> Diabetes Facts > Strange Sensation: Could it be Diabetic Neuropathy?

Strange Sensation: Could it be Diabetic Neuropathy?

Numbness, shooting pains, weakness, tingling and burning sensation, are symptoms commonly presented by patients to us neurologists. Hearing these kinds of complaints, the first thing that comes to my mind is, “Is this patient suffering from neuropathy?”.

The word “neuropathy” may sound strange to our patients but it simply means “disease of the nerve“. The nerve is a basic structure of the nervous system that transmits signals “to and from” the brain and the spinal cord. So, it is like a relay system that enables our body to communicate to the outside world and at the same time pick up information from the environment. Depending on the severity, acuteness, chronicity, and type of nerve that is damaged, patients will experience varied kinds of symptoms.

The different nerve types
Our nerves are highly specialized with distinct structures and functions. There are three main types of nerves, namely: Motor nerves which control voluntary movements; Sensory nerves which carry sensation; and Autonomic nerves which carry information to different organs and glands.

Damage to a motor nerve will manifest as weakness. Voluntary movement is affected and can also lead to abnormal changes in the muscle, bone or even the skin. A sensory nerve involvement, on the other hand, may present as tingling sensation, numbness, burning sensation, loss of position sense causing incoordination, or pain. The autonomic nerve, being responsible for the regulation of involuntary muscle movement like the blood vessels, gastrointestinal tracts, glands, respiratory system and sex organs may manifest as dizziness, constipation, gastroparesis*, sexual dysfunction, blurred vision, reduce sweating, or fainting spells.

Neuropathy may manifest symptoms of any single type of nerve, or a combination of two or all three kinds of nerves. The cause may be varied: genetic/ familial, infection or inflammation, metabolic or systemic, exposure to poisonous substance, chemicals or drugs, cancer, direct compression or injury, ischemia (decrease or loss of blood supply), or idiopathic (unknown cause). These numerous causes indicate how vulnerable the nerve is, and practically anything can affect its viablility.

How diabetes causes nerve damage
Diabetes Mellitus is one metabolic disorder commonly associated with neuropathy. About 60 to 70 % of patients with diabetes can develop diabetic neuropathy at any time with the highest incidence within 10 to 25 years from the diagnosis of diabetes. Earlier onset may be expected from those with uncontrolled blood sugar level. Obesity, high blood fat and hypertension are also conditions commonly seen in patients with diabetic neuropathy.

No single cause has been identified yet to explain the problem of diabetic neuropathy. However, multiple factors may lead to nerve damage among patients with diabetes. Researchers are more inclined to believe that these factors maybe a combination of the following: Metabolic factors because of prolonged exposure of the nerve to high glucose level leading to chemical changes and impairment of the nerves’ ability to transmit signals; Neurovascular factors causing damage to the nerve because of lack of oxygen and nutrients tothe nerves; Autoimmune factors causing inflammation to the nerve; or mechanical factors. At this point, just like most neurological conditions, exact pathophysiologic cause for Diabetic neuropathy still remains elusive.

Signs and symptoms of diabetic nerve damage
Diabetic Neuropathy is classified according to how different parts of the body are affected. Peripheral Neuropathy is the most common type and as the word “peripheral” implies, it involves the distal portion of the body specifically the hands and feet. Thus, the term “glove and stocking” type of numbness or discomfort. It involves the hands, arms, feet, toes and legs. Depending on what type of nerve is affected, patients can manifest different symptoms in the above mentioned areas.

Proximal Neuropathy, on the other hand, affects the thighs, hips, buttocks and legs. It is sometimes referred to as diabetic “amyothrophy” and oftentimes manifests as pain involving one side of the body. Since it’s the more proximal muscle of the lower extremity that is involves, patients affected with this kind of complication would have difficulty standing from a sifting position. Older diabetic patients are affected more than the younger ones.

Another type of Diabetic Neuropathy affects only a single type of nerve and specific part of the body. This is called Focal neuropathy and it may involve the eyes causing double or blurred vision, the ears causing impaired hearing, weakness of one side of the face, pain on the chest which can mimic a heart attack, or even afocal abdominal pain which can be mistaken as appendicitis.

A more serious or even a life-threatening type of Diabetic Neuropathy is Diffuse Autonomic Neuropathy which was briefly discussed above (affecting different types of nerves). Patients with Autonomic Neuropathy may not be able to tolerate sudden changes in position (i.e., from lying to sifting or from sifting to standing because of the body’s inability to control drops in blood pressure. Patients may suddenly become dizzy or even faint. This condition is called “Orthostatic Hypotension”. As you can see, diabetic neuropathy can affect almost the whole body, from the eyes down to the toes. Even the internal regulation of some body functions may be affected.

Diagnosis of any neurologic illness always starts with a good history. There are a lot of factors to consider when dealing with neuropathy in general and diabetic neuropathy in particular. Thus, complete information revolving around the symptomatology of the patient is necessary. A thorough physical examination and neurologic examination focused on the muscle strength, reflexes, detailed sensory examination including position, vibration sense, temperature and light touch should not be missed. Complaints of Autonomic Dysfunction may need more specialized tests like a tilt table test which is usually conducted by a cardio-physiologist. EMG-NCV (electromyography/nerve conduction study) is one test often requested to determine objectively the presence of neuropathy and it also give us information as to the severity of the nerve damage and what type of nerve is affected.

Treatment of diabetic nerve damage
Treatment options for patients with diabetic neuropathy may be varied depending on the presenting symptoms. However, the first step should be to bring the blood glucose level to normal range. Decreased exposure of the nerve to high glucose may not bring back the nerve to its normal state but it may prevent further damage to the nerve. Simultaneously, control of hypertension, normalizing the fat level and aiming for an ideal weight should be done. Other lifestyle modification modalities like smoking cessation, regular exercise and a balanced healthy diet should be encouraged.

Different symptoms may be addressed individually. Numbness is a very common complaint. But, unfortunately there is no specific treatment for numbness. Other common symptoms are tingling/ burning sensation or increased sensitivity to touch, which, like numbness, may be hard to control. However, some patients may respond to anticonvulsants (gabapentin or carbamazepine) and tricyclic antidepressants.

They may be used singly or in combination. These are also the drugs of choice for painful diabetic peripheral neuropathy. A natural, non-systemic alternative is capsaicin which can be applied to affected areas and may help relieve the burning sensation. Capsaicin is a topical cream which is a component of pepper extract and may be effective in alleviating the burning sensation or the local pain caused by diabetic neuropathy. When applied, it may initially cause some irritation but the skin eventually adapts and becomes desensitized to the irritation and also to the burning sensation. This can be used in combination with other oral pain medications.

For patients with autonomic diabetic neuropathy, specific symptoms are treated with different modalities. Mild constipation may be treated by laxatives, suppositories or spacing of meals or a high fiber diet; urinary problems may be addressed by taking medicines that will improve bladder control; sweating problems may take the form of “not sweating a lot” or “sweating a lot” with use of moisturizers for the former or avoiding intense heat or humidity for the latter may be encouraged; a visit to your urologist for a prescription drug to improve sexual function may be necessary.

A more serious problem
that may arise from autonomic diabetic neuropathy is orthostatic hypotension. Compression stockings to improve circulation may be used for mild cases. However, for more severe and debilitating cases, regular intake of the low dose steroid, fludrocortisone, may be necessary. This medication is not locally available so most patients get it from relatives from the U.S. or other countries.

Generally, CURE for Diabetic Neuropathy is still elusive. Prevention of diabetes and control of the glucose level for those who are already diabetics are the only options by which one can minimize his or her chances of getting Diabetic Neuropathy.

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