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Diabetic Neuropathy About 60-70% of people with diabetes have mild to severe forms of nervous system damage, including: Impaired sensation or pain in the feet or hands Slowed digestion of food in the stomach Carpal tunnel syndrome Other nerve problems More than 60% of nontraumatic lower-limb amputations in the United States occur among people with diabetes.
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Risk Factors Glucose control Duration of diabetes Damage to blood vessels Mechanical injury to nerves Autoimmune factors Genetic susceptibility Lifestyle factors Smoking Diet
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Pathogenesis of Diabetic Neuropathy Metabolic factors High blood glucose Advanced glycation end products Sorbitol Abnormal blood fat levels Ischemia Nerve fiber repair mechanisms
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Diagnostic Tests Assess symptoms - muscle weakness, muscle cramps, prickling, numbness or pain, vomiting, diarrhea, poor bladder control and sexual dysfunction Comprehensive foot exam Skin sensation and skin integrity Quantitative Sensory Testing (QST) X-ray Nerve conduction studies Electromyographic examination (EMG) Ultrasound
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Classification of Diabetic Neuropathy Symmetric polyneuropathy Autonomic neuropathy Polyradiculopathy Mononeuropathy
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Symmetric Polyneuropathy Most common form of diabetic neuropathy Affects distal lower extremities and hands (“stocking-glove” sensory loss) Symptoms/Signs Pain Paresthesia/dysesthesia Loss of vibratory sensation
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Complications of Polyneuropathy Ulcers Charcot arthropathy Dislocation and stress fractures Amputation - Risk factors include: Peripheral neuropathy with loss of protective sensation Altered biomechanics (with neuropathy) Evidence of increased pressure (callus) Peripheral vascular disease History of ulcers or amputation Severe nail pathology
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Treatment of Symmetric Polyneuropathy Glucose control Pain control Tricyclic antidepressants Topical creams Anticonvulsants Foot care
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Essentials of Foot Care Examination Annually for all patients Patients with neuropathy - visual inspection of feet at every visit with a health care professional Advise patients to: Use lotion to prevent dryness and cracking File calluses with a pumice stone Cut toenails weekly or as needed Always wear socks and well-fitting shoes Notify their health care provider immediately if any foot problems occur
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Autonomic neuropathy Affects the autonomic nerves controlling internal organs Peripheral Genitourinary Gastrointestinal Cardiovascular Is classified as clinical or subclinical based on the presence or absence of symptoms
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Peripheral Autonomic Dysfunction Contributes to the following symptoms/signs: Neuropathic arthropathy (Charcot foot) Aching, pulsation, tightness, cramping, dry skin, pruritus, edema, sweating abnormalities Weakening of the bones in the foot leading to fractures Testing Direct microelectrode recording of postglanglionic C fibers Galvanic skin responses Measurement of vascular responses
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Peripheral Autonomic Dysfunction, cont. Treatment Foot care/elevate feet when sitting Eliminate aggravating drugs Reduce edema midodrine diuretics Support stockings Screen for CVD
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Genitourinary Autonomic Neuropathy
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Gastrointestinal Autonomic Neuropathy Symptoms/Signs Gastroparesis resulting in anorexia, nausea, vomiting, and early satiety Diabetic enteropathy resulting in diarrhea and constipation Treatment Other causes of gastroparesis or enteropathy should first be ruled out Gastroparesis - Small, frequent meals, metoclopramide, erythromycin Enteropathy - loperamide, antibiotics, stool softeners or dietary fiber
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Cardiovascular Autonomic Neuropathy Symptoms/Signs Exercise intolerance Postural hypotension Treatment Discontinue aggravating drugs Change posture (make postural changes slowly, elevate bed) Increase plasma volume
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Polyradiculopathy Lumbar polyradiculopathy (diabetic amyotrophy) Thigh pain followed by muscle weakness and atrophy Thoracic polyradiculopathy Severe pain on one or both sides of the abdomen, possibly in a band-like pattern Diabetic neuropathic cachexia Polyradiculopathy + peripheral neuropathy Associated with weight loss and depression
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Polyradiculopathy, cont. Polyradiculopathies are diagnosed by electromyographic (EMG) studies Treatment Foot care Glucose control Pain control
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Mononeuropathy Peripheral mononeuropathy Single nerve damage due to compression or ischemia Occurs in wrist (carpal tunnel syndrome), elbow, or foot (unilateral foot drop) Symptoms/Signs numbness edema pain prickling
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Cranial mononeuropathy Affects the 12 pairs of nerves that are connected with the brain and control sight, eye movement, hearing, and taste Symptoms/Signs unilateral pain near the affected eye paralysis of the eye muscle double vision Mononeuropathy multiplex Mononeuropathy, cont.
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Mononeuropathy, cont. Treatment Foot care Glucose control Pain control
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Other Treatment Options Aldose reductase inhibitors ACE inhibitors Weight control Exercise
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References American Diabetes Association: Preventive Foot Care in Diabetes (Position Statement). Diabetes Care 27 (Suppl.1): S63-S64, 2004 Feldman, EL: Classification of diabetic neuropathy. In UpToDate. Wellesley, MA, UpToDate, 2003 National Diabetes Information Clearinghouse. Diabetic Neuropathies: The Nerve Damage of Diabetes. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health (NIH), DHHS; 2002 National Diabetes Information Clearinghouse. Prevent Diabetes Problems: Keep Your Feet and Skin Healthy. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health (NIH), DHHS; 2003
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References, cont. Feldman, EL: Pathogenesis and prevention of diabetic polyneuropathy. In UpToDate. Wellesley, MA, UpToDate, 2003. Feldman, EL, McCulloch, DK: Treatment of diabetic neuropathy. In UpToDate. Wellesley, MA, UpToDate, 2003. Stevens, MJ: Diabetic autonomic neuropathy. In UpToDate. Wellesley, MA, UpToDate, 2003. Feldman, EL: Clinical manifestations and diagnosis of diabetic polyneuropathy. In UpToDate. Wellesley, MA, UpToDate, 2003.
on Apr 25, 2013 Says :
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