Diabetic Neuropathy: Difference between revisions

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== Introduction  ==
== Introduction  ==
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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. 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. 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">Rayaz A. Malik ;[https://pubmed.ncbi.nlm.nih.gov/24962918/ Which Test for Diagnosing Early Human Diabetic Neuropathy? Diabetes.] 2014;63:[[Tel:2206–2208|2206–2208]]</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 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>.


== Clinically Relevant Anatomy ==
== 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>.   
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>.   


In diabetic neuropathy, they’re 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" />.
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>.


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


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" />.  
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" />.  
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== Risk Factors<ref>Kartha C,  Ramachandran S,  Pillai RM, editors. Mechanisms of Vascular Defects in Diabetes Mellitus. Springer. 2017. p.163</ref> ==
== Risk Factors<ref>Kartha C,  Ramachandran S,  Pillai RM, editors. Mechanisms of Vascular Defects in Diabetes Mellitus. Springer. 2017. p.163</ref> ==


* Poor glycemic control.  
* Poor glycemic control.  
* High blood pressure  
* [[Hypertension|High blood pressure]]
* Smoking.  
* [[Smoking Cessation and Brief Intervention|Smoking]].
* Advance age.  
* Advance age.  
* Advanced duration of Diabetes disease.  
* Advanced duration of Diabetes disease.  
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== Clinical Presentation  ==
== Clinical Presentation  ==


More than half of the cases are distal symmetric polyneuropathy. Focal syndromes such as [[Carpal Tunnel Syndrome|carpal tunnel syndrome]]<ref>Singh R, Gamble G, Cundy T. 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. 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  ===
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>:


Motor problems may include distal, proximal, or more focal weakness.
* 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
#In the upper limbs-&nbsp;distal motor symptoms often include impaired fine hand coordination.
* Pain in the hands, feet, or legs
#In the lower limbs -&nbsp;Mild foot drop or frequent tripping may be early symptoms of lower limb weakness. Symptoms of proximal limb weakness include difficulty climbing up and downstairs, difficulty getting up from a seated or supine position, [[falls]] due to the [[Knee|knees]] giving way, and difficulty raising the arms above the shoulders.
* 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]].  
=== 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.
 
*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.  
*Positive symptoms may be described as burning, prickling pain, tingling, electric shock–like feelings, aching, tightness, or hypersensitivity to touch.


== 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 the reduction of vibratory and pinprick sensation over the toes. As the 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 loose 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" />.
* 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" />.


Vibratory sense in the feet is tested with a 128-Hz tuning fork placed at the base of the great toenail.<br>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>.
* 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>.


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. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3806590/ Assessing decreased sensation and increased sensory phenomena in diabetic polyneuropathies]. Diabetes. 2013; 62:[[Tel:3677–3686|3677–3686]]</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)
* Peripheral neuropathy / diabetic nerve pain / distal polyneuropathy.
*Generalised symmetrical polyneuropathies
* Autonomic neuropathy.
*Sensory neuropathy
* Focal neuropathy / mononeuropathy.
*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)


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. Available from: http://emedicine.medscape.com/article/1170337-clinical#a0256 (Accessed 26 May 2020)</ref>
=== Staging  ===
=== Staging  ===


A common staging scale of diabetic polyneuropathy is as follows:&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  
*N0 - No neuropathy.
*N1a - Signs but no symptoms of neuropathy  
*N1a - Signs but no symptoms of neuropathy.
*N2a - Symptomatic mild diabetic polyneuropathy; sensory, motor, or autonomic symptoms; patient able to heel walk  
*N2a - Symptomatic mild diabetic polyneuropathy; sensory, motor, or [[Autonomic Nervous System|autonomic]] symptoms; patient able to heel walk.
*N2b - Severe symptomatic diabetic polyneuropathy (as in N2a, but patient unable to heel walk)
*N2b - Severe symptomatic diabetic polyneuropathy, and patient unable to heel walk.
*N3 - Disabling diabetic polyneuropathy
*N3 - Disabling diabetic polyneuropathy.


==Medical Management / Interventions==
==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.  
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.  


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 medicines to treat the proposed pathophysiology of diabetic neuropathy, 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>.
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>.


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


== Physiotherapy Management and Exercise ==
== Physiotherapy Management and Exercise ==
[[File:Falls class.png|frameless|417x417px|center]]Research has shown that strength training can moderately improve muscle function in people with peripheral neuropathy (PN). Regular [[Therapeutic Exercise|exercise]] can also help reduce [[Neuropathic Pain|neuropathic pain]] and help control blood sugar levels.<ref name=":0">The Foundation for peripheral neuropathy. [https://www.foundationforpn.org/living-well/lifestyle/exercise-and-physical-therapy/ Exercise and physical therapy for neuropathy]. Available from: https://www.foundationforpn.org/living-well/lifestyle/exercise-and-physical-therapy/ (last accessed 10.3.2019)</ref> Diabetic clients must tightly monitor their blood sugar levels during exercise to prevent major fluctuations. This may involve educating clients and monitoring blood sugars, ideally through a multi-disciplined approach in rehabilitation.
[[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" /> ====
* 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" />


==== Specific exercise programs should include ====
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>
* Flexibility (progressive stretching and self stretches)
* Muscle strengthening ( using a variety of modes as appropriate eg isometric, graded weight progression, open and close chain)
* Aerobic activity  ( aiming for 30 minutes 4 times a week)
* [[Balance]] ( for falls prevention and stability)
* [[Gait]] (can improve gait pattern or walking in patients with diabetic neuropathy) Evidence shows that resistant strengthening exercises lower blood glucose level<ref>The daily star. [https://www.thedailystar.net/health/how-to-prevent-diabetic-neuropathy-by-physiotherapy-1512505 Physiotherapy for diabetic neuropathy.] Available from: https://www.thedailystar.net/health/how-to-prevent-diabetic-neuropathy-by-physiotherapy-1512505 ( accessed 10 April 2019)</ref>
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>


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;1(4):441-5. Available from: https://www.sciencedirect.com/science/article/pii/S235201321400091X (accessed 9 March 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.  
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>
{{#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>


Physiotherapy may also involve splinting for mononeuropathies eg. [[Carpal Tunnel Syndrome|carpal tunnel]] or for muscle weakness eg Ankle foot orthoses.<ref name=":0" /> [[File:Carpal tunnel splint.jpg|frameless|200x200px]]
=== Physiotherapy Management of Pain in Diabetic Neuropathy ===
 
As a consequence of diabetic neuropathy physiotherapist are involved in
 
The [[The Diabetic Foot|Diabetic Foot]].
 
The [[The Diabetic Amputee|Diabetic Amputee]].
 
==== Physiotherapeutic Management of Pain in Diabetic Neuropathy ====
see also [[Nerve Injury Rehabilitation Physiotherapy]]
see also [[Nerve Injury Rehabilitation Physiotherapy]]


'''Evidence has been provided for:'''
'''Evidence has been provided for:'''


#[[Transcutaneous Electrical Nerve Stimulation (TENS)|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. 2000; 23:365 -370.</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 Level Laser Therapy|Low-intensity 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  ==


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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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