Diabetic Neuropathy: Difference between revisions

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== Introduction  ==
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== Introduction  ==
Diabetic neuropathy is dysfunction and damage in the peripheral  nerves in people with diabetes<ref>Rosenberger DC, Blechschmidt V, Timmerman H, Wolff A, Treede RD. [https://pubmed.ncbi.nlm.nih.gov/32036431/ Challenges of neuropathic pain: focus on diabetic neuropathy.] J Neural Transm (Vienna). 2020 Apr;127(4):589-624.</ref>. [[Neuropathies]] are characterized by a progressive loss of nerve fibre function<ref>Boulton AJ, Malik RA. [https://pubmed.ncbi.nlm.nih.gov/9706126/ Diabetic neuropathy]. Med Clin North Am. 1998;82(4):909-29</ref>. Diabetic neuropathy is a common complication of [[Diabetes|Diabetes Mellitus]] (DM), estimated to affect up to  51% of patients with both [[Diabetes Mellitus Type 1|type 1]] and [[Diabetes Mellitus Type 2|type 2]] DM<ref name=":1">Hicks CW, Selvin E. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6755905/#:~:text=The%20prevalence%20of%20peripheral%20neuropathy,asymptomatic%20to%20painful%20neuropathic%20symptoms. Epidemiology of Peripheral Neuropathy and Lower Extremity Disease in Diabetes.] Curr Diab Rep. 2019 Aug 27;19(10):86.</ref><ref>Dyck PJ, Kratz KM, Karnes JL, Litchy WJ, Klein R, Pach JM, et al. [https://pubmed.ncbi.nlm.nih.gov/8469345/ The prevalence by staged severity of various types of diabetic neuropathy, retinopathy, and nephropathy in a population-based cohort: the Rochester Diabetic Neuropathy Study]. Neurology. 1993;43(4):817-24</ref>. The clinical presentation of diabetic neuropathy varies, from asymptomatic to severe [[Neuropathic Pain|neuropathic pain]] and numbness<ref name=":1" />. Diabetic neuropathy is associated with increased risk of [[The Diabetic Foot|foot ulcers]], lower limb [[Amputations|amputation]] and mortality<ref name="rayaz">Malik RA. [https://pubmed.ncbi.nlm.nih.gov/24962918/ Which Test for Diagnosing Early Human Diabetic Neuropathy?] Diabetes. 2014 Jul;63(7):2206-8</ref><ref name=":2">Sloan G, Selvarajah D, Tesfaye S. [https://pubmed.ncbi.nlm.nih.gov/34050323/ Pathogenesis, diagnosis and clinical management of diabetic sensorimotor peripheral neuropathy]. Nat Rev Endocrinol. 2021 Jul;17(7):400-420.</ref>.


Diabetic neuropathy is the most common complication of Diabetes Mellitus (DM), affecting as many as 50% of patients with type 1 and type 2 DM.&nbsp;A large American study<ref>Dyck PJ, Kratz KM, Karnes JL, Litchy WJ, Klein R, Pach JM, et al. The prevalence by staged severity of various types of diabetic neuropathy, retinopathy, and nephropathy in a population-based cohort: the Rochester Diabetic Neuropathy Study. Neurology. Apr 1993;43(4):817-24</ref> estimated that 47% of patients with diabetes have some peripheral neuropathy.Diabetes increases&nbsp;the risk of foot ulceration and amputation more than 23-fold and neuropathy is the major contributory factor to&nbsp;this increased risk. Neuropathy presents as painful neuropathy&nbsp;in 20% of patients and it independently predicts&nbsp;all-cause and diabetes-related mortality .<ref name="rayaz">Rayaz A. Malik ;Which Test for Diagnosing EarlyfckLRHuman Diabetic Neuropathy? Diabetes 2014;63:2206–2208</ref>&nbsp;Neuropathies are characterized by a progressive loss of nerve fibre function<ref>Boulton AJ, Malik RA. Diabetic neuropathy. Med Clin North Am. Jul 1998;82(4):909-29</ref>.
== Clinically Relevant Anatomy ==
The peripheral nervous system refers to the components of the nervous system outside of the [[Brain Anatomy|brain]] and [[Spinal cord anatomy|spinal cord]]. The nerve roots exit the spinal cord and then branch out into  smaller peripheral nerves. The peripheral nerves consist of motor and sensory fibers<ref>Spine-Health. Peripheral Nervous System Anatomy. Available from: https://www.spine-health.com/conditions/spine-anatomy/anatomy-nerve-pain (Accessed 06/07/22). </ref>.


== Clinically Relevant Anatomy&nbsp;<ref name="dyck" />  ==
In diabetic neuropathy, there is degeneration in  the type, severity, and distribution  of these receptors, nerve fibers, or neurons, with the degeneration beginning distally and symmetrically, and spreading proximally<ref name="dyck">Dyck PJ, Herrmann DN, Staff NP, Dyck PJ. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3806590/ Assessing decreased sensation and increased sensory phenomena in diabetic polyneuropathies.] Diabetes. 2013 Nov;62(11):3677-86</ref>.
[[File:Nerve structure.jpg|right|frameless|202x202px]]
Cutaneous and deep sensations are mediated by superficial and deep topically distributed receptors and nerve fibers. In most patients with peripheral neuropathy, loss of sensation is directly attributable to kind, severity, and distributed loss of these sensory receptors, nerve fibers, or neurons .&nbsp;There is a degree of functional specificity of cutaneous and deep receptors and of their sensory nerve fibers. Thus, touch-pressure sensation of nonhairy skin is mediated by Meissner corpuscles with small receptive fields, sharp borders, and low thresholds that accommodate rapidly. Pacinian corpuscles respond to vibratory stimuli and have large receptive fields with sloping borders and low thresholds that accommodate quickly. Cooling receptors are more widely distributed and more frequent than warm receptors.<br>


== Mechanism of Injury / Pathological Process  ==
== Mechanism of Injury / Pathological Process  ==


=== Causes  ===
The pathological process of diabetic neuropathy is not completely understood, and is likely multifactoral<ref>Zochodne DW. [https://pubmed.ncbi.nlm.nih.gov/18769245/ Diabetic polyneuropathy: an update]. Curr Opin Neurol. 2008;21(5):527-33</ref>. Research suggests  neuronal inflammation, oxidative stress, mitochondrial dysfunction and cell death is caused by hyperglycaemia, dyslipidaemia and microvascular disease<ref name=":2" />.
 
[[File:Smoking-1026556 960 720-2.jpg|thumb|250x250px]]
Current thinking on the causes of diabetic neuropathy is that it is likely to be multifactorial<ref>Sugimoto K, Murakawa Y, Sima AA. Diabetic neuropathy--a continuing enigma. Diabetes Metab Res Rev. Nov-Dec 2000;16(6):408-33</ref><ref>Zochodne DW. Diabetic polyneuropathy: an update. Curr Opin Neurol. Oct 2008;21(5):527-33</ref>  
 
Contributary factors:
 
*Hyperglycaemic exposure -&nbsp;causing increased levels of intracellular glucose in nerves, leading to saturation of the normal glycolytic pathway
*Elevated lipids
*Hypertension<br>
*Increased production of free radicals in diabetes - this may be detrimental via several mechanisms that are not fully understood<ref>Figueroa-Romero C, Sadidi M, Feldman EL. Mechanisms of disease: The oxidative stress theory of diabetic neuropathy. Rev Endocr Metab Disord. Dec 2008;9(4):301-14</ref><br>
 
Development of symptoms depends on many factors, such as total hyperglycemic exposure and other risk factors such as elevated lipids, blood pressure, smoking, increased height, and high exposure to other potentially neurotoxic agents such as ethanol. Genetic factors may also play a role. Important contributing biochemical mechanisms in the development of the more common symmetrical forms of diabetic polyneuropathy likely include the polyol pathway, advanced glycation end products, and oxidative stress.<br>  
 
=== Risk Factors  ===


Risk factors&nbsp;associated with more severe symptoms:
== Risk Factors<ref>Kartha C,  Ramachandran S,  Pillai RM, editors. Mechanisms of Vascular Defects in Diabetes Mellitus. Springer. 2017. p.163</ref> ==


*smoking
* Poor glycemic control.
*poor glycaemic control
* [[Hypertension|High blood pressure]]
*advanced age  
* [[Smoking Cessation and Brief Intervention|Smoking]].
*long duration of Diabetes disease  
* Advance age.
*heavy alcohol intake  
* Advanced duration of Diabetes disease.
[[File:Smoking-1026556 960 720-2.jpg|right|frameless|150x150px]]
* Heavy alcohol intake.  
* tall stature!<ref>J Clin Diagn Res. Feb 2013; 7(2): 296–301.fckLRPeripheral Insensate Neuropathy-Is Height a Risk Factor?fckLRG S Sharath Kote,1 Ajay N Bhat,2 Thajuddeen K,3 Mohammed H Ismail,4 and Abhishek Gupta5</ref> It is thought that this may be because longer nerve fibres are more susceptible to injury.<br>
* Tall stature<ref>Kote GS, Bhat AJ, Thajuddeen K, Ismail MH, Gupta A.[https://pubmed.ncbi.nlm.nih.gov/23542767/ Peripheral Insensate Neuropathy-Is Height a Risk Factor?] J Clin Diagn Res. 2013; 7(2): 296–301</ref><br>  


== Clinical Presentation  ==
== Clinical Presentation  ==


More than half of cases are distal symmetric polyneuropathy. Focal syndromes such as carpal tunnel syndrome<ref>Singh R, Gamble G, Cundy T. Lifetime risk of symptomatic carpal tunnel syndrome in Type 1 diabetes. Diabet Med. May 2005;22(5):625-30</ref> (14-30%), radiculopathies/plexopathies, and cranial neuropathies account for the rest<ref>Shaw JE, Zimmet PZ. The epidemiology of diabetic neuropathy. Diabetes Reviews. 1999;7:245-52</ref>.<br>
More than half of the cases are distal symmetric polyneuropathy<ref>Bodman MA, Varacallo M[https://www.ncbi.nlm.nih.gov/books/NBK442009/ . Peripheral Diabetic Neuropathy]. 2022 May 1. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan</ref>. Asymmetrical or focal syndromes, such as [[Carpal Tunnel Syndrome|carpal tunnel syndrome]]<ref>Singh R, Gamble G, Cundy T. [https://pubmed.ncbi.nlm.nih.gov/15842519/ Lifetime risk of symptomatic carpal tunnel syndrome in Type 1 diabetes.] Diabet Med. 2005;22(5):625-30</ref> (14-30%), [[Radiculopathy|radiculopathies]]/plexopathies and cranial neuropathies, account for the rest<ref>Shaw JE, Zimmet PZ. [https://research.sahmri.org.au/en/publications/the-epidemiology-of-diabetic-neuropathy The epidemiology of diabetic neuropathy]. Diabetes Reviews. 1999;7:245-52</ref>.
 
=== Motor Symptoms  ===
 
Motor problems may include distal, proximal, or more focal weakness.
 
#In the upper limbs- &nbsp;distal motor symptoms often include impaired fine hand coordination.
#In the lower limbs -&nbsp;&nbsp;Mild drop foot or frequent tripping may be early symptoms of lower limb weakness. Symptoms of proximal limb weakness include difficulty climbing up and down stairs, difficulty getting up from a seated or supine position, falls due to the knees giving way, and difficulty raising the arms above the shoulders.
 
=== Sensory Symptoms  ===
 
A slow, insidious onset sensory neuropathy typically shows a stocking-and-glove distribution in the distal extremities.  


Sensory symptoms may be negative or positive, diffuse or focal.  
The most common symptoms are<ref>Cedars Sinai. Diabetic Neuropathy. Available from: https://www.cedars-sinai.org/health-library/diseases-and-conditions/d/diabetic-neuropathy.html (Accessed 09/07/2022)</ref>:


*Negative sensory symptoms include feelings of numbness or deadness, which patients may describe as being akin to wearing gloves or socks. Loss of balance, especially with the eyes closed, and painless injuries due to loss of sensation are common.  
* Numbness in the hands or feet, often on both sides, described as a stocking-and-glove distribution
*Positive symptoms may be described as burning, prickling pain, tingling, electric shock–like feelings, aching, tightness, or hypersensitivity to touch.
* Tingling/"pins and needles" or burning sensation in the feet
* Pain in the hands, feet, or legs
* Dry or cracked skin or calluses on the [[The Aged Foot|feet]].
* Distal, proximal or more focal weakness, including foot drop or frequent [[Falls|tripping]].  


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==


Testing includes assessment of gross light touch and pinprick sensation. The first clinical sign that usually develops in diabetic symmetrical sensorimotor polyneuropathy is reduction of vibratory and pinprick sensation over the toes. As disease progresses, the level of decreased sensation may move upward into the legs and then from the hands into the arms, a pattern often referred to as "stocking and glove" sensory loss. Very severely affected patients may lose sensation in a "shield" distribution on the chest.  
* Subjective history of symptoms, recent foot trauma and previous ulcers or wounds<ref name=":3">Bandyk DF. [https://www.sciencedirect.com/science/article/abs/pii/S0895796719300110?via%3Dihub The diabetic foot: Pathophysiology, evaluation, and treatment.] Semin Vasc Surg. 2018 Jun-Dec;31(2-4):43-48</ref>.  
 
* Physical examination of skin condition, foot anatomy, and vascular perfusion<ref name=":3" />.  
Vibratory sense in the feet is tested with a 128-Hz tuning fork placed at the base of the great toenail.<br>  
* Testing includes assessment of gross light touch and pinprick sensation, using simple hand held devices (e.g. cotton wool, stick pins or monofilament)<ref name="dyck" />. 


Deep tendon reflexes are commonly hypoactive or absent.  
* Vibratory sense in the feet is tested with a 128-Hz tuning fork placed at the base of the great toenail<ref>American Diabetes Association. Vibration Testing Detects Diabetic Peripheral Neuropathy Earlier than the 10-g Monofilament. Available from: https://professional.diabetes.org/abstract/vibration-testing-detects-diabetic-peripheral-neuropathy-earlier-10-g-monofilament (Accessed 09/07/2022)</ref>.
 
* Deep tendon [[reflexes]] are commonly hypoactive or absent<ref>Medscape. How are deep tendon reflexes assessed in diabetic neuropathy? Available from https://www.medscape.com/answers/1170337-4949/how-are-deep-tendon-reflexes-assessed-in-diabetic-neuropathy (Accessed 09/07/2022)</ref>.
The latest recommendations continue to advocate&nbsp;a multimodal approach to assessing diabetic neuropathy.&nbsp;This should include symptoms and signs, quantitative&nbsp;sensory testing, and electrophysiology <ref name="dyck">Dyck PJ, Herrmann DN, Staff NP, Dyck PJ. Assessing decreased sensation and increased sensory phenomena in diabetic polyneuropathies. Diabetes 2013; 62:3677–3686</ref>
* Nerve conduction studies or needle electromyogram<ref>Yang Z, Zhang Y, Chen R, Huang Y, Ji L, Sun F, Hong T, Zhan S. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6513498/ Simple tests to screen for diabetic peripheral neuropathy. Cochrane Database Syst Rev.] 2018 Jul 30;2018(7)</ref>.


=== Classification  ===
=== Classification  ===
Diabetic neuropathy can be classified into 4 subgroups:<ref>Endocrine Web. Types of Diabetic Neuropathy. Available from: https://www.endocrineweb.com/guides/diabetic-neuropathy/types-diabetic-neuropathy (Accessed 07/07/2022)</ref>


A classification system by Thomas <ref>Thomas PK. Classification, differential diagnosis, and staging of diabetic peripheral neuropathy. Diabetes. Sep 1997;46 Suppl 2:S54-7.</ref>&nbsp;combines anatomy and pathophysiology.  
* Proximal neuropathy/ diabetic amyotrophy.  
 
*Hyperglycemic neuropathy (acute)
*Generalized symmetrical polyneuropathies
*Sensory neuropathy
*Sensorimotor neuropathy (chronic, symmetric)
*Autonomic neuropathy (cardiovascular, gastrointestinal, genitourinary, sudomotor)
*Focal and multifocal neuropathies: this category includes cranial neuropathy, proximal motor neuropathy (amyotrophy), thoracic or lumbar radiculopathies, and focal limb neuropathies (entrapment neuropathies)
*Superimposed chronic inflammatory demyelinating polyneuropathy (CIDP)
 
<br>


Another generally accepted classification of diabetic neuropathies divides them broadly into symmetrical and asymmetrical neuropathies.&nbsp;<ref name="dianna">Dianna Quan,Helen C Lin ; Diabetic Neuropathy Clinical Presentation; http://emedicine.medscape.com/article/1170337-clinical#a0256</ref>
* Peripheral neuropathy / diabetic nerve pain / distal polyneuropathy.
* Autonomic neuropathy.
* Focal neuropathy / mononeuropathy.


=== Staging  ===
=== Staging  ===


A common staging scale of diabetic polyneuropathy is as follows&nbsp;:&nbsp;<ref name="dianna" />  
A common staging scale of diabetic neuropathy is as follows:&nbsp;<ref name="dianna">Dianna Quan,Helen C Lin ; Diabetic Neuropathy Clinical Presentation. Available from: http://emedicine.medscape.com/article/1170337-clinical#a0256 (Accessed 26 May 2020)</ref>
 
*NO - No neuropathy
*N1a - Signs but no symptoms of neuropathy
*N2a - Symptomatic mild diabetic polyneuropathy; sensory, motor, or autonomic symptoms; patient able to heel walk
*N2b - Severe symptomatic diabetic polyneuropathy (as in N2a, but patient unable to heel walk)  
*N3 - Disabling diabetic polyneuropathy
 
== Management / Interventions  ==
 
=== Medical Management of Pain in Diabetic Neuropathy  ===
 
'''Anticonvulsants:'''
 
*Gabapentin
*Pregabalin
*Valproate
 
'''Antidepressants:&nbsp;'''


*Amitriptyline
*N0 - No neuropathy.
*Duloxetine
*N1a - Signs but no symptoms of neuropathy.
*Venlafaxine
*N2a - Symptomatic mild diabetic polyneuropathy; sensory, motor, or [[Autonomic Nervous System|autonomic]] symptoms; patient able to heel walk.
*N2b - Severe symptomatic diabetic polyneuropathy, and patient unable to heel walk.
*N3 - Disabling diabetic polyneuropathy.


'''Opioids '''
==Medical Management / Interventions==
Medical management starts with 0ptimized glycemic control (mainly for type 1 DM) and lifestyle interventions<ref>Cernea S, Raz I. [https://pubmed.ncbi.nlm.nih.gov/34411554/ Management of diabetic neuropathy]. Metabolism. 2021 Oct;123:154867.</ref>. Lifestyle intervention includes physical exercise and weight loss.


*Dextromethorphan
Tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors (e.g. duloxetine) and anticonvulsants (e.g. pregabalin and gabapentin) are commonly prescribed treatments for neuropathic pain<ref>Callaghan BC, Gallagher G, Fridman V, Feldman EL. [https://pubmed.ncbi.nlm.nih.gov/31974731/ Diabetic neuropathy: what does the future hold?] Diabetologia. 2020 May;63(5):891-897.</ref>.  At present, there are no universally accepted disease modifying medicines, but this is currently being researched and developed<ref>Røikjer J, Mørch CD, Ejskjaer N. [https://pubmed.ncbi.nlm.nih.gov/32735526/ Diabetic Peripheral Neuropathy: Diagnosis and Treatmen]t. Curr Drug Saf. 2021;16(1):2-16.</ref>.
*Morphine sustained release
*Oxycodone
*Tapentadol
*Tramadol


'''Others'''
Moreover, multidisciplinary team management is required for the prevention and management of diabetic foot complications<ref name=":2" />.


*Topical nitrate sprays
== Physiotherapy Management and Exercise ==
*Capsaicin cream<br>  
[[File:Falls class.png|300x300px|alt=|thumb]]Research has shown that strength training can moderately improve muscle function, reduce [[Neuropathic Pain|neuropathic pain]] and help control blood sugar levels for people with diabetic neuropathy<ref name=":0">The Foundation for Peripheral Neuropathy. Exercise and physical therapy for neuropathy. Available from: https://www.foundationforpn.org/living-well/lifestyle/exercise-and-physical-therapy/ (Accessed 10/07/2022)</ref>. Therefore, exercise can help to improve quality of life for this patient group<ref>Jahantigh Akbari N, Hosseinifar M, Naimi SS, Mikaili S, Rahbar S. [https://pubmed.ncbi.nlm.nih.gov/33553048/ The efficacy of physiotherapy interventions in mitigating the symptoms and complications of diabetic peripheral neuropathy: A systematic review.] J Diabetes Metab Disord. 2020 Oct 12;19(2):1995-2004.</ref>. Diabetic clients must take precautions, including monitoring their blood sugar levels during exercise and snacking beforehand to prevent major fluctuations<ref>Diabetes.co.uk. Exercise for Diabetics. Available from: https://www.diabetes.co.uk/exercise-for-diabetics.html (Accessed 10/07/2022)</ref>.
[[File:Carpal_tunnel_splint.jpg|alt=|thumb|300x300px]]


#
==== Specific exercise programs should include<ref name=":0" /> ====
[[File:Falls class.png|right|frameless|259x259px]]
* Flexibility (progressive stretching and self stretches).
* Muscle strengthening (using a variety of modes as appropriate eg isometric, graded weight progression, open and close chain)<ref>Win MMTM, Fukai K, Nyunt HH, Linn KZ. [https://pubmed.ncbi.nlm.nih.gov/31876991/ Hand and foot exercises for diabetic peripheral neuropathy: A randomized controlled trial.] Nurs Health Sci. 2020 Jun;22(2):416-426.</ref>.
* Aerobic activity.
* Posture and [[balance]] training (for falls prevention and stability)<ref>Thukral N, Kaur J, Malik M. [https://pubmed.ncbi.nlm.nih.gov/32619175/ A Systematic Review and Meta-analysis on Efficacy of Exercise on Posture and Balance in Patients Suffering from Diabetic Neuropathy.] Curr Diabetes Rev. 2021;17(3):332-344</ref>.
*[[Gait]] (can improve proprioception and gait pattern in patients with diabetic neuropathy)<ref>The Daily Star. Physiotherapy for diabetic neuropathy. Available from: https://www.thedailystar.net/health/how-to-prevent-diabetic-neuropathy-by-physiotherapy-1512505 (Accessed 10 April 2019)</ref><ref>Ahmad I, Verma S, Noohu MM, Shareef MY, Hussain ME. [https://pubmed.ncbi.nlm.nih.gov/32481239/ Sensorimotor and gait training improves proprioception, nerve function, and muscular activation in patients with diabetic peripheral neuropathy: a randomized control trial.] J Musculoskelet Neuronal Interact. 2020 Jun 1;20(2):234-248.</ref>.
* [[Splinting]] for mononeuropathies eg. [[Carpal Tunnel Syndrome|carpal tunnel]] or for muscle weakness e.g. ankle foot [[Orthoses for Management of Musculoskeletal Impairment|orthoses]].<ref name=":0" />


=== '''Physiotherapy Management''' ===
The youtube below shows some good exercises that a physiotherapist can employ to help manage the symptoms of diabetic neuropathy:{{#ev:youtube|https://www.youtube.com/watch?v=n23mUQexmKw|width}}<ref>Physical Therapy Video. Peripheral neuropathy relief in the feet and legs. Available from: https://www.youtube.com/watch?v=n23mUQexmKw (accessed 9 March 2019)</ref>
Specific exercise programme including range of motion, muscle strengthens and gait training can improve gait pattern or walking in patients with diabetic neuropathy. Evidence shows that resistant strengthening exercises lower blood glucose level


The youtube below shows some good exercises that a physiotherapist can employ to help manage the symptoms of diabetic neuropathy.{{#ev:youtube|https://www.youtube.com/watch?v=n23mUQexmKw|width}}<ref>Physical Therapy Video. Peripheral neuropathy relief in the feet and legs. Available from: https://www.youtube.com/watch?v=n23mUQexmKw (last accessed 9.3.2019)</ref>
A 2014 review found that the biggest consequence of diabetic neuropathy was a increase in risk of falls <ref>Pan X, Bai JJ. [https://www.sciencedirect.com/science/article/pii/S235201321400091X Balance training in the intervention of fall risk in elderly with diabetic peripheral neuropathy: A review]. International Journal of Nursing Sciences. 2014;1(4):441-5. </ref>. Therefore [[Balance|balance and falls prevention]] programs and training, in the senior diabetic clientele in particular, is very beneficial.  
{{#ev:youtube|https://www.youtube.com/watch?v=BNC4bi3Ucac|width}}<ref>Physical Therapy Video. 7 balance exercises for seniors fall prevention. Available from: https://www.youtube.com/watch?v=BNC4bi3Ucac (accessed 9 March 2019)</ref>


A 2014 review found that the biggest consequence of diabetic neuropathy was a increase in risk of falls. <ref>Pan X, Bai JJ. Balance training in the intervention of fall risk in elderly with diabetic peripheral neuropathy: A review. International Journal of Nursing Sciences. 2014 Dec 1;1(4):441-5. Available from: https://www.sciencedirect.com/science/article/pii/S235201321400091X (last accessed 9.3.2019)</ref> Therefore [[Balance|balance and falls prevention]] programs and or training, in the senior diabetic clientele in particular, by a physiotherapy is very beneficial.
=== Physiotherapy Management of Pain in Diabetic Neuropathy ===
{{#ev:youtube|https://www.youtube.com/watch?v=BNC4bi3Ucac|width}}<ref>Physical Therapy Video. 7 balance exercises for seniors fall prevention. Available from: https://www.youtube.com/watch?v=BNC4bi3Ucac (last accessed 9.3.2019)</ref>
see also [[Nerve Injury Rehabilitation Physiotherapy]]


=== Physiotherapeutic Management of Pain in Diabetic Neuropathy ===
'''Evidence has been provided for:'''
'''Evidence has been provided for:'''


#Transcutaneous Nerve Stimulation (TENS)<ref>Hamza MA, White PF, Craig WF, Ghoname ES, Ahmed HE, Proctor TJ: Percutaneous electrical nerve stimulation: a novel analgesic therapy for diabetic neuropathic pain. Diabetes Care 23:365 -370, 2000</ref>
#[[Transcutaneous Electrical Nerve Stimulation (TENS)|Transcutaneous Nerve Stimulation]] (TENS)<ref>Kumar SP, Adhikari P, Jeganathan PS, D'Souza SC. [https://ijcrr.com/article_html.php?did=2219 PHYSIOTHERAPY MANAGEMENT OF PAINFUL DIABETIC PERIPHERAL NEUROPATHY: A CRITICAL REVIEW OF TREATMENT METHODS FOR CLINICAL DECISION MAKING IN PRACTICE AND RESEARCH.] International Journal of Current Research and Review. 2010. 02(09):29-39</ref>.
#Static magnetic field therapy  
#Massage<ref>Gok Metin Z, Arikan Donmez A, Izgu N, Ozdemir L, Arslan IE. [https://pubmed.ncbi.nlm.nih.gov/28605119/ Aromatherapy Massage for Neuropathic Pain and Quality of Life in Diabetic Patients.] J Nurs Scholarsh. 2017 Jul;49(4):379-388.</ref>.
#Low-intensive laser therapy
#Static magnetic field therapy<ref>Weintraub MI, Wolfe GI, Barohn RA, Cole SP, Parry GJ, Hayat G, Cohen JA, Page JC, Bromberg MB, Schwartz SL; [https://pubmed.ncbi.nlm.nih.gov/12736891/ Magnetic Research Group. Static magnetic field therapy for symptomatic diabetic neuropathy: a randomized, double-blind, placebo-controlled trial.] Arch Phys Med Rehabil. 2003 May;84(5):736-46</ref>.
#Monochromatic infrared light
#[[Low Level Laser Therapy|Low-intensity laser therapy]]<ref>Cotler HB, Chow RT, Hamblin MR, Carroll J. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4743666/ The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain]. MOJ Orthop Rheumatol. 2015;2(5):00068</ref>.
#Monochromatic infrared light<ref>Robinson CC, Klahr PDS, Stein C, Falavigna M, Sbruzzi G, Plentz RDM. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5537484/#:~:text=Monochromatic%20infrared%20energy%20(MIRE)%20or,available%20primary%20results%20are%20inconsistent. Effects of monochromatic infrared phototherapy in patients with diabetic peripheral neuropathy: a systematic review and meta-analysis of randomized controlled trials]. Braz J Phys Ther. 2017 Jul-Aug;21(4):233-243</ref>.
#Acupuncture<ref>Dimitrova A, Murchison C, Oken B. [https://pubmed.ncbi.nlm.nih.gov/28112552/ Acupuncture for the Treatment of Peripheral Neuropathy: A Systematic Review and Meta-Analysis.] J Altern Complement Med. 2017 Mar;23(3):164-179.</ref>.
== Differential Diagnosis  ==
== Differential Diagnosis  ==


'''Other possible causes of neuropathy include:'''
'''Other possible causes of neuropathy include'''<ref>Cleveland Clinic. Neuropathy. Available from: https://my.clevelandclinic.org/health/diseases/14737-neuropathy (Accessed 07/07/22)</ref>''':'''


*Toxins (eg, alcohol, occupational, vitamin B6)
* Autoimmune disorders (e.g.  [[Guillain-Barre Syndrome|Guillain-Barré syndrome]], [[Systemic Lupus Erythematosus|systemic lupus erythematosus]], and [[Rheumatoid Arthritis|rheumatoid arthritis]])  
*medications (eg, amiodarone)
* Inherited disorders (e.g. [[Charcot-Marie-Tooth Disease]])
*Hypothyroidism
* Infections (e.g. chicken pox, [[HIV/AIDS|HIV]], [[Hepatitis A, B, C|hepatitis c]] and [[Lyme Disease|Lyme disease]])
*Pernicious anaemia
* Alcoholism
*Malignancies
* Vitamin deficiency (e.g. [[Vitamin B12 Deficiency|vitamins B1, B6, B12]], vitamin E and niacin)
*Amyloidosis
* Trauma
*Collagen vascular disease
 
*Neurosarcoidosis.
*Toxins (e.g. heavy metals and industrial chemicals)
*Tabes dorsalis
*Medications (e.g. some [[antibiotics]] or [[Chemotherapy Side Effects and Syndromes|chemotherapy]])
*AIDS.
*[[Hypothyroidism]]
*Spinal cord disease
*Vascular disorders.
*Cauda equina syndrome.<br>


== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
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<rss>http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1JEkdnYNUQx0r8vhk7y3</rss>
</div>
== References  ==
== References  ==
<references /> &nbsp;
<references /> &nbsp;
[[Category:Neuropathy]]
[[Category:Neuropathy]]
[[Category:Diabetes]]
[[Category:Diabetes]]
[[Category:Medical]]
[[Category:Medical]]
[[Category:Foot]]
[[Category:Ankle]]
[[Category:Conditions]] 
[[Category:Foot - Conditions]]
[[Category:Ankle - Conditions]]

Latest revision as of 12:13, 10 July 2022

Original Editor - Wendy Walker

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Introduction[edit | edit source]

Diabetic neuropathy is dysfunction and damage in the peripheral nerves in people with diabetes[1]. Neuropathies are characterized by a progressive loss of nerve fibre function[2]. Diabetic neuropathy is a common complication of Diabetes Mellitus (DM), estimated to affect up to 51% of patients with both type 1 and type 2 DM[3][4]. The clinical presentation of diabetic neuropathy varies, from asymptomatic to severe neuropathic pain and numbness[3]. Diabetic neuropathy is associated with increased risk of foot ulcers, lower limb amputation and mortality[5][6].

Clinically Relevant Anatomy[edit | edit source]

The peripheral nervous system refers to the components of the nervous system outside of the brain and spinal cord. The nerve roots exit the spinal cord and then branch out into smaller peripheral nerves. The peripheral nerves consist of motor and sensory fibers[7].

In diabetic neuropathy, there is degeneration in the type, severity, and distribution of these receptors, nerve fibers, or neurons, with the degeneration beginning distally and symmetrically, and spreading proximally[8].

Mechanism of Injury / Pathological Process[edit | edit source]

The pathological process of diabetic neuropathy is not completely understood, and is likely multifactoral[9]. Research suggests neuronal inflammation, oxidative stress, mitochondrial dysfunction and cell death is caused by hyperglycaemia, dyslipidaemia and microvascular disease[6].

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Risk Factors[10][edit | edit source]

Clinical Presentation[edit | edit source]

More than half of the cases are distal symmetric polyneuropathy[12]. Asymmetrical or focal syndromes, such as carpal tunnel syndrome[13] (14-30%), radiculopathies/plexopathies and cranial neuropathies, account for the rest[14].

The most common symptoms are[15]:

  • Numbness in the hands or feet, often on both sides, described as a stocking-and-glove distribution
  • Tingling/"pins and needles" or burning sensation in the feet
  • Pain in the hands, feet, or legs
  • Dry or cracked skin or calluses on the feet.
  • Distal, proximal or more focal weakness, including foot drop or frequent tripping.

Diagnostic Procedures[edit | edit source]

  • Subjective history of symptoms, recent foot trauma and previous ulcers or wounds[16].
  • Physical examination of skin condition, foot anatomy, and vascular perfusion[16].
  • Testing includes assessment of gross light touch and pinprick sensation, using simple hand held devices (e.g. cotton wool, stick pins or monofilament)[8].
  • Vibratory sense in the feet is tested with a 128-Hz tuning fork placed at the base of the great toenail[17].
  • Deep tendon reflexes are commonly hypoactive or absent[18].
  • Nerve conduction studies or needle electromyogram[19].

Classification[edit | edit source]

Diabetic neuropathy can be classified into 4 subgroups:[20]

  • Proximal neuropathy/ diabetic amyotrophy.
  • Peripheral neuropathy / diabetic nerve pain / distal polyneuropathy.
  • Autonomic neuropathy.
  • Focal neuropathy / mononeuropathy.

Staging[edit | edit source]

A common staging scale of diabetic neuropathy is as follows: [21]

  • N0 - No neuropathy.
  • N1a - Signs but no symptoms of neuropathy.
  • N2a - Symptomatic mild diabetic polyneuropathy; sensory, motor, or autonomic symptoms; patient able to heel walk.
  • N2b - Severe symptomatic diabetic polyneuropathy, and patient unable to heel walk.
  • N3 - Disabling diabetic polyneuropathy.

Medical Management / Interventions[edit | edit source]

Medical management starts with 0ptimized glycemic control (mainly for type 1 DM) and lifestyle interventions[22]. Lifestyle intervention includes physical exercise and weight loss.

Tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors (e.g. duloxetine) and anticonvulsants (e.g. pregabalin and gabapentin) are commonly prescribed treatments for neuropathic pain[23]. At present, there are no universally accepted disease modifying medicines, but this is currently being researched and developed[24].

Moreover, multidisciplinary team management is required for the prevention and management of diabetic foot complications[6].

Physiotherapy Management and Exercise[edit | edit source]

Research has shown that strength training can moderately improve muscle function, reduce neuropathic pain and help control blood sugar levels for people with diabetic neuropathy[25]. Therefore, exercise can help to improve quality of life for this patient group[26]. Diabetic clients must take precautions, including monitoring their blood sugar levels during exercise and snacking beforehand to prevent major fluctuations[27].

Specific exercise programs should include[25][edit | edit source]

  • Flexibility (progressive stretching and self stretches).
  • Muscle strengthening (using a variety of modes as appropriate eg isometric, graded weight progression, open and close chain)[28].
  • Aerobic activity.
  • Posture and balance training (for falls prevention and stability)[29].
  • Gait (can improve proprioception and gait pattern in patients with diabetic neuropathy)[30][31].
  • Splinting for mononeuropathies eg. carpal tunnel or for muscle weakness e.g. ankle foot orthoses.[25]

The youtube below shows some good exercises that a physiotherapist can employ to help manage the symptoms of diabetic neuropathy:

[32]

A 2014 review found that the biggest consequence of diabetic neuropathy was a increase in risk of falls [33]. Therefore balance and falls prevention programs and training, in the senior diabetic clientele in particular, is very beneficial.

[34]

Physiotherapy Management of Pain in Diabetic Neuropathy[edit | edit source]

see also Nerve Injury Rehabilitation Physiotherapy

Evidence has been provided for:

  1. Transcutaneous Nerve Stimulation (TENS)[35].
  2. Massage[36].
  3. Static magnetic field therapy[37].
  4. Low-intensity laser therapy[38].
  5. Monochromatic infrared light[39].
  6. Acupuncture[40].

Differential Diagnosis[edit | edit source]

Other possible causes of neuropathy include[41]:

References[edit | edit source]

  1. ↑ Rosenberger DC, Blechschmidt V, Timmerman H, Wolff A, Treede RD. Challenges of neuropathic pain: focus on diabetic neuropathy. J Neural Transm (Vienna). 2020 Apr;127(4):589-624.
  2. ↑ Boulton AJ, Malik RA. Diabetic neuropathy. Med Clin North Am. 1998;82(4):909-29
  3. ↑ 3.0 3.1 Hicks CW, Selvin E. Epidemiology of Peripheral Neuropathy and Lower Extremity Disease in Diabetes. Curr Diab Rep. 2019 Aug 27;19(10):86.
  4. ↑ Dyck PJ, Kratz KM, Karnes JL, Litchy WJ, Klein R, Pach JM, et al. The prevalence by staged severity of various types of diabetic neuropathy, retinopathy, and nephropathy in a population-based cohort: the Rochester Diabetic Neuropathy Study. Neurology. 1993;43(4):817-24
  5. ↑ Malik RA. Which Test for Diagnosing Early Human Diabetic Neuropathy? Diabetes. 2014 Jul;63(7):2206-8
  6. ↑ 6.0 6.1 6.2 Sloan G, Selvarajah D, Tesfaye S. Pathogenesis, diagnosis and clinical management of diabetic sensorimotor peripheral neuropathy. Nat Rev Endocrinol. 2021 Jul;17(7):400-420.
  7. ↑ Spine-Health. Peripheral Nervous System Anatomy. Available from: https://www.spine-health.com/conditions/spine-anatomy/anatomy-nerve-pain (Accessed 06/07/22).
  8. ↑ 8.0 8.1 Dyck PJ, Herrmann DN, Staff NP, Dyck PJ. Assessing decreased sensation and increased sensory phenomena in diabetic polyneuropathies. Diabetes. 2013 Nov;62(11):3677-86
  9. ↑ Zochodne DW. Diabetic polyneuropathy: an update. Curr Opin Neurol. 2008;21(5):527-33
  10. ↑ Kartha C, Ramachandran S, Pillai RM, editors. Mechanisms of Vascular Defects in Diabetes Mellitus. Springer. 2017. p.163
  11. ↑ Kote GS, Bhat AJ, Thajuddeen K, Ismail MH, Gupta A.Peripheral Insensate Neuropathy-Is Height a Risk Factor? J Clin Diagn Res. 2013; 7(2): 296–301
  12. ↑ Bodman MA, Varacallo M. Peripheral Diabetic Neuropathy. 2022 May 1. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan
  13. ↑ Singh R, Gamble G, Cundy T. Lifetime risk of symptomatic carpal tunnel syndrome in Type 1 diabetes. Diabet Med. 2005;22(5):625-30
  14. ↑ Shaw JE, Zimmet PZ. The epidemiology of diabetic neuropathy. Diabetes Reviews. 1999;7:245-52
  15. ↑ Cedars Sinai. Diabetic Neuropathy. Available from: https://www.cedars-sinai.org/health-library/diseases-and-conditions/d/diabetic-neuropathy.html (Accessed 09/07/2022)
  16. ↑ 16.0 16.1 Bandyk DF. The diabetic foot: Pathophysiology, evaluation, and treatment. Semin Vasc Surg. 2018 Jun-Dec;31(2-4):43-48
  17. ↑ American Diabetes Association. Vibration Testing Detects Diabetic Peripheral Neuropathy Earlier than the 10-g Monofilament. Available from: https://professional.diabetes.org/abstract/vibration-testing-detects-diabetic-peripheral-neuropathy-earlier-10-g-monofilament (Accessed 09/07/2022)
  18. ↑ Medscape. How are deep tendon reflexes assessed in diabetic neuropathy? Available from https://www.medscape.com/answers/1170337-4949/how-are-deep-tendon-reflexes-assessed-in-diabetic-neuropathy (Accessed 09/07/2022)
  19. ↑ Yang Z, Zhang Y, Chen R, Huang Y, Ji L, Sun F, Hong T, Zhan S. Simple tests to screen for diabetic peripheral neuropathy. Cochrane Database Syst Rev. 2018 Jul 30;2018(7)
  20. ↑ Endocrine Web. Types of Diabetic Neuropathy. Available from: https://www.endocrineweb.com/guides/diabetic-neuropathy/types-diabetic-neuropathy (Accessed 07/07/2022)
  21. ↑ Dianna Quan,Helen C Lin ; Diabetic Neuropathy Clinical Presentation. Available from: http://emedicine.medscape.com/article/1170337-clinical#a0256 (Accessed 26 May 2020)
  22. ↑ Cernea S, Raz I. Management of diabetic neuropathy. Metabolism. 2021 Oct;123:154867.
  23. ↑ Callaghan BC, Gallagher G, Fridman V, Feldman EL. Diabetic neuropathy: what does the future hold? Diabetologia. 2020 May;63(5):891-897.
  24. ↑ Røikjer J, Mørch CD, Ejskjaer N. Diabetic Peripheral Neuropathy: Diagnosis and Treatment. Curr Drug Saf. 2021;16(1):2-16.
  25. ↑ 25.0 25.1 25.2 The Foundation for Peripheral Neuropathy. Exercise and physical therapy for neuropathy. Available from: https://www.foundationforpn.org/living-well/lifestyle/exercise-and-physical-therapy/ (Accessed 10/07/2022)
  26. ↑ Jahantigh Akbari N, Hosseinifar M, Naimi SS, Mikaili S, Rahbar S. The efficacy of physiotherapy interventions in mitigating the symptoms and complications of diabetic peripheral neuropathy: A systematic review. J Diabetes Metab Disord. 2020 Oct 12;19(2):1995-2004.
  27. ↑ Diabetes.co.uk. Exercise for Diabetics. Available from: https://www.diabetes.co.uk/exercise-for-diabetics.html (Accessed 10/07/2022)
  28. ↑ Win MMTM, Fukai K, Nyunt HH, Linn KZ. Hand and foot exercises for diabetic peripheral neuropathy: A randomized controlled trial. Nurs Health Sci. 2020 Jun;22(2):416-426.
  29. ↑ Thukral N, Kaur J, Malik M. A Systematic Review and Meta-analysis on Efficacy of Exercise on Posture and Balance in Patients Suffering from Diabetic Neuropathy. Curr Diabetes Rev. 2021;17(3):332-344
  30. ↑ The Daily Star. Physiotherapy for diabetic neuropathy. Available from: https://www.thedailystar.net/health/how-to-prevent-diabetic-neuropathy-by-physiotherapy-1512505 (Accessed 10 April 2019)
  31. ↑ Ahmad I, Verma S, Noohu MM, Shareef MY, Hussain ME. Sensorimotor and gait training improves proprioception, nerve function, and muscular activation in patients with diabetic peripheral neuropathy: a randomized control trial. J Musculoskelet Neuronal Interact. 2020 Jun 1;20(2):234-248.
  32. ↑ Physical Therapy Video. Peripheral neuropathy relief in the feet and legs. Available from: https://www.youtube.com/watch?v=n23mUQexmKw (accessed 9 March 2019)
  33. ↑ Pan X, Bai JJ. Balance training in the intervention of fall risk in elderly with diabetic peripheral neuropathy: A review. International Journal of Nursing Sciences. 2014;1(4):441-5.
  34. ↑ Physical Therapy Video. 7 balance exercises for seniors fall prevention. Available from: https://www.youtube.com/watch?v=BNC4bi3Ucac (accessed 9 March 2019)
  35. ↑ Kumar SP, Adhikari P, Jeganathan PS, D'Souza SC. PHYSIOTHERAPY MANAGEMENT OF PAINFUL DIABETIC PERIPHERAL NEUROPATHY: A CRITICAL REVIEW OF TREATMENT METHODS FOR CLINICAL DECISION MAKING IN PRACTICE AND RESEARCH. International Journal of Current Research and Review. 2010. 02(09):29-39
  36. ↑ Gok Metin Z, Arikan Donmez A, Izgu N, Ozdemir L, Arslan IE. Aromatherapy Massage for Neuropathic Pain and Quality of Life in Diabetic Patients. J Nurs Scholarsh. 2017 Jul;49(4):379-388.
  37. ↑ Weintraub MI, Wolfe GI, Barohn RA, Cole SP, Parry GJ, Hayat G, Cohen JA, Page JC, Bromberg MB, Schwartz SL; Magnetic Research Group. Static magnetic field therapy for symptomatic diabetic neuropathy: a randomized, double-blind, placebo-controlled trial. Arch Phys Med Rehabil. 2003 May;84(5):736-46
  38. ↑ Cotler HB, Chow RT, Hamblin MR, Carroll J. The Use of Low Level Laser Therapy (LLLT) For Musculoskeletal Pain. MOJ Orthop Rheumatol. 2015;2(5):00068
  39. ↑ Robinson CC, Klahr PDS, Stein C, Falavigna M, Sbruzzi G, Plentz RDM. Effects of monochromatic infrared phototherapy in patients with diabetic peripheral neuropathy: a systematic review and meta-analysis of randomized controlled trials. Braz J Phys Ther. 2017 Jul-Aug;21(4):233-243
  40. ↑ Dimitrova A, Murchison C, Oken B. Acupuncture for the Treatment of Peripheral Neuropathy: A Systematic Review and Meta-Analysis. J Altern Complement Med. 2017 Mar;23(3):164-179.
  41. ↑ Cleveland Clinic. Neuropathy. Available from: https://my.clevelandclinic.org/health/diseases/14737-neuropathy (Accessed 07/07/22)

 

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