DIABETIC NEUROPATHY

- AARTHI A
BOT 3RD YEAR
SRIHER
 INTRODUCTION
• Peripheral neuropathy is the term refers that damage to nerves of the peripheral nervous system,
which may be caused either by diseases of the nerve or from the side effects of systemic illness.

• The causes are multiple:

Hereditary - Charcot-Marie-Tooth disease

Infections - Leprosy, Lyme disease, HIV

Inflammatory – Gullian-Barre syndrome

Toxins – Lead, Alcohol

Metabolic – DM , Renal failure, Hypothyroidism

Traumatic – Incision, Compression, Stretching

• Diabetes is a near-epidemic disease causing a number of different neuropathic
presentations, involving the motor, sensory and autonomic functions.

• The most common complication of diabetes is caused by hyperglycemia which can

damage nerve fibers throughout the body.

• In DM, 66% of patients had some types of signs of a diabetic neuropathy, but only
20% of patients were symptomatic.

• Diabetic neuropathy is the more common and debilitating complication that result
in pain, decreased motility and amputation
 Hyperglycemia

Oxidative stress in neurons

Activation of biochemical pathways

Nerve damage
PREVALENCE
- The exact prevalence is not known, it is estimated between 5% and
66% of patients with DM develop diabetic neuropathy

RISK FACTORS
MODIFIYABLE RISK FACTORS NON-MODIFIYABLE RISK
FACTORS
-Poor glycemic control -Obesity
(Elevated HbA1c)
-Age
-Alcohol consumption
-Gender
-Smoking
-Hereditary
-Hypertension
-Longer duration of diabetes
-Hypertriglyceridemia
Small fiber versus Large fiber neuropathy

• Nerve axons are further subdivided into small and large fibers

• Large fibers are inshealthed by an insulating membrane called

the myelin shealth, which is produced by the Schwann cells.

• The large fibers transmit motor signals to the muscles, and

sensory signals that convey vibratory sensations or
information about the position of joints in space.

• The small fibers remain unmyelinated; they transmit signals

from pain receptors in the skin.

• They also form the autonomic fibers that send signals to and
from the internal organs
CLASSIFICATION OF DN

• Distal symmetric sensory motor polyneuropathy

• Diabetic autonomic neuropathy
• Diabetic neuropathic cachexia
• Diabetic poly-radiculopathy
- Asymmetric painful poly-radiculopathy
- Symmetric painless poly-radiculopathy
• Focal limb neuropathies ( Entrapment neuropathy)
Distal symmetric sensorimotor polyneuropathy

• DSPN is the most common form of diabetic neuropathy

• It is LENGTH-DEPENDENT Neuropathy
• Individuals develop sensory loss beginning in the toes, which gradually progress up
to the legs and to the fingers and arms

CLINICAL SYMPTOMS
• Paresthesia
• Lancinating pain
• Burning or deep aching discomfort
• A severe loss of sensation can lead to increased risk from trauma to the
extremities with secondary infection, ulceration and charcot joints.
• Cramping sensations in the legs are common, as is nocturnal allodynia evoked by
rubbing the feet against bedclothes;
• These symptoms are generally worse at night and disturb sleep
Laboratory features

• An increased risk of impaired glucose tolerance on oral glucose tolerance test

• Up to 50% of patients with DM have reduced sensory nerve action potential

(SNAP) amplitudes and slow conduction velocities of the sural or plantar nerves

• Quantitative sensory testing may reveal reduced vibratory and thermal perception

• Autonomic testing may also be abnormal ,in particular quantitative sweat testing

• Electromyography exam

• Nerve conduction study

PATHOGENESIS

The pathogenic basis for DSPN is unknown. The major theories involve a metabolic
process, microangiopathic ischemia ,or an immunological disorder

TREATMENT
Diabetic Autonomic Neuropathy
• Autonomic neuropathy typically is seen in combination with DSPN

• The autonomic neuropathy can manifest as

- Abnormal sweating
- Dysfunctional thermoregulation
- Dry eyes and mouth
- Pupillary abnormalities
- Cardiac arrhythmias
- Postural hypotension
- Gastro-intestinal abnormalities( eg, gastroparesis,
postprandial bloating, chronic diarrhea,or constipation)
- Genitourinary dysfunction( eg, Impotence, retrograde
ejaculation, and incontinence)
Laboratory Features:
• Sympathetic skin response test
• Quantiative sudomotor axon reflex testing
• Sensory and motor NCS

HISTOPATHOLOGY
- Degeneration of sympathetic and parasympathetic neurons

TREATMENT
- Pancreatic transplantation may stabilize or slightly improve autonomic
dysfunction
- For symptomatic orthostatic hypotension, we initiate treatment with
fluodrocortisone (0.1mg) or midodrine (10mg)
- NSAIDs
- Metaclopramide – diabetic gastroparesis
- Sildenafil – erectile dysfunction
Diabetic neuropathic cachexia
• This form of diabetic neuropathy is more common in men(usually
associated with type2 DM) than in women(most cases associated with
type1 DM)
• Rarely occur
• It is also known as acute painful diabetic neuropathy

CLINICAL FEATURES
- Patients with DNC develop an abrupt onset of severe generalized
painful paresthesia involving the trunk and all four limbs
- Usually with precipitous weight loss
- Mild sensory loss will be present along with reduced muscle stretch
reflexes
- Weakness and atropy
- Gradual onset of intolerable burning pain over the soles of the feet
and legs accompanied by allodynia
Laboratory Features
- Cerebrospinal fluid(CSF) protein may be increased
- Sensory nerve action potentials may be absent or have very low
amplitudes
- Normal or slightly diminished compound muscle action
potentials(CMAP)amplitudes with mild slowing of conduction velocities

Histopathology
- Nerve biopsies demonstrate severe loss of axonal degeneration
TREATMENT
Most patients improve spontaneously, with control over the DM within
1-3 years.
Symptomatic treatment of the painful paresthesia is the same as that
described for DSPN
Asymmetric, painful diabetic polyradiculopathy
-It is also known as diabetic amyotropy
-It more commonly affects the older patients with DM type2
CLINICAL FEATURES:
- Severe pain in the low back, hip, and thigh in one leg
- Atrophy and weakness of proximal and distal muscles in the affected leg
become apparent within a few days or weeks
- Paresthesia
- Patients undergo unnecessary laminectomies because the severe
radicular pain and weakness suggest a structural impingement
- Polyradiculoneuropathy is often accompanied by severe weight loss
- Loss of sensation
- Onset is unilateral, after several weeks or months later the contralateral
leg becomes affected
Muscle wasting is more
common in diabetic
amyotrophy
Laboratory Features
- Lumbar puncture usually reveals an elevated CSF protein
- ESR is increased
- MRI scans of the nerve roots and plexus can reveal enhancement
- NCS reveal features of multifocal axonal damage to the roots and plexus
with reduced or low amplitudes of SNAPs and CMAPs
- Needle EMG

HISTOPATHOLOGY
Sural, superficial peroneal and lateral femoral cutaneous nerve biopsies
reveal loss of myelinated nerve fibers along with axonal degeneration
TREATMENT
Immunosuppressive therapy
- IVIG (Intra-venous immunoglobulin)
- Prednisone
Symmetric, Painless, Diabetic Polyradiculopathy
• It presents with a progressive, relatively painless, symmetrical proximal and
distal weakness
• It evolves over weeks to months and clinically resembles CIDP(chronic
inflammatory demyelinating polyneuropathy)
• It occurs in both types 1 and 2
• The pattern of weakness is distal muscles are more affected than proximal
muscles
• More common in males
• Caused by damage to the myelin shealth of the peripheral nerves
Laboratory features
• CSF protein concentration is usually increased
• NCS demonstrate mixed axonal and demyelinating features with absent or
reduced SNAP and CMAP amplitudes
• EMG
• Autonomic studies may demonstrate abnormalities in sudomotor,
cardiovagal, and adrenergic functions
HISTOPATHOLOGY
• Sural nerve biopsies demonstrate a loss of large and small myelinated
nerve fibers, with axonal degeneratiion
• Inflammation of cells occur in the peri- and epineurium
PATHOLOGY
• Diabetic neuropathy caused by the associated metabolic disturbances
such as uremia
TREATMENT
• Immunotherapy
- IVIG
- Plasma exchange
- Corticosteroids
FOCAL MONONEUROPATHY
• Mononeuropathies typically occur in older diabetic individuals

• It is usually acute in onset and associated with pain

• Recovery is spontaneous and occurs over 6 to 8 weeks

• Cranial nerves 3,6,7 and median, ulnar, peroneal nerves are most
commonly affected

• Caused by- microvascular infractions

• Patients with diabetes are more predisposed to entrapment neuropathies

• Carpel Tunnel Syndrome is 3 times more common in individuals with

diabetes than in general population
 STAGES

A common staging scale of diabetic polyneuropathy

• N0 - No neuropathy
• N1a - Signs but no symptoms of neuropathy
• N2a - Symptomatic mild diabetic polyneuropathy
(sensory, motor, or autonomic symptoms; patient able to heel
walk)
• N2b - Severe symptomatic diabetic polyneuropathy
(as in N2a, but patient unable to heel walk)
• N3 - Disabling diabetic polyneuropathy
Scales used in diabetic neuropathy

- UENS

- Michigan Neuropathic Screening Instrument

- Neuropathy Disability Score

UTAH EARLY NEUROPATHY SCALE
EVALUATION AND ASSESSMENT

• Sensory Examination
 Test for Pain – Pin Prick testing
 Test for Temperature awareness – Test tubes
 Test for Touch sensation – Two point discrimination
 Test for touch pressure - Monofilament
 Test for position sense
• Muscle Strength – MMT
• Reflex Testing – It mostly shows areflexia or hyporeflexia
• Girth Measurement – To detect the degree of wasting or atrophy
• Gait:
Assessment of gait reveals difficulty in walking, twisting of ankles,
slapping of the feet, or loss of heel-to-toe pattern and patient may walk with
high steppage gait (foot drop)
• Autonomic dysfunction:
Sweating occurs due to poor vasomotor control and leads to
cold feet with blotching or pallor skin
• Neuropathic pain( burning, tingling and shooting)
• Fatigue evaluation
- Fatigue Severity Scale
• Balance Assessment – Berg balance scale
• ADL Assessment – FIM scale
Problems relevant to OT

• Problems in ADL
• Problems in fine motor and gross motor skills
• Loss of balance
• Postural instability
• Lack of co-ordination
• Lack of sensation awareness
• Muscle atrophy
• Reduced ROM
• Psychological problems
FUNCTIONAL LIMITATIONS

• The severity of the symptoms can range from mild discomfort and pain
to severe disability with reduced quality of life.

• Falls are more likely to occur in individuals with diabetic neuropathy

Issues in QUALITY OF LIFE
“ Quality of life” is a measure of well patients adjust to their well known condition. It
measures many factors
- Physical and mental well being
- Social relationship with other people
- Social activities
- Personal fulfillment
- Recreational activities
- Health status

Chronic neuropathic pain can be very debiliating and affect several dimensions of daily life are
- Psychological health(eg; depression, anxiety)
- Work related problems(eg; reduced level of productivity, absenteeism)
- Sleep disturbances
- Feeling of isolation
- Sense of disappointment
 Goal of an Occupational therapist

• The goals of rehabilitation for patients with Diabetic neuropathy are

to maximize and prolong independent and safe locomotion and
function, inhibit physical deformity, and provide access to full
integration into society.
Occupational therapy Management
• Muscle strength Training
The aim is to maintain the strength of weak muscles which can be
achieved by following techniques:
- Active exercise
- Proprioceptive Neuromuscular Facilitation(PNF)
- Progressive resisted exercises
- Suspension therapy exercises
• Balance Training – To reduce the risk of falling
• Gait Training
• Foot care management
• Sensory re-education
• ADL training
• Hand function training
• Structured Graded Desensitization Program
Desensitization is a useful strategy for patients with allodynia or
hyperalgesia. The goal is to normalize sensitivity in a progressive manner.
3 methods are:
- THERMAL
- TACTILE
- PRESSURE
Protective Sensory Re-education

• People who lack protective sensation are at risk for serious injury since they cannot feel pinprick or hot or cold exposure.
Blisters may develop after holding objects and people do not realize it until they visually examine the hand.

• If the client lacks protective sensation, he or she will be burned without feeling the painful sensory stimulus of the
hot stove.

Callahan identified the following instructions for protective sensory re-education

• Protect from being exposed to sharp items or to cold or heat.

• Try to soften the amount of force used when gripping an object.

• Use built-up handles on objects whenever possible to distribute gripping pressure over a greater surface area.

• Do not persist in an activity for prolonged periods. Instead, change the tool used and rotate the work task often.

• Visually examine the skin for edema, redness, warmth, blisters, cuts, or other wounds. This is important because tissue
heals more slowly when a nerve injury has occurred.

• If there is tissue injury or damage, be very careful in treating and try to avoid infection.

• Maintain skin suppleness as much as possible by applying moisturizing agents.

 There are the several lifestyle style modifications that may help to reduce discomfort and
maximize functional status of the individuals are;

• Fastidious foot care is for preventing injury, infection and other complications ( Careful foot
washing and daily inspection for cuts, pressure spots, blisters or callus

• Foot massage – increase circulation and reduce pain

• Avoid wearing tight-fitting shoes and socks, shoes should be padded, supportive, and
comfortable

• Avoid smoking and alcohol

• Regular exercise

• Avoid crossing knees and leaning on elbows for prolonged period( Avoid prolonged
pressure)

• Loss of temperature awareness, be cautious of possible heat injury from showers, stoves
etc
PAIN MANAGEMENT

• Transcutaneous electrical nerve stimulation{TENS} – also known as

electrotherapy TENS is effective in reducing localized pain and discomfort
for the duration of treatment in DP
• Frequency-modulated electromagnetic neural stimulation(FREMS)-Results
indicated a significant reduction in pain, and increase in sensory tactile
perception, motor nerve conduction velocity and sensation of foot
vibration for atleast four months
• Acupuncture
• Biofeedback- It’s a technique that teaches individuals how to deal with
pain by learning to divert their attention or to perceive the pain
differently. It is also useful in increasing the temperature awareness
• Relaxation/Massage therapy
COMPLICATIONS
FOOT INSPECTION
• Daily inspection of soles of the feet and area between the toes
• Use of padded socks
• Wearing well-fitting and supportive shoes
• Caution with exposure to heat
• Creams for dry or cracking skin
• Keeping toenails carefully trimmed

SHOES
- Acorn padded slippers
- Sheepskin moccasins
SOCKS
- Salk Diabetic Socks
Symptoms of diabetic autonomic neuropathy are treated individually, for Eg;

• For postural hypotension- patient should attempt to wear supportive

clothing that increase blood circulation(eg. Body stocking) and
medications like clonidine, metaclopramide may be useful

• For gastrointestinal motor symptoms- meal schedule and size may need to
be modified and fat intake should be reduced

• For bladder problems- urinary catheterization may provide releif

• For sweating disturbances- avoidance of certain foods(eg. Spicy foods or

cheese) may reduce symptoms
Assistive Devices
Mechanical aids and other assistive devices can help reduce pain and lessen the impact of
physical disability and muscle weakness. To help you remain as independent as possible, and
maintain your own safety, it’s important to have the tools you need.

Getting Dressed:

• Use a bath mat in the tub or shower to keep from slipping. If the feeling of the mat is
uncomfortable, wear flip-flops or other waterproof shoes like Aquasox.
• Use a bath chair if you cannot stand unassisted
• LED Shower Water Thermometer
• Sock Aid
• Orthopedic shoes can improve gait disturbances and help prevent foot injuries in people with
a loss of pain sensation.
• Hair Dryer stand
• Long handled bath tools – brushes or sponges
• Electric toothbrush
• Zipper pulls
• Velcro closures on shoes
• Button Hook
Around the House:

• Use handrails and grab bars, if needed, for balance

• Use gloves when doing housework. Be sure to check for any cuts,
abrasions, burns or injury to your hands

• Automated soap dispensers

• Universal Hand Clip

• Easy-Grip Contoured carving Knife & Fork

• Easy-Twist Grip Jar Opener

• EZ Key Turner
Getting Around:

• Hand or foot braces can compensate for muscle weakness or alleviate

nerve compression

• Cane – make sure you are fitted properly so you do not compound the
problem with balance

• Walker – have the walker adjusted to the proper height so you are not
leaning over too far

• Wheelchair
Bathroom Modifications
APPROACHES

- Rehabilitative frames of reference

- MOHO

- PNF

- CBT

- PEOP

- Sensory Integration Therapy

- Psychodynamic frames of reference

REFERENCES

- Medifocus guidebook on peripheral neuropathy

- Neuromuscular Disorders (Anthony A. Amato. James A Russell)

- PEDRETTI’S Occupational Therapy Practice Skills for Physical Dysfunction

THANK YOU