Diabetic Peripheral Neuropathy

What is diabetic peripheral neuropathy?

Neuropathy refers to nerve damage that can cause a variety of symptoms, including pain and numbness. There are four main types of diabetic-related neuropathy, including:

• Peripheral neuropathy
• Autonomic neuropathy
• Radiculoplexus neuropathy
• Mononeuropathy

Diabetic peripheral neuropathy is a type of nerve pain that involves the peripheral nervous system (PNS). The PNS includes all of the nerves that come from your spinal cord and innervate the rest of your body. The central nervous system, on the other hand, is focused on your brain and spinal cord.

As with all types of neuropathy, people with diabetic peripheral neuropathy may not notice signs or symptoms of the condition until nerves are already damaged. Because of this, it’s important to keep a close eye on potential causes and early symptoms.

What causes diabetic peripheral neuropathy?

Peripheral neuropathy can be caused by many conditions including:

• Vitamin deficiencies
• Alcoholism
• Autoimmune diseases
• Certain medications
• Unknown causes
• Diabetes

One of the more common causes of peripheral neuropathy is poor blood sugar control related to diabetes. Excessive and fluctuating amounts of sugar in the blood injure the capillary walls (small blood vessels) that supply your nerves, especially in your hands and feet. This destruction can cause nerve damage that may manifest as pain, numbness, or tingling. These symptoms usually begin in the toes and move towards the head.

Do I have diabetic peripheral neuropathy?

When your peripheral nerves become damaged, they do not function properly and can eventually produce symptoms such as pain, tingling, or numbness.

Other diabetic peripheral neuropathy symptoms to look out for include:

• Cramps
• Hypersensitivity to touch
• Weakness in the extremities, particularly the legs and feet
• Poor reflexes
• Poor balance and coordination
• Increase in foot problems, such as infections or slow-healing wounds

In men with poorly controlled diabetes, erectile dysfunction is also common as these blood vessels are damaged, too.

Another complication from the nerve damage produced by diabetes is neuropathy involving the gastrointestinal system. Damage to these nerves can cause problems with nausea, vomiting, diarrhea, or constipation. Postural hypotension may also ensue due to a progression of your peripheral neuropathy.

All of these symptoms – including pain – are usually located in the lower extremities and are often worse at night.

Diagnosis

Diabetic peripheral neuropathy can be difficult to diagnose. A neurological and physical exam as well as a thorough medical history can help rule out the possibility of other conditions. Certain lab tests may be ordered by your physician in order to rule out other potential causes of peripheral neuropathy, such as a vitamin B12 deficiency.

Other tools for diagnosis include:

• Nerve conduction studies: Measures how quickly your nerves respond to electrical signals
• Electromyography (EMG): Measures discharge of electricity from muscles
• Filament test: Tests the sensitivity of your skin
• Quantitative sensory testing: Evaluates how your nerves respond to vibration and temperature changes

A proper early diagnosis is crucial, so if you have diabetes and are experiencing any of the symptoms above, talk to your doctor.

Diabetic peripheral neuropathy treatment approaches

Even more difficult than diagnosing diabetic peripheral neuropathy is treating it. There is no cure for this condition. The goal of treatment is to relieve your symptoms and slow or stop progression of nerve damage.

There are no quick fixes for diabetic peripheral neuropathy, so your physician may recommend several different approaches until you find which is most effective for you. Often, you’ll use a variety of treatments to manage your symptoms. Left untreated, diabetic peripheral neuropathy is a serious complication of diabetes that can even result in amputation of the affected limb.

These are the most common diabetic peripheral neuropathy treatment options:

1. Blood sugar control
2. Exercise
3. Foot care
4. Supplements
5. Biofeedback
6. Acupuncture
7. Over-the-counter pain relievers
8. Membrane-stabilizing medications
9. Other prescribed medications
10. Transcutaneous electrical nerve stimulation (TENS)
11. Spinal cord stimulation (SCS)

Blood sugar control

Most importantly, maintaining normal blood sugar levels is the first-line treatment and prevention for diabetic peripheral neuropathy. The main cause of peripheral neuropathy in people with diabetes is nerve damage caused by wildly fluctuating blood glucose levels. Controlling your blood sugar with insulin (if necessary) is crucial to prevent further damage.

In addition to diabetic peripheral neuropathy, diabetes is a severe risk factor for cardiovascular disease, kidney disease, and retinopathy (affecting the eyes), so strict blood sugar control is crucial for preventing these and other diabetes-related complications.

Foot care

While foot care is not necessarily a treatment for diabetic neuropathy, it can help diagnose the condition and monitor its progress.

Check your feel every day for cuts, blisters, swelling, and redness. Keeping feet clean and dry helps keep them healthy, as does applying a daily moisturizer and getting regular foot massages to increase circulation. Wear good-fitting shoes and clean socks, too.

Exercise

Exercise is also extremely important in patients with diabetes.

For patients with newly-diagnosed Type 2 diabetes, diet, exercise, and weight loss can help prevent further complications and may even help you avoid the need for further medication. For patients with Type 1 diabetes who still require medication to manage their diabetes, regular exercise uses excess blood sugar for energy and also increases the body’s sensitivity to insulin.

Exercise also helps you maintain a better overall level of physical and mental health.

Nutritional and vitamin supplements

Certain nutritional supplements may help treat and prevent diabetic peripheral neuropathy. The more well-researched options include:

• Alpha-lipoic acid
• Acetyl-L-carnitine
• Benfotiamine
• Methylcobalamin
• Topical capsaicin

Other potential nutritional supplements include vitamin E, glutathione, folate, pyridoxine, biotin, omega-3 and -6 fatty acids, L-arginine, L-glutamine, taurine, N-acetylcysteine, zinc, magnesium, chromium, and St. John’s wort.

Always talk to your doctor before taking any new supplements to ensure that they’ll be helpful in your case and won’t interact with any of your current medications.

Biofeedback

Studies on the psychological assessment and treatment of neuropathic pain conditions, including diabetic peripheral neuropathy, showed that cognitive-behavioral interventions could improve the quality of life in these patients. One example of this is biofeedback.

Biofeedback is a non-invasive way to refocus on the body’s stress response. This can be helpful for patients with diabetes as they can recognize complications or symptoms of peripheral diabetic neuropathy.

Acupuncture

Acupuncture is a treatment that may help reduce pain in patients with diabetic peripheral neuropathy.

One study in 2010 found that two weeks of acupuncture completely relieved the pain and numbness of this condition. Another study involving acupuncture in the treatment of diabetic peripheral neuropathy found that 77% of patients had significant improvement in their symptoms, with 21% noting that their symptoms cleared completely. The study concluded that acupuncture is a safe and effective therapy for the long-term management of painful diabetic neuropathy.

With an increase in the diagnosis of Type 2 diabetes, researchers continue to study acupuncture as a safe, effective, and non-invasive treatment for the pain and numbness of diabetic peripheral neuropathy.

Over-the-counter pain relievers

Pain relievers, such as non-steroidal anti-inflammatory drugs (NSAIDs), may offer some pain relief.

Since there is a concern about overuse and dependence, along with other side effects, it’s best to take these under your doctor’s supervision and primarily for acute pain episodes.

Membrane-stabilizing medications

Membrane-stabilizing medications calm irritated nerves but can have a high rate of side effects that may limit their use. Because of this, these medications are best used in conjunction with other non-invasive treatment approaches and always under the supervision of your doctor.

Some of the medications that are particularly effective at treating nerve pain include Cymbalta, Elavil, Tramadol, and Neurontin. Note that these medications may relieve pain, but do not help to prevent the progression of the disease.

Other prescribed medications

Some patients also find symptom relief with anti-seizure drugs (e.g. pregabalin and gabapentin), while others find that antidepressants help by disrupting their brain chemistry. Both types of medications can come with significant side effects, so it’s important to talk to your doctor and ask about potential drug interactions.

Opioids are typically not the drug of choice when treating nerve pain and have not demonstrated effective relief of symptoms.

Transcutaneous electrical nerve stimulation (TENS)

Transcutaneous electrical nerve stimulation (TENS) uses a weak electrical current delivered to the spinal nerves to disrupt pain signals. Pain is replaced with a mild tingling sensation instead.

Since this is a non-invasive treatment approach, it can be used alongside medications or other interventions.

Spinal cord stimulation (SCS)

At Arizona Pain, we have successfully treated patients with painful diabetic peripheral neuropathy using spinal cord stimulation (SCS).

With this treatment, leads are implanted next to the nerve roots in the spine and deliver a mild electrical current that disrupts pain signals. Think of it like a pacemaker for pain management. It can be a very effective long-term treatment for diabetic peripheral neuropathy (and other difficult-to-treat pain syndromes).

References

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2. Ahn AC, Bennani T, Freeman R, Hamdy O, Kaptchuk TJ. Two styles of acupuncture for treating painful diabetic neuropathy–a pilot randomized
   control trial Acupunct Med. 2007 Jun;25(1-2):11-7.
3. Abuaisha BB, Costanzi JB, Boulton AJ. Acupuncture for the treatment of chronic painful peripheral diabetic neuropathy: a long-term study.
   Diabetes Res Clin Pract. 1998 Feb;39(2):115-21
4. Haythornthwaite JA, Benrud-Larson LM. Psychological assessment and treatment of patients with neuropathic pain. Curr Pain Headache Rep. 2001 Apr;5(2):124-9.
5. Head KA Peripheral neuropathy: pathogenic mechanisms and alternative therapies. Altern Med Rev. 2006 Dec;11(4):294-329