Professional Documents
Culture Documents
Evaluation and Prevention of Diabetic Neuropathy
Evaluation and Prevention of Diabetic Neuropathy
of Diabetic Neuropathy
ANN M. ARING, M.D., Riverside Methodist Hospital, Columbus, Ohio
DAVID E. JONES, M.D., D.P.M., Columbus, Ohio
JAMES M. FALKO, M.D., Riverside Methodist Hospital, Columbus, Ohio
Diabetic neuropathy is a debilitating disorder that occurs in nearly 50 percent of patients with
diabetes. It is a late finding in type 1 diabetes but can be an early finding in type 2 diabetes. The
primary types of diabetic neuropathy are sensorimotor and autonomic. Patients may present
with only one type of diabetic neuropathy or may develop combinations of neuropathies (e.g.,
distal symmetric polyneuropathy and autonomic neuropathy). Distal symmetric polyneuropa-
thy is the most common form of diabetic neuropathy. Diabetic neuropathy also can cause motor
deficits, silent cardiac ischemia, orthostatic hypotension, vasomotor instability, hyperhidrosis,
gastroparesis, bladder dysfunction, and sexual dysfunction. Strict glycemic control and good
daily foot care are key to preventing complications of diabetic neuropathy. (Am Fam Physician
2005;71:2123-8, 2129-30. Copyright© 2005 American Academy of Family Physicians.)
D
Patient information: iabetic neuropathy can affect any various forms of diabetic neuropathy are
▲
June 1, 2005 ◆ Volume 71, Number 11 www.aafp.org/afp American Family Physician 2123
Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright© 2005 American Academy of Family Physicians. For the private, noncommercial
use of one individual user of the Web site. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.
Strength of Recommendations
2124 American Family Physician www.aafp.org/afp Volume 71, Number 11 ◆ June 1, 2005
Diabetic Neuropathy
TABLE 3
Evaluation for Diabetic Neuropathy
History
Screen for symptoms of diabetic neuropathy (see Table 2). Thigh muscle atrophy is prominent, disabling, and
Review diabetes history, disease management, daily usually limited to the iliopsoas, quadriceps, and adduc-
glycemic records, and previous hemoglobin A1C levels. tor muscles. Less often, the anterolateral calf muscles
Identify any family history of diabetes or neuropathy. are involved. Recovery usually is spontaneous in six to
Review medication history (including use of over-the- 12 months, but amyotrophy may recur. Increasing
counter products and herbal or homeopathic products) circumferential thigh measurements may not indicate
and environmental exposures.
recovery because muscle can be replaced by fatty tissue.
Review for other causes of neuropathy, including vitamin
B12 deficiency, alcoholism, toxic exposures, medications,
cancers, and autoimmune disease. Diabetic Autonomic Neuropathy
Physical examination Diabetic autonomic neuropathy can develop in patients
Vital signs and pain index with type 1 or type 2 diabetes. Although autonomic
Supine and standing blood pressure for postural neuropathy may occur at any stage of diabetes,3,4 usu-
hypotension ally it develops in patients who have had the disease for
Cardiovascular examination to look for arrhythmias, absent 20 years or more with poor glycemic control. The
or diminished pulses, edema, or delayed capillary refilling reported prevalence of diabetic autonomic neuropathy
Cutaneous examination to look for extremity hair loss, skin varies widely, depending on the cohort studied and the
or nail changes (including callus), and pretrophic (red) methods of assessment.7
areas, especially between toes
In autonomic disease, the sympathetic, parasympa-
Neurologic examination using the 5.07 Semmes-Weinstein
(10-g) nylon filament test (10-g monofilament test) thetic, and enteric nerves are affected. Myelinated and
Inspection of feet for asymmetry, loss of arch height, or unmyelinated nerve damage is found. Diabetic auto-
hammer toes nomic neuropathy may lead to hypoglycemic unaware-
Evaluation of all positive screening findings ness and increased pupillary latency. Many investigators
Annual diabetes evaluation have considered autonomic neuropathies to be irrevers-
Evaluation for neuropathy as discussed above ible. However, cardiac sympathetic dysinnervation has
Sensorimotor examination and evaluation of cranial nerves, been shown to regress with tight glycemic control.8
muscle strength, and range of motion
CARDIOVASCULAR AUTONOMIC NEUROPATHY
Document distribution, intensity, and type of sensory or
motor deficits. The risk of cardiovascular events is at least two to four
Evaluate small nerve fibers with temperature, light touch, times higher in patients with diabetes.9 Cardiovascular
or pinprick testing. neuropathy is a result of damage to vagal and sympa-
Test large nerve fibers by vibratory sensation, position thetic nerves. Clinical findings may include exercise
sense, muscle strength, sharp-dull discrimination, and
two-point discrimination. intolerance, persistent sinus tachycardia, no variation in
Autonomic examination, including orthostatic blood heart rate during activities, and bradycardia. Barorecep-
pressure measurements tor disease contributes to supine hypertension.
Consider heart rate variability tests and electrocardiography In a patient with type 1 diabetes, an autonomic
if sensory neuropathy is present or symptoms warrant imbalance may result in a prolonged QT interval on the
further evaluation. electrocardiogram (ECG), which may predispose the
Consider heart rate variability tests in the patient who patient to life-threatening cardiac arrhythmias and sud-
has had type 1 diabetes for 10 years or type 2 diabetes den death.7 Diabetic neuropathy also can reduce appre-
for five years; consider cardiac stress testing before the
patient starts an exercise program. ciation of ischemic pain, which may delay appropriate
medical therapy and lead to death.7
Orthostatic blood pressure measurements may be
used to evaluate cardiovascular autonomic dysfunc-
DIABETIC AMYOTROPHY tion.10 Stress testing should be considered before any
Diabetic amyotrophy, also known as femoral neuropa- patient with diabetes starts an exercise program.
thy or proximal motor neuropathy, usually is bilateral
VASOMOTOR NEUROPATHY
and frequently is associated with weight loss. This con-
dition causes thigh muscle weakness, as well as variable Vasomotor neuropathy frequently causes orthostatic
pain and loss of the patellar reflex. Diabetic amyotrophy hypotension by affecting the splanchnic and peripheral
tends to occur more often in older male patients with vascular beds. Symptoms of syncope or dizziness often
type 2 diabetes. have day-to-day variability and may be exacerbated by
June 1, 2005 ◆ Volume 71, Number 11 www.aafp.org/afp American Family Physician 2125
insulin therapy or the postprandial state, in which there and distal symmetric polyneuropathy are considered
is splanchnic shunting of blood. The evaluation should necessary for the development of Charcot’s disease (dia-
include vital signs, an ECG, and orthostatic blood pres- betic neuropathic arthropathy).12
sure measurements.
SUDOMOTOR NEUROPATHY
In diabetic neuropathy, neuronal input to the periph-
eral vasculature is decreased or absent. Resultant periph- Sudomotor neuropathy may cause hyperhidrosis and heat
eral vasomotor instability can manifest as persistent intolerance in the upper torso or anhidrosis in the lower
excess peripheral circulation (hyperemia) and periph- extremities. Temperature elevation is rare, but sometimes
eral edema. Loss of sympathetic tone in the blood vessels occurs. The skin of the extremities may feel pruritic and
results in maximal may display thinning, hair loss, dryness, flaking, cracks,
vasodilation, which increased callus formation, and nail dystrophies. These
Stress testing should be
can lead to arterio- skin changes increase the risk of ulceration.
considered before any
venous shunting in
patient with diabetes GASTROINTESTINAL AUTONOMIC NEUROPATHY
the soft tissue and
starts an exercise program.
bone. Increased Gastrointestinal autonomic neuropathy may cause pare-
blood flow through sis anywhere in the digestive tract, with damage to
the bone causes calcium to wash from the cortical stores. small myelinated and unmyelinated splanchnic nerves.
Defective bone homeostasis and bone demineralization Reduced contraction amplitudes of the tubular esopha-
may result.11 gus may cause mild dysphagia. Motility studies, such as
The occurrence of peripheral vasomotor instability scintigraphy after a radiolabeled meal, are helpful in the
and peripheral sudomotor neuropathy is termed “auto- evaluation of nausea, vomiting, early satiety, and delayed
sympathectomy.” The patient with autosympathectomy gastric emptying.
has peripheral vasomotor reflexes similar to those in a Diabetic diarrhea is caused by increased or uncoordi-
nondiabetic patient after sympathectomy. The mecha- nated transit time in the small intestine, bacterial over-
nism by which the body senses and responds to changes growth, or increased intestinal secretion.13 Stool cultures
in blood pressure by reflex vasodilation or contraction and flexible sigmoidoscopy may be helpful in excluding
of peripheral vessels is impaired. Autosympathectomy other causes of diarrhea, such as parasitic infection, colon
cancer or polyps, celiac sprue, and inflammatory bowel
disease.
The Authors Decreased transit time in the large intestine may cause
ANN M. ARING, M.D., is assistant program director for the fam- constipation or impacted stool. Abdominal radiography
ily practice residency program at Riverside Methodist Hospital, or computed tomography may reveal megacolon or fecal
Columbus, Ohio, and clinical assistant professor in the Department impaction. Neuropathic fecal incontinence also may
of Family Medicine at Ohio State University College of Medicine occur in patients with gastrointestinal autonomic neu-
and Public Health, Columbus. Dr. Aring graduated from Ohio State
ropathy. A reduced threshold of conscious rectal sensa-
University College of Medicine and Public Health and completed a
family practice residency at Riverside Methodist Hospital. tion is manifested by a decreased resting anal sphincter
pressure.14
DAVID E. JONES, M.D., D.P.M., is a podiatrist in Columbus, Ohio.
He is a graduate of the Ohio College of Podiatric Medicine, DIABETIC BLADDER DYSFUNCTION
Cleveland, and the Universidad International de Las Americas
School of Medicine, San Jose, Costa Rica. Dr. Jones completed a
In patients with diabetic bladder dysfunction, inability
podiatry residency at Northern General Hospital for Joint Diseases, to sense a full bladder and detrusor muscle hypoactivity
New York, N.Y. cause retention and incomplete voiding of urine. These
conditions can progress to overflow incontinence and
JAMES M. FALKO, M.D., is professor emeritus of medicine in
urinary tract infections. Hyperglycemia alone also can
the Division of Endocrinology, Diabetes and Metabolism at Ohio
State University College of Medicine and Public Health. Dr. Falko cause increased urine production and incontinence.
also is director of academic affairs, internal medicine, at Riverside The evaluation of the patient with diabetes who has
Methodist Hospital. bladder dysfunction should begin with a review of medi-
cations. Drugs that impair detrusor contractility and
Address correspondence to Ann M. Aring, M.D., Riverside
Family Practice, 697 Thomas Ln., Columbus, OH 43214 (e-mail:
increase urethral tone include calcium channel blockers,
aringa@ohiohealth.com). Reprints are not available from the anticholinergics, alpha- and beta-adrenergic agonists,
authors. narcotics, antidepressants, and antipsychotics. Further
2126 American Family Physician www.aafp.org/afp Volume 71, Number 11 ◆ June 1, 2005
Diabetic Neuropathy
ERECTILE DYSFUNCTION
June 1, 2005 ◆ Volume 71, Number 11 www.aafp.org/afp American Family Physician 2127
Diabetic Neuropathy
2128 American Family Physician www.aafp.org/afp Volume 71, Number 11 ◆ June 1, 2005