Dibetic Periheral Neuropathy

Dibetic Periheral Neuropathy

DIABETIC PERIPHERAL NEUROPATHY

What is Neuropathy?
Neuropathy is a general term for physical damage to or impairment
of the human nervous system. It has many causes, and many symptoms. Because
a long period of time with elevated blood glucose can damage nerve fibers, diabetes
is one cause of neuropathy. The Centers for Disease Control suggests up to 70%
of diabetics may have measurable neuropathy, though a number of other diseases
(and some medications) can also cause this condition.
"Diabetic neuropathy occurs in both type 1 and type 2 diabetes"
(says Johns Hopkins' "InteliHealth," an Internet magazine),"
and it is most common in those whose blood glucose levels have been poorly controlled.
Although diabetic neuropathy can occur in patients who have had diabetes for
a short time, it is most likely to affect those who have been diabetic for more
than a decade, especially those over age 40. Diabetics who smoke are especially
at risk."
The human nervous system is enormously complex. The peripheral
nerves carry information to and from the brain, connecting it with the rest
of the body. These nerves can be motor, sensory, or autonomic. Motor nerves
carry messages from the brain for the contraction of different muscles. Sensory
nerves relay to the brain sensations of touch, temperature, position and pain,
from the body's periphery. Autonomic nerves carry the brain's commands to organs
such as the heart, the stomach, lungs, and liver; and autonomic neuropathy,
a potentially severe condition though thankfully rare, will receive its own
separate coverage later.
The longer the nerve fibers, the more likely they are to show
damage from long-term high blood glucose. Such damage generally appears at the
nerve terminus, at the end furthest away from the central nervous system (brain
and spine). For peripheral neuropathy, the damage commonly manifests at the
nerve terminals of feet, lower legs, and hands. Doctors call this common form
distal sensory polyneuropathy.
Symptoms can include diminished tactile sensation, numbness,
loss of reflex reaction, and various types and degrees of pain, from "pins
and needles" to extreme burning sensations. As neuropathy progresses, the
symptoms frequently change. CAUTION: Diabetics experiencing neuropathy sometimes
have other ramifications as well, and these have their own symptoms. Sometimes
symptoms overlap, and diagnosis can be confusing. Diabetic nephropathy--kidney
failure--can exacerbate neuropathy, due to the uremic toxicity of the condition.
Other pain can be a symptom of undiagnosed orthopedic problems, other medical
conditions, drugs, or exposure to toxic chemicals. If you are experiencing pain
or abnormal sensations in hands, feet, or legs, check with your doctor.
The simplest way your doctor can check for the diminished sensation
that can be an early sign of neuropathy in your feet is with a monofilament,
a thin, flexible filament of nylon or broomcorn. The doctor will press it gently
against areas of your foot and lower leg, and ask you if you can feel the touch.
Where you cannot, early neuropathy may be present. The monofilament, the only
tool this test requires, is extremely inexpensive, and the test is highly advisable.
More sophisticated tests can be carried out with a tuning fork,
and where the doctor needs to inspect a nerve path more closely, by a test called
an electromyelogram (EMG). The EMG tracks the movement of electrical impulses
along the nerve path, and can reveal whether impairment is due to diabetes or
follows a compression injury, such as back problems or carpal tunnel syndrome.

Prevention and Treatment
As diabetic neuropathy follows extended periods of hyperglycemia,
its best prevention is good blood glucose management, "tight control,"
with numbers down in the normal range. A healthy lifestyle, with plenty of exercise
and careful attention to diet, helps too. Incidentally, the same "tight
control" regime can help those with already established neuropathy. Although
it is not clear exactly how it happens (there are several theories), experience
shows that getting your diabetes under control, and keeping it there, can, over
a several-month period, alleviate at least some of neuropathy's symptoms.
Individual symptoms are as varied as individuals, but the most
common complaint is pain, and pain control becomes the single biggest challenge
in dealing with established neuropathy. Doctors have prescribed aspirin, acetaminophen,
and various other nonsteroidal anti-inflammatory drugs, the anticonvulsants
Dilantin and carbamazepine (Tegretol), and tricyclic antidepressants such as
paroxetine (Paxil) and amytriptaline (Elavil), or a combination of vitamins
B1, B6, and Glutamine, with varying results. Along with the drugs, some are
prescribing capsaicin cream (Zostrix and its equivalents), a topical ointment
originally formulated for arthritis pain. Some use the epilepsy drug gabapentin
(Neurontin), while others relieve symptoms with local anesthetics or muscle
relaxants. Still others are investigating acupuncture, although not enough is
known about it to say for certain if it works in such cases. T.E.N.S., transcutaneous
electrical stimulation (of the affected nerves) with a short jolt of electricity,
appears to interrupt the transmission of pain signals, and works for some. Researchers
are also experimenting with aldose reductase inhibitors such as Sorbinil and
Zenerstat, but these have not yet been approved in the USA. And of course the
search for new treatments goes on, with tests of antioxidants, nerve growth
factors (rhNGF), blood vessel expanders, and various herbal/naturopathic substances.
There is a lot of disagreement over effective treatments for
neuropathy pain. Folks swear by their particular remedy. You need to find and
use what works for you. Beware of extravagant claims for pill or technique;
there are no "miracle cures."
None of the pills and creams is as effective in bringing relief
as is getting your blood sugars into good control and keeping them there. The
International Diabetes Center's website advises:
"The best way to treat or prevent neuropathy in any area
of the body is to control your blood glucose levels. Good glucose control may
not reverse numbness or tingling, but it can slow or stop additional nerve damage.
Good control also can bring on dramatic pain relief. Medications can be used
to control the symptoms of painful neuropathy and gastroparesis (autonomic neuropathy
of the digestive system) as well."

Consequences of Neuropathy
The main reason we, as human beings, have a pain reflex, is
because pain lets us know something is wrong in the affected area. If it hurts,
we do something about it. With its biggest symptoms being pain (when nothing
is there) and diminished sensation/numbness (when something is present), neuropathy
can seriously interfere with a diabetic's self-care, especially care of the
feet. Circulatory problems stemming from diabetes can lead to dry skin on the
feet, with the risk of ulcers and lesions. Lacking normal pain reflexes, the
diabetic with neuropathy may not be aware his or her feet are in trouble. Even
stepping on a tack may be pain-free. This means otherwise treatable lesions
are allowed to progress into severe infection, sometimes into gangrene itself.
Amputation is a common result of this progression of events, and complications
of diabetes account for the majority of nontraumatic amputations in the U.S.
today. All diabetics need to frequently inspect their feet, but individuals
with neuropathy need to be especially thorough, as early detection of foot problems
can be critical to saving the infected foot.

Other Coping Strategies
Although there are lots of variations, with the rule being "do
what works for you," there are a number of non-medicinal ways folks cope
with neuropathy pain. One individual, who reported "burning feet"
at night, slept with her feet uncovered, and a fan blowing cool air on them.
Many others cushion aching feet with thick, seamless hikers' socks, especially
those made of cotton, or of man-made materials such as Thorlo.
Some folks report that exercise brings relief, however temporary.
Others use meditation-based relaxation techniques to help them manage. Another
approach, followed by many, is to wear high-quality, proper-fitting athletic
shoes with good support, or support sandals such as Birkenstocks, along with
the socks mentioned above.
Many individuals whose feet are affected by diabetic neuropathy
are also dealing with circulatory/microvascular problems. Their ability to heal
from otherwise minor cuts and scrapes may be seriously impaired, leading to
a history of ulceration, or even a partial amputation. Special therapeutic shoes,
with custom inserts, or "extra-depth shoes," or several other shoe
modifications, are covered by Medicare as durable medical equipment. Discuss
this with your doctor.

New Research
Although many medicines are used for treatment of neuropathy's
symptoms, none are yet officially FDA-licensed for such use. However, doctors
have wide leeway in such "off-label" prescribing, and these medications
have passed safety inspection-and are now being evaluated for their efficacy
as neuropathy treatments.
There are also new medications under investigation; some to
treat symptoms, and others that might someday treat the underlying cause, the
demyelinating nerve damage. At press time, CenterWatch, a clinical trials listing
service, lists 56 separate FDA-mandated clinical trials of new neuropathy medications
underway in the United States on human subjects! One such study is of the drug
memantine, which has been proved effective in rat-based pain-reduction studies,
and is now in FDA-mandated Phase II clinicals. There are many more studies at
the "test tube" stage, or currently in animal trials.

Conclusion
Unexplained pain or abnormal sensation is a serious matter.
It may indicate neuropathy, which may be from diabetes, or it may stem from
some other condition--and your doctor needs to promptly determine its source.
Neuropathy is NOT an inevitable ramification of diabetes, but you shouldn't
just "grin and bear it," either. A lot of different therapies and
interventions bring relief to many diabetics. Keep the best blood glucose control
you can, keep your doctor informed, and don't lose hope.

For Further Reading
A great deal of research is being done on this subject. Although
most findings are published in professional research journals, World Wide Web
searches on "neuropathy" reveal hundreds of timely listings, many
linked to other sources. Here are a few websites you might find worthwhile:
http://www.niddk.nih.gov/health/diabetes/ndic.htm -- The National
Institutes of Diabetes, Digestive, and Kidney Diseases
http://www.centerwatch.com/studies/cat253.htm -- CenterWatch
http://www.intelihealth.com/IH/itlH -- Johns Hopkins IntelliHealth
http://www.cdc.gov/nccdphp/ddt/ddthome.htm -- U.S. Centers for
Disease Control
http://www.diabetesmonitor.com/dr-00005.htm#neurop -- "Diabetes
Monitor"'s neuropathy page
http://www.hsmnet.com/IDC-Main.htm -- (International Diabetes
Center's Home Page)

Published Sources
"Diabetic Neuropathy: Current Practice and Promising New
Therapies," "Interdisciplinary Medicine" (March 1999) Vol. 4
No. 1, Dept. GN173B, 405 Trimmer Road, PO Box 458, Califon, NJ 07830.
"Taming the Pain of Nerve Disease," "Diabetes
Advisor" (May/June 1999) Vol. 7, No. 3.
"New Treatments for Diabetic Neuropathy" by Keith
R. Edwards, MD. "Home Health Care Consultant" (March 1999) Vol. 6,
No. 3.
"Pathophysiology of Painful Neuropathy" by Mark Granberry,
PharmD, Suresh Baliga, MD, and Vivian Fonseca, MD. "Practical Diabetology"
(June 1999) Vol. 18, No. 2.