Diabetic Peripheral Neuropathy

Diabetic peripheral neuropathy is a progressive nerve disorder that occurs due to the damaging effects of chronically elevated blood sugar levels on the nerves. The exact mechanisms by which high blood sugar damages the nerves are not fully understood, but it is believed to involve a combination of metabolic, vascular, and autoimmune factors.

High glucose levels can lead to metabolic changes, inflammation, and reduced blood flow to the nerves, causing them to become damaged or dysfunctional. Over time, this nerve damage can lead to a range of symptoms and complications.

The symptoms of DPN can vary from person to person, depending on the type and extent of nerve damage. Common symptoms include:

• Tingling or numbness in the feet and legs
• Burning or shooting pain
• Sensitivity to touch
• Muscle weakness or loss of coordination
• Loss of reflexes
• Foot deformities
• Ulcers or sores that are slow to heal
• Increased susceptibility to infection
• Changes in skin, such as dryness or discoloration

DPN increases the risk of foot ulcers and amputation. Due to nerve damage in their feet and toes, people with diabetes who have DPN often do not notice minor cuts, sores, or blisters in these areas. If left untreated, these small wounds can easily become infected, lead to gangrene, and may eventually require amputation of the affected area.

The prevalence of diabetic peripheral neuropathy (DPN) is relatively high among individuals with diabetes. According to studies, it is estimated that approximately 50% of people with diabetes will develop some form of neuropathy during their lifetime, and DPN is the most common type.

The prevalence rates vary depending on the duration of diabetes, age, and overall glycemic control. Among individuals with type 1 diabetes, the prevalence of DPN ranges from 20% to 34%. In type 2 diabetes, the rates are higher, with estimates ranging from 30% to 50%.

The risk of developing DPN also increases with the duration of diabetes. It is worth noting that these prevalence rates may vary across different populations and studies. Additionally, as diabetes rates continue to rise globally, the prevalence of DPN is expected to increase as well. Early detection, regular screenings, and appropriate management are crucial for reducing the burden of DPN among individuals with diabetes (Owolabi et al., 2022).

Several factors contribute to the development of DPN and the interplay between these factors varies among individuals.

• Hyperglycemia: Persistently elevated blood glucose levels can lead to metabolic imbalances within the nerves, disrupting their normal functioning and causing damage over time. The exact mechanisms by which high glucose levels induce nerve damage include increased oxidative stress, altered nerve metabolism, and impaired nerve cell signaling.
• Microvascular damage: Diabetes-related vascular changes can result in the narrowing and damage of the small blood vessels that supply the nerves. Reduced blood flow to the nerves deprives them of essential nutrients and oxygen, leading to nerve damage and dysfunction.
• Inflammation: Chronic inflammation plays a significant role in the development and progression of DPN. Diabetes can trigger an inflammatory response within the nerves, leading to the release of inflammatory mediators that contribute to nerve damage.
• Genetic factors: Some individuals may have a genetic predisposition to developing DPN. Certain genetic variations are associated with an increased susceptibility to nerve damage in the presence of high blood sugar levels.
• Lifestyle factors: Factors such as smoking, excessive alcohol consumption, and obesity can exacerbate the risk of developing DPN. These factors can further contribute to inflammation, impaired blood flow, and overall nerve damage.

DPN is primarily caused by long-term uncontrolled diabetes, but several factors contribute to its development which include:

• Duration of diabetes: The longer an individual has diabetes, the higher their risk of developing DPN. Nerve damage tends to occur gradually over time, and the risk increases with prolonged exposure to high blood sugar levels.

• Poor glycemic control: Inadequate management of blood glucose levels is a significant risk factor for DPN. Chronic hyperglycemia (high blood sugar) can contribute to nerve damage and increase the likelihood of developing neuropathy.

• Age: The risk of developing DPN tends to increase with age. Older individuals with diabetes have a higher likelihood of experiencing nerve damage compared to younger individuals.

• Type of diabetes: Both type 1 and type 2 diabetes carry a risk of developing DPN. However, individuals with type 2 diabetes, especially those with poor glycemic control, are more prone to developing neuropathy.

• Other medical conditions: Certain coexisting medical conditions can increase the risk of DPN. These include hypertension, dyslipidemia (abnormal lipid levels), obesity, and kidney disease. These conditions may contribute to nerve damage independently or in combination with diabetes.

• Smoking: Smoking is a modifiable risk factor that can significantly increase the risk of DPN. Smoking exacerbates nerve damage and interferes with blood flow, further compromising the health of the peripheral nerves.

• Alcohol abuse: Excessive alcohol consumption can damage nerves and increase the risk of developing DPN, especially in individuals with diabetes.

• Genetic predisposition: Some individuals may have a genetic susceptibility to developing DPN. Certain genetic variations may influence how the nerves respond to high blood sugar levels and contribute to the development of neuropathy.

Diagnosing DPN involves a comprehensive evaluation of a patient’s medical history, physical examination, and various tests. The healthcare provider may assess symptoms, perform a neurological examination, check reflexes, and evaluate the patient’s ability to sense light touch, temperature, and vibration.

Additionally, tests such as nerve conduction studies, electromyography, and blood tests may be conducted to confirm the diagnosis and rule out other causes of neuropathy.

1. Medical history and physical examination: The healthcare provider will first conduct a detailed medical history interview, focusing on symptoms such as pain, numbness, tingling, or weakness in the extremities. They will also inquire about the duration and progression of symptoms. A physical examination will be performed to assess sensory perception, reflexes, muscle strength, and overall nerve function.

2. Neurological examination: A neurological examination helps evaluate the extent and distribution of nerve damage. The healthcare provider may use various tools, such as monofilaments (to test for loss of protective sensation), tuning forks (to assess vibration sense), and reflex hammers (to check reflexes).

3. Nerve conduction studies (NCS): NCS is a common diagnostic test for DPN. It involves placing electrodes on the skin to measure the speed and strength of electrical impulses as they travel along the nerves. NCS can determine the extent of nerve damage, identify the specific nerves affected, and differentiate between different types of neuropathy.

4. Electromyography (EMG): EMG measures the electrical activity of muscles and can help assess muscle function and detect any abnormalities caused by nerve damage.

5. Quantitative sensory testing (QST): QST evaluates sensory perception and measures the thresholds for sensations such as touch, temperature, and vibration. It can provide additional information about the extent and type of nerve damage.

6. Autonomic testing: Autonomic nerve function can be assessed using various tests, including heart rate variability (HRV), tilt table testing, and sudomotor function testing. These tests evaluate the integrity of the autonomic nervous system, which controls involuntary functions like heart rate, blood pressure, and sweating.

7. Blood tests: Blood tests may be ordered to evaluate blood sugar levels, kidney function, lipid profile, and other factors that can contribute to nerve damage.

The treatment of diabetic peripheral neuropathy (DPN) aims to alleviate symptoms, slow down the progression of nerve damage, and improve overall quality of life. The treatment approach may involve a combination of lifestyle modifications, medications, and therapies (Lin et al., 2021).

• Glycemic control: Maintaining good blood sugar control is crucial in managing DPN. This involves adhering to a diabetes management plan, which may include dietary changes, regular physical activity, and appropriate use of diabetes medications or insulin. Tight glycemic control can help slow down the progression of nerve damage and reduce symptoms.
• Medications: Medications such as over-the-counter pain relievers (e.g., acetaminophen) or prescription drugs (e.g., tramadol, opioids, or certain antidepressants) may be prescribed to manage pain associated with DPN. Topical creams or patches containing capsaicin provide localized pain relief.
• Physical therapy and occupational therapy: Physical therapy can help improve strength, balance, and coordination, reducing the risk of falls and enhancing mobility. Occupational therapy can assist in managing daily activities and adapting to functional limitations caused by DPN.
• Transcutaneous electrical nerve stimulation (TENS): TENS involves the use of a small device that delivers low-voltage electrical currents to the affected area. It can help alleviate pain and improve sensory perception.
• Lidocaine Infusions: It is a local anesthetic that can be administered intravenously in the form of infusions to manage pain associated with diabetic peripheral neuropathy. It acts by blocking the transmission of pain signals in damaged nerves. Lidocaine infusions have been shown to provide significant pain relief in some individuals with DPN. The treatment is typically delivered over several hours in a controlled medical setting.
• Ketamine Infusions: Ketamine, primarily known as an anesthetic agent, has also demonstrated potential in managing neuropathic pain. Ketamine infusions work by modulating the activity of certain receptors in the brain and spinal cord, which helps reduce pain signals. Research has shown that ketamine infusions can provide substantial pain relief and improve the quality of life in some patients with DPN. Similar to lidocaine infusions, ketamine infusions are administered under medical supervision and require careful monitoring due to potential side effects.
• Botox Injections: Botulinum toxin type A, commonly known as Botox, is a neurotoxin that can be injected locally to alleviate pain associated with diabetic peripheral neuropathy. While Botox is most well-known for its cosmetic use, it has also shown promise in managing chronic pain conditions, including neuropathic pain. Botox injections inhibit the release of certain chemicals involved in pain signaling. Botox injections may provide relief for localized neuropathic pain and muscle spasms, particularly in cases where other treatments have been ineffective

At our clinic, we offer the following interventions for diabetic peripheral neuropathy:

• Lidocaine infusions
• Ketamine infusions
• Botox injections
• Kinesiology education sessions

Preventing the development or progression of diabetic peripheral neuropathy (DPN) involves effectively managing diabetes and maintaining overall health. Key preventive measures include:

• Glycemic control: Maintaining target blood sugar levels through proper diabetes management, including regular monitoring, medication adherence, and lifestyle modifications.
• Healthy lifestyle: Adopting a balanced diet, engaging in regular physical activity, maintaining a healthy weight, and avoiding smoking and excessive alcohol consumption.
• Regular check-ups: Undergoing routine medical check-ups, including foot examinations, to detect early signs of neuropathy and address any underlying health issues promptly.
• Foot care: Practicing good foot hygiene, inspecting feet regularly for wounds or injuries, wearing proper footwear, and seeking prompt treatment for any foot problems.