Diabetic neuropathy file:///D:/html/neuropathy.

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Diabetic neuropathy

Introduction
Symptoms
Tests
Treatment
Further reading
Insensitive foot

Up to 50% of people with type 2 diabetes have significant neuropathy and

at-risk feet.

Sensorimotor neuropathy and peripheral sympathetic neuropathy are major risk

factors for diabetic foot ulcers.

Neuropathy cannot be diagnosed on history alone; a careful neurological

examination of the feet is mandatory.

People with a high risk for future ulceration can be identified with simple
diagnostic tests, such as the 10 g Semmes- Weinstein monofilament.

Introduction

Diabetic neuropathy is defined as 'the presence of symptoms and/or signs of peripheral nerve
dysfunction in people with diabetes after exclusion of other causes', as described in the Guidelines
for the outpatient diagnosis and management of diabetic peripheral neuropathy (Boulton, 1998)
and it can be further classified according to clinical manifestations. Chronic sensorimotor and
peripheral sympathetic neuropathies are confirmed risk factors for foot lesions. For example, in
prospective studies, the loss of pain and large-fibre sensation (vibration, pressure, touch) have
been shown to be major risk factors for foot ulceration. It must be remembered that in the total
absence of any previous neuropathic symptoms, foot ulceration may itself be the presenting
feature of neuropathy. Thus, neuropathy cannot be diagnosed on history alone; a careful
neurological examination of the feet is mandatory.

Symptoms

Symptoms of peripheral neuropathy include hyperesthesia, burning pain, stabbing pain,

paraesthesia, and hot and cold sensations, all of which are prone to nocturnal exacerbation. Signs
include reduced sensation to pain, temperature and vibration, small muscle wasting, the absence
of sweating, and distended dorsal foot veins. The latter two are evidence of autonomic dysfunction
involving sympathetic nerve fibres. This results in increased arteriovenous shunting, which leads to
a warm foot. Thus, a warm but insensate foot is very much a 'high-risk' foot.

Tests

As prospective studies have demonstrated that sensory loss is a major predictor of foot ulcers,
annual neurological examination of the feet of all patients with diabetes is essential. This
examination can include testing of vibratory sense using a 128 Hz tuning fork; discrimination using
a pin (only when the skin is intact); and deep sensation using a tendon hammer (Achilles tendon
reflex). In addition to this simple examination, the following semi-quantitative tests can be used:

Semmes-Weinstein monofilaments

Prospective studies have shown that the inability to perceive the 10 g monofilament (5.07) at the
toes or dorsum of the foot predicts future occurrence of a diabetic foot ulcer. At present, there are
no evidence-based data describing how often and where on the foot a monofilament should be
applied. The advantages of this test are its simplicity and low costs. Therefore, experts advise that
the 10 g monofilament is a useful test to determine the future risk of ulceration. However, caution

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should be exercised when purchasing filaments: studies suggest that several filaments that
supposedly assess 10 g pressure sensation are inaccurate.

Tests of vibration perception

Prospective studies have shown that a decrease in vibratory perception predicts subsequent
ulceration. These studies were performed using small, portable electronic instruments to
semi-quantatively determine the vibratory perception threshold. Unfortunately, these instruments
(eg biothesiometer or neuro-esthesiometer) are too expensive for many centres. The graduated
128 Hz tuning fork could be used as an alternative to measure vibratory sense semi-quantatively,
as it was found in one study to correlate with the threshold of vibration perception.

Detailed quantitative tests of vibration or thermal perception

These may be used in specialist centres.

It should be noted that loss of sensation to a 10 g monofilament or loss of vibration perception

does not rule out distal symmetrical diabetic neuropathy. These tests are particularly helpful in
determining the future risk of foot ulceration; additional tests are necessary to diagnose or exclude
neuropathy.

Treatment

There are currently no pharmacological treatments with major beneficial effects on the natural
history of peripheral diabetic neuropathy, which is a slow but progressive loss of nerve fibres.
However, there are pharmacological agents that can relieve symptoms in painful neuropathy.

In summary, neuropathy can be diagnosed easily in community and hospital practice by a simple
neurological examination of the feet. In addition, there are several tests which can predict future
ulceration. If a diagnosis of diabetic neuropathy is made, the only treatment option currently
available is tight metabolic control to slow the progression of disease, as shown by the DCCT and
UKPDS trials. For further details, the reader is referred to the aforementioned neuropathy
consensus document and the 2005 ADA statement on neuropathy.

Further reading

Boulton AJM, Gries FA, Jervell JA. Guidelines for the outpatient diagnosis and management of
diabetic peripheral neuropathy. Diabet Med 1998; 15: 508-14.

Boulton AJM, Malik RA, Arezzo JC, Sosenko JM. Diabetic somatic neuropathies: a technical
review Diabetes Care 2004; 27: 1458-86.

Vinik AI, Mehrabyan A. Diabetic neuropathies Med Clin North Am 2004; 88: 947-99. Boulton AJM,
Vinik AI, Arezzo JC, Bril V, Feldman EL, Freeman R, Malik RA, Maser RE, Sosenko JM, Ziegler D;
American Diabetes Association. Diabetic neuropathies: a statement by the American Diabetes
Association. Diabetes Care 2005; 28: 956-62.

Argoff CE, Backonja MM, Belgrade MJ, Bennett GJ, Clark MR, Cole BE, Fishbain DA, Irving GA,
McCarberg BH, McClean MJ. Consensus guidelines: treatment planning and options. Diabetic
peripheral neuropathic pain. Mayo Clin Proc. 2006; 81(4 Suppl): S12-S25.

Insensitive foot

Insensitive foot

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42-year old male with painful neuropathy was

"treated" with moxa (Chinese heat therapy).

Due to severe sensory neuropathy the treatment

caused a burn without alarming pain sensation.

47-year old male lost his lighter; after walking for

three hours he found it back in his shoe, not
knowing that he had insensitive feet. He lost his
first toe because of this.

67-year old lady walked with a piece of porcelain

in her shoe, causing a large plantar ulcer.

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