The average person walks about 115,000 miles in a lifetime: more than four trips around the globe. So diabetic neuropathy, the nerve damage that affects the legs and feet of 60 to 70 percent of all diabetics, can be a debilitating problem.
Diabetes results when the body is unable to take up glucose, either because of a lack of insulin in the body, or a resistance to it. Insulin helps cells absorb glucose from the bloodstream, so insulin issues cause sugar to remain in the body, thereby causing glucose levels rise. Prolonged levels of high blood sugar can cause a variety of health problems.
Diabetic neuropathy is damage to the body’s delicate nerve fibers that results from high blood sugar. Symptoms can range from tingling and numbness to debilitating pain. And because diabetic neuropathy develops over time, symptoms may not arise until the damage to the nerves is significant.
Although diabetic neuropathy can develop at any time, the risk rises with age and duration of diabetes. In fact, patients who have had diabetes for 25 years or more demonstrate the highest occurrence of diabetic neuropathy. Likewise, those who struggle to control their blood sugar, those with high levels of blood fat, and those with high blood pressure face the highest risk. Additionally, diabetic neuropathy can occur in both type 1 and type 2 diabetes.1
The danger of diabetic neuropathy is real because damaged nerve fibers often send messages to the body too slowly, or at the wrong times, and sometimes fail to send messages at all. This can result in a failure to detect problems in the body, or constant sensation in the body. And though diabetic neuropathy usually occurs in the legs and feet, it can impact every nerve system in the body, including the heart, sex organs, and digestive tract.
Researchers are constantly studying the prolonged effects of high blood sugar on the body’s nerve system, but the reality is that neuropathy is likely caused by a combination of factors:
- high blood glucose, high blood fat levels, and low insulin levels
- long duration of diabetes
- injury to nerves (carpal tunnel syndrome, for example)
- smoking or alcohol use
The other reality is that the causes of diabetic neuropathy are likely different for each of the four types.
Four types of neuropathy
Peripheral neuropathy is nerve damage that results when nerve cells are damaged or destroyed, distorting the way the nerves communicate with the brain and with each other. It generally affects the arms and legs, though damage typically occurs in the legs and feet before it occurs in the arms and hands. The symptoms often begin as numbness, tingling or prickling in the fingers and toes and are typically worse at night. Pain is usually felt equally on both sides of the body and it may cause burning, freezing or throbbing sensations. Symptoms of peripheral neuropathy often develop slowly and may include:
- Extreme sensitivity to touch
- Pain that feels like freezing or burning
- Sharp, shooting or jabbing pain
- A sensation of wearing a glove or a sock
- Muscle twitching or cramping
- Muscle weakness
- Loss of balance
- Pulse abnormalities
Patients often report weakness or an inability to hold something, not knowing where their feet are and a burning or stabbing pain in the limbs and the symptoms generally depend on which kind of peripheral nerves have been damaged.
Peripheral neuropathy can cause muscle weakness and loss of reflexes and can cause changes to the way the patient walks. Foot deformities like hammertoes and collapsed arches can occur, and injuries to the foot can go unnoticed because of numbness. It is vitally important that diabetics check their feet daily because untreated blisters and sores can cause an infection that spreads to the bone, sometimes leading to amputation.
Autonomic neuropathy impacts the nerves that control the body systems, and those functions of the body that we don’t consciously think about: heart, blood pressure, and blood glucose. It also affects many of the internal organs, resulting in dysfunction with digestion, respiration, sexual response, urination, and vision. Because autonomic neuropathy affects the body’s ability to control blood glucose levels, it can result in the body’s inability to return glucose levels to normal after a hypoglycemic episode in which glucose levels drop below normal levels. Symptoms of autonomic neuropathy include:
- Indigestion or heartburn
- Nausea or vomiting
- Diarrhea or constipation
- Loss of bowel control
- Frequent bladder infections
- Erectile dysfunction or vaginal dryness
- Unexplained fainting
- Rapid heartbeat
- Abnormal sweating (sweating while eating or inability to sweat)
- Weight loss
Autonomic neuropathy interferes with the body’s ability to regulate common daily activities because nerve damage prevents the body from communicating effectively. As a result, patients report losing the ability to control everyday bodily functions such as food digestion and emptying of the bladder. And because autonomic neuropathy can cause fainting, it can result in a loss of independence for patients because daily activities such as driving, showering, and caring for children can be unsafe.
Proximal neuropathy generally begins as pain in the hips, thighs, legs or buttocks, and usually occurs on one side of the body. It is most common in patients with type 2 diabetes and older adults. Proximal neuropathy causes weakness and pain in the legs and often results in patients requiring help to move from a sitting to a standing position. Often called “muscle wasting,” it is the second most common type of neuropathy in diabetics. Symptoms of proximal neuropathy include:
- Relentless burning or jabbing pain in the affected area
- Inability to walk
- Difficulty sleeping due to pain
- Muscle atrophy and loss of muscle coordination
- Weight loss
- Loss of appetite
Pain associated with proximal neuropathy often presents suddenly and is very intense. Typically, these episodes last for a few weeks, usually no longer than three months, and then pain dissipates.
Focal neuropathy begins suddenly and affects specific nerves, specifically those in the head, legs and torso. It is unpredictable and it occurs most frequently in older diabetics. Focal neuropathy is painful, but it generally improves on its own over the course of six to eight weeks, and it doesn’t cause any long-term damage. Symptoms of focal neuropathy include:
- Inability to focus eyes
- Aching behind the eye
- Double vision
- Facial paralysis on one side called Bell’s Palsy
- Severe lower back or pelvic pain
- Pain the in the shin or inside of the foot
- Pain in the chest, side or stomach
- Pain in the front of the thigh
- Chest or abdominal pain that mimics heart disease, heart attack or appendicitis
Focal neuropathy is far less common than peripheral neuropathy or autonomic neuropathy, but it can be instigated by pressure points such as sitting with one leg crossed over the other knee or leaning the elbows on a hard surface.2
Doctors must first have a complete medical history and a thorough physical exam before diagnosing diabetic neuropathy, and patient feedback can help the doctor determine which groups of nerves are involved. While most patients suffer from polyneuropathy, damage to many nerves at the same time, many patients have damage to only one or two types of nerves found in the human body. 3
Three types of nerves
Motor nerves are responsible for sending messages from the brain to all the body’s muscles and are responsible for our ability to walk, pick things up and throw a ball. Damage to motor nerves often causes difficulty walking or moving limbs, muscle weakness or muscle cramps and spasms.
Sensory nerves send messages in the opposite direction, from the muscles back to the brain and help people sense whether an object is smooth or rough; sharp or dull; hot or cold; still or moving. Damage to these nerves often causes the tingling, numbness, pain and sensitivity to touch reported by patients.
Autonomic nerves control those parts of the body that are involuntary or semi-voluntary, like heart rate, digestion, sweating and blood pressure. Patients may report an irregular heartbeat, dizziness while standing, excessive sweating or inability to sweat, difficulty swallowing, diarrhea or constipation, nausea, vomiting, difficulty urinating, unusual pupil size or sexual dysfunction.4
Nerve specialists can employ a series of tests to determine the location and degree of a patient’s nerve damage. Nerve conduction studies apply brief pulses of electricity to different parts of the body, typically arms and legs, to measure the time required for the nerve to stimulate the appropriate muscles to twitch. The nerve conduction velocity measures whether the nerve is sufficiently controlling the muscles. Similarly, electromyograms measure the muscle’s response to electrical activity through a thin needle electrode inserted through the skin.
Neuropathy and the foot
More than 60 percent of non-traumatic lower-limb amputations in the U.S. occur in people with diabetes, according to the National Institute of Diabetes and Digestive and Kidney Diseases. In 2004, about 71,000 amputations resulted from diabetes.5
Because the nerves that lead to the feet are the longest in the body and are the most susceptible to nerve damage, experts recommend regular, comprehensive exams of the feet. Loss of sensation in the feet means that small, minor cuts or blisters can go undetected, leading to infection. Diabetes can also restrict the blood flow to the feet, which can slow healing of a sore or infection. As a result, infections that never heal can lead to gangrene or the death of body tissue. Gangrene can lead to amputation of a toe, foot or part of the leg. Sometimes, in fact, surgeons must perform amputations to prevent the infection from spreading to the remainder of the body, where it could be fatal.
Alternatively, sometimes diabetic neuropathy can change the shape of the foot, in the case of Charcot’s foot. A condition which can cause the bottom of the foot to be shaped like a rocker, Charcot’s foot begins with redness, swelling, and warmth. Eventually, the bones in the feet and toes can break, causing the foot to become deformed.
Prevention, then, is key to protecting the feet, and foot care programs can reduce amputation rates by 45 to 85 percent, according to the NIDDK. Doctors recommend checking feet daily to identify problems early. Look for:
- Swelling or blisters
- Ingrown toenails
- Plantar warts,
- Corns or calluses
- Warm spots
- Athlete’s foot
- Cuts, sores or redness
Doctors recommend washing the feet daily in warm water, but warn that soaking the feet will remove too much moisture from the skin. They also prescribe checking the feet each evening to identify trouble spots before they worsen. Remember to check between toes, and use a mirror or ask for help if you are unable to fully see the whole foot. Use talcum powder on the feet to keep the skin dry, and avoiding putting lotion between the toes where skin tends to stay moist.6
Shoes and socks should be worn at all times to protect the feet from injury which could go undetected. Furthermore, check the inside of shoes before putting them on to ensure that there are no foreign objects inside which could cause damage, and choose socks with light padding and no seams.
Shoes should fit well and allow the feet to breathe. (Avoid vinyl and plastic shoes.) Buy shoes that have enough room for your toes, and shop at the end of the day when feet are the largest. Avoid shoes with high heels or pointed toes, because they put too much pressure on the toes. Wear new shoes for a few hours at a time when breaking them in.
Feet should be protected from hot and cold temperatures. Realize, too, that nerve damage to the feet can allow you to injure your feet without realizing it.
- Wear shoes at the beach and on pavement
- Keep feet away from open fires and heaters.
- Do not use a heating pad or hot water bottle on feet.
- Use sunscreen on feet to prevent sunburn.
- Wear waterproof boots in wet weather to keep feet dry.
- Wear socks to bed to prevent cold feet.
Finally, you can prevent problems by encouraging blood flow to the feet. Elevate the feet when you are sitting, and wiggle your toes throughout the day to keep blood flowing. Move your ankles periodically as well. Do not wear elastic stockings or tight socks. Move your body, but choose activities that are gentle to the feet like swimming, walking, bike riding or yoga. And because smoking can restrict blood flow to the feet, quitting smoking reduces the risk of foot problems related to diabetic neuropathy.7
Neuropathy and the mouth
Since the salivary glands are controlled by the autonomic system, diabetic neuropathy can cause changes to salivary secretion, resulting in dry mouth. Dry oral surfaces are more easily irritated and can result in “burning mouth” syndrome. Dry surfaces also encourage fungal growth, increasing the risk of thrush for diabetic patients. Gum disease also affects diabetics at a rate of about 1 in 3 patients over the life of their disease. Studies suggest, too, that diabetic patient who suffers from oral infection may experience a worsening of glucose control over time. 8
The American Diabetes reports findings that habitual exercise or physical activity are associated with improved glycemic control and lower mortality rates. Physically activity may delay or prevent the development of diabetic neuropathy and many other resulting problems by increasing circulation in the body. Move your feet, even when you’re not walking, to increase blood flow.
Because aerobic exercise can moderate glucose and improve circulation, the surgeon general’s recommendation of 30 minutes of aerobic activity each day is ideal, although some patients choose fewer, longer sessions. Studies show that increased glucose control lasts 24-72 hours beyond the activity, so doctors recommend that patients should not go more than 2 consecutive days without physical activity. Interestingly, too, studies have found that glucose control may last beyond 72 hours with resistance training because the increase in muscle mass changes the body’s requirements.
The ADA reports finding that diet-induced weight loss and increased physical activity are effective together at improving patient glucose levels. Furthermore, research indicates that either change can positively impact diabetic patients. But the most successful programs are those that combine diet, exercise and behavior modification because individual changes tend to produce modest results. Obese people, for example, may have difficulty performing enough exercise to raise the heart rate and create the required energy deficit to produce benefits. Similarly, patients who only exercise may counteract any benefits by eating more or becoming more sedentary outside of exercise sessions.9
Because there is a shortage research on the risks of exercise for diabetic patients who suffer from neuropathies, patients should consult a physician before beginning a new exercise program to prevent injury or complications. Doctors may recommend non-load bearing activities such as swimming or bicycling for patients suffering from certain neuropathies.
Detecting nerve damage
Because nerve damage related to diabetic neuropathy develops so slowly, patients should have their feet checked at each doctor visit, at least four times a year. Removing the shoes and socks each time you visit will remind your provider to check your feet. Providers should test the patient’s ability to sense temperature, vibration, pinprick and position of the feet at least annually.
Things to remember
- Diabetic neuropathies occur in patients with both type 1 and type 2 diabetes.
- Good blood glucose levels may prevent or delay the onset of diabetic neuropathy.
- High blood pressure and high cholesterol increase the risks of developing neuropathy.
- Alcohol use, smoking and being overweight may also contribute to diabetic neuropathy.
- Foot care is vital for patients with diabetic neuropathy. Daily foot inspection prevents undetected injuries, which can cause infection and lead to amputation.
Diabetes around the world
The World Health Organization reports that the number of people with diabetes in 2014 had risen to 422 million worldwide, with the prevalence of diabetes rising rapidly in low-income and middle-income countries. In fact, the prevalence of diabetes has doubled since 1980. The WHO projects that, by the year 2030, diabetes will be the 7th leading cause of death in the world.
The International Diabetes Federation reports that 5 million people died from diabetes in 2015; one person every six seconds. The IDF further reports that 1 in 2 people are undiagnosed, and the average time between the onset of the disease and its diagnosis is seven years. About 86 million people are living with prediabetes, a condition that increases the risk of developing type 2 diabetes and other chronic diseases.
The ADA estimates that in 2012, the cost of diabetes in the United States was $245 billion in medical costs, disability, lost work and premature death.10 The average diabetic spends 2.3 times more on their health than those without the disease. That calculates to $13,700 per person, $7,900 of which is directly related to the treatment of diabetes. Additionally, a diagnosis of diabetes can lead to natural emotions like anger, stress, and denial, and it is important that patients address these emotions so that they don’t become barriers to effective self-care.
Diabetes is a growing health problem and has reached epidemic proportions. Although type 1 diabetes cannot be prevented, type 2 diabetes is largely influenced by urbanization, and access to processed foods that are high in fat, refined carbohydrates and sugar. At the same time, sedentary lifestyles are also contributing to the growth of diabetes worldwide. Type 2 diabetes is often preventable by maintaining a healthy weight, exercising, and developing healthy food behaviors. The IDF recommends the following dietary guidelines for the general population:
- Drink water, tea or coffee instead of soda, fruit juice or other sweetened drinks.
- Eat up to three servings of fresh fruit daily.
- Eat at least three servings of vegetables daily, including green leafy vegetables.
- Limit alcohol intake to no more than two standard drinks per day
- Choose lean, white meat, poultry or seafood instead of red meat or processed meat.
- Chose whole-grain bread rice or pasta instead of the white varieties.
- Choose unsaturated fats (canola, corn, olive and sunflower oils) instead of saturated fats (ghee, butter, coconut or palm oils)
- Limit daily sugar intake.
We hope that this is able to give you and your loved ones a better understanding of the different types of neuropathy. For a more detail understanding about neuropathy, feel free to contact your doctor or a medical professional.
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