. The time spent in normoglycaemia, ie 70-180 mg / dl (3.9-10 mmol / l) should be more than 70%.  The time spent in hypoglycaemia should be less than 4%. These times are generally measured over three months. The statistics provided by the software of a continuous blood glucose monitoring sensor will be used for this purpose.

The main ways to prevent the occurrence of diabetic neuropathy are the following:  

•  individual 

•  blood pressure control 

•  dyslipidemia control 

•  avoid smoking 

•  avoid alcohol

Common treatment of all diabetic neuropathies

Regardless of the form of diabetic neuropathy, the treatment has a common part and a special part to each neuropathy. The common treatment trunk refers to those therapeutic measures that are universally valid. Diabetic neuropathy is treatable only if it is started with these measures and then continues with those specific to each individual form of neuropathy. The common part of the treatment of diabetic neuropathy covers the following aspects:  

•  Lifestyle optimisation  

•  Avoiding hypoglycemia 

•  Increased time spent on normoglycemia 

•  Decreased time spent on hyperglycemia 

•  Blood pressure control 

•  Optimized lipid-lowering treatment 

•  Quit smoking for smokers 

•  Minimising alcohol consumption

The treatment of diabetic neuropathy is therefore multifactorial. It has a common part, described above and a particular part addressed to the following issues:  

•  Pain relief 

•  Preventive foot care 

•  Fall prevention 

•  Treatment of cardiovascular vegetative neuropathy 

•  Treatment of gastrointestinal vegetative neuropathy 

•  Treatment of genitourinary vegetative neuropathy 

•  Treatment of sudo-motor vegetative neuropathy

About one in five patients with diabetic neuropathy has pain in their legs. This is a complication of diabetes that is annoying enough to require treatment. There is generally a fairly long period of time from when the pain associated with diabetic neuropathy occurs and the start of a specific treatment. The treatment is based on the principles of the common treatment trunk presented above. There is, of course, a special part:

  • pathophysiological treatment – The term pathophysiological refers to the effect of medication to relieve nerve damage caused by diabetic neuropathy. Medication is based on the principle that removing the cause of the pain will relieve the pain.   This type of approach is preferred in the treatment of diabetic neuropathy because it promotes tissue repair. The adverse effects of this type of therapeutic approach are significantly lower compared to symptomatic treatment
  • symptomatic treatment – The term  symptomatic refers to the principle of making the patient no longer care about the existence of pain (neuropathic lesion). It creates a kind of local pseudo-anaesthesia (not exactly anaesthesia). It decreases the intensity of the pain without affecting the nerve injury. This type of medication does nothing to help repair the nerve damage.   Without signalling to the patient through the pain, the nerve damage will be ignored. Ignoring nerve damage does not help to repair it.   On the contrary, they will progress continuously to injuries associated with potentially much higher risks compared to those that cause pain (diabetic foot). For this reason, this approach in the treatment of diabetic neuropathy should be taken with caution and preferably added to the pathophysiological one.

Preventive foot care with diabetic neuropathy

Diabetic neuropathy is a major risk factor for the occurrence of  diabetic foot . Skin lesions specific to the diabetic foot are callus and plantar ulcer. These lesions greatly increase the risk of amputation, especially of foot ulcers. The risk of amputation can be significantly reduced by preventive care of the foot affected by diabetic neuropathy. Treatment is based on the above-mentioned common treatment for diabetic neuropathy, to which are added the following measures. following:

•  Daily inspection using a hard-to-reach mirror 

•  Daily foot washing with mild, gentle skin soap 

•  Carefully dry after washing the feet, especially between the toes 

•  Applying a moisturizer after washing the feet 

•  Hand checking the temperature of the water with which the foot is washed or the water in the tub before inserting foot in it 

•  Never walk barefoot 

•  Avoid walking on hot sand at sea 

•  Carefully maintain your toenails 

•  Socks should be made of cotton, loose and changed daily 

•  Shoes should be comfortable, with thick soles and wide spaces for fingers 

•  Shoelaces are tightened so that the shoe is slightly loose 

•  Gradually insert a new shoe, using it only 1-2 hours a day initially

•  Rotate 2-3 pairs of shoes daily to prevent excessive pressure in the same area 

•  Wear custom-made (orthopedic) shoes when the foot is deformed 

•  Use soft insoles as long as the shoe is wide enough and the laces are not tightened too much 

•  Request a dermatological consultation for any minor foot injuries

    Prevention of falls in diabetic neuropathy- diabetic neuropathy may lead in its evolution to instability in walking. This instability significantly increases the patient’s risk of tripping and falling. Trauma from these falls can sometimes be dangerous. If fractures occur, subsequent immobilisation is associated with additional risks, sometimes difficult to anticipate.  

Treatment of vegetative gastrointestinal neuropathy 

Where gastrointestinal vegetative neuropathy is the primary or secondary cause of gastrointestinal neuropathy, treatment should necessarily include the common portion of the standard treatment of diabetic neuropathy (see  above ). To these generally valid measures will be added the measures specific to each digestive pathology, discussed in turn below.

Treatment of gastroesophageal reflux disease – Treatment of gastroesophageal reflux disease includes dietary, medicinal and surgical measures. For proper treatment it is recommended to consult a gastroenterologist. The main dietary measures in the treatment of gastroesophageal reflux disease are the following:  

•  Avoid sitting horizontally for three hours after a meal 

•  Weight loss if you are overweight or recently gaining weight 

  • Raising the head of the bed by 10-20 degrees 

•  Avoid coffee and chocolate 

•  Avoid fizzy drinks 

•  Avoid high-fat or spicy foods 

•  Avoid smoking 

•  Avoid alcohol 

•  Avoid very tight clothes on the abdomen 

•  Using chewing gum

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