Neuropathy in a diabetic

Neuropathy or involvement of nerves is the commonest complication of diabetes. The nervous system is a common target organ normally damaged by diabetes. In spite of good diabetic control, neuropathy does occur in majority of cases. Only the intensity of symptoms would vary with the diabetic control, meaning that if one has glucose well controlled within normal limits, symptoms may be less severe; with poor control, more, but they are bound to develop after long standing diabetes. Neuropathy can affect all types of nerves in the body. At times more than one kind of nerve may be involved thus compounding the problem. Involvement of the peripheral nerves (nerves which carry sensations from the body to the brain) is the most common manifestation of long standing diabetes. There may be tingling, numbness, burning sensation, diminished sensations, sense of insects crawling mostly in the hands and feet. This sensory abnormality is called “glove and stocking” because of its typical distribution. Initially these sensory abnormalities may be mild and intermittent. But with time they may progress to become worse. The person may suffer from burning sensation in the feet which may worsen while sleeping. Result of this peripheral neuropathy is loss of efficient functioning of the hands and feet. It is also one of the reasons for “diabetic foot”, another well known complication of diabetes. In this condition, because of reduced sensation and blood supply, a person develops resistant, bad wounds and ulcers in the feet. If unchecked this can also lead to gangrene, necessitating amputation of the foot. Muscle pains are common which are often masked by other more severe symptoms. Associated affection of the motor nerves (nerves which are concerned with execution of movements) can lead to wasting and paralysis of hands and feet. Reflexes and coordination of the hands and feet are lost thus leading to further loss of efficiency of hands and feet. Affection of the thigh muscles causes difficulty in climbing stairs and uphill. Deformities of joints may also develop in chronic cases of diabetic peripheral neuropathy. Smoking and alcoholism can aggravate this problem further. Autonomic nervous system (system which is not under voluntary control and regulates basic body functions) when involved, causes a series of problems for the diabetic patient. Change in the bowel habit in the form of onset of constipation or diarrhoea becomes troublesome for the patient. Another problem that can commence is postural hypotension. With change in posture, mostly standing up from a sitting or lying position, the blood pressure falls down. The person thus feels giddy while standing or walking. Excess sweating or nocturnal sweating is yet another distressful symptom and may lead the patient to be investigated unnecessarily for possible infectious diseases. An important consequence of diabetic autonomic neuropathy is “silent heart attack”. Because of blunting of sensations and diminished response to sympathetic activity a person may develop a “heart attack” without the warning tell-tale symptom of chest pain. As a result there is delay in diagnosis of the myocardial infarction, causing high prevalence of sudden cardiac arrest and other complications of infarction. This risk is enhanced by the hyperlipidemia (increased levels of fats or lipids in blood) occurring in diabetics. Diabetic autonomic neuropathy is one of the most common causes for sexual impotence in men which is very distressing for the sufferer. There may also be urinary retention and or incontinence in an individual. In elderly men diabetic autonomic neuropathy along with enlargement of prostate gland multiplies the discomfort manifold. Resulting urinary retention, incontinence, repeated urinary tract infections not only make life very uncomfortable for the sufferer but also pose a risk for developing renal failure. A diabetic is already prone to develop kidney failure as kidney is also one of the organs damaged by long standing diabetes. Infections due to autonomic neuropathy hasten this process. Cranial nerves may be involved indirectly in diabetic patients because of the increased susceptibility to stroke which is the fall out of both hyperlipidemia and hyperglycemia. Sudden blindness may occur due to damage to optic nerve which is responsible for vision. Neuropathy is postulated to occur in diabetics because of reduced blood supply to the nerve. Many factors may be involved but the exact cause cannot be pin pointed. Many times diabetes itself is diagnosed when the person presents with signs of neuropathy. Nerve conduction studies and electromyography can be done to confirm and asses the damage to nerves and muscles. In the early stages of neuropathy, tight diabetic control may help in preventing the progression of neuropathy and minimizing the symptoms. Although many drugs have been tried for neuropathy, none has proved very successful. In severe neuropathy, use of anticonvulsants like carbamazepine and gaba pentin is of some help. Antidepressants are also useful in relieving the symptoms to some extent. Antidepressants and anti-inflammatory drugs help marginally to relieve the troublesome pain of, “burning feet syndrome”. Pyridoxine (Vitamin B6) along with other nutritional supplements is also used for this condition and provides relief. Pain killers and anti-inflammatory drugs are used for muscle pains. Regular exercises and physiotherapy can keep the neuromuscular pains to minimum but total amelioration is not possible. Physiotherapy can also help a person having difficulty in working or walking due to diabetic neuropathy. Wherever possible, surgery can be carried out in persons having joint deformities because of diabetic neuropathy. Special care is needed to prevent the, “diabetic foot”. A diabetic is taught to keep his feet as clean and dry as his face. He should never remain without shoes because walking bare footed will expose him to injuries. He needs to be very careful while cutting toe nails to avoid any trauma even minimal. Injuries and ulcers in the feet howsoever small should be given due attention. Elastic stockings should be used while standing for long or walking, to avoid postural hypotension. They improve venous return to the heart by compressing lower limb veins thus improving venous return to the heart and increasing the blood pressure. If one sits with legs spread in front or lies with legs slightly elevated, low blood pressure improves. Constipation and diarrhoea can be controlled by slight alterations in diet. Drinking lots of water and a high fiber diet is very helpful. Medicines can be taken for short term relief. But these problems are life long and taking medicines for all that time will invariably produce side effects and hence should be avoided. The patient suffering from urinary retention can be trained to empty his bladder periodically by applying suprapubic pressure. Hot compressions applied suprapubically over the bladder also help in emptying the bladder. Similarly one having urinary incontinence needs to be trained like a toddler to go to the toilette at fixed intervals. Thus he would not have to face the embarrassing situation of passing urine involuntarily. Drinking plenty of water is also helpful to prevent or minimize recurrent urinary tract infections. Antibiotics may be needed to treat urinary tract infections as and when they arise because apart from the neuropathy, diabetics are more prone to infections of urinary tract. Counseling is needed for the person suffering from erectile dysfunction. Vacuum devices, penile implants are treatment modalities available. But they are expensive and not readily available. Drugs like slidenafil citrate may boost the sexual function slightly but they are unsafe because of the risk of adverse effects especially sudden cardiac arrest. There is no reason why a diabetic having neuropathy cannot lead a normal life. With good control of diabetes by means of a diabetic diet, exercise and medication the neuropathy can be retarded or kept to minimum. If still some problem occurs it should be accepted boldly as being part of the life. Contact: rachna212002@yahoo.co.uk