DIABETIC NEUROPATHY: HOW TO NAVIGATE NERVE PAIN AND COMPLICATIONS

Medically Reviewed by Dr. Sony Sherpa, (MBBS) - September 24, 2024

Diabetes is a chronic condition affecting millions across the globe. It can cause various complications, such as heart disease, kidney failure, and vision loss. One of the most common and debilitating complications of diabetes is diabetic neuropathy, nerve damage that can cause pain, numbness, and weakness in different parts of the body.

Diabetic neuropathy is prevalent in up to 50% of people with diabetes and can have a significant impact on their quality of life, mobility, and mental health. It can also increase the risk of infections, ulcers, and amputations. Therefore, it is important to address diabetic neuropathy for individuals with diabetes and to prevent or delay its onset and progression.

What is Diabetic Neuropathy?

Neuropathy is a broad term for nerve damage or dysfunction. It can be caused by various factors, such as injury, infection, toxins, or diseases. Diabetic neuropathy is a particular type of neuropathy that develops as a result of high blood sugar levels over a long period of time. High blood sugar can damage the small blood vessels that supply oxygen and nutrients to the nerves, leading to nerve injury or death.

Types of Diabetic Neuropathy

Neuropathy is categorized according to the affected nerve or nerve group.

Peripheral Neuropathy - affecting the nerves in the feet, legs, hands, and arms^[1] - is the most common type seen in those with diabetes, present in up to 50% of patients with diabetic neuropathy.

Other types of diabetic neuropathy include:

• Autonomic Neuropathy affects just over 30% of those with diabetic neuropathy and involves the nerves that regulate involuntary functions, such as digestion, heart rate, blood pressure, and sweating.
• Proximal Neuropathy is found in less than 1% of patients. Nerve dysfunction includes the thighs, hips, or buttocks.

In addition to the body site, neuropathy may affect one nerve or group (focal neuropathy), or multiple nerves or groups (polyneuropathy).

Focal neuropathy is less common than polyneuropathy, affecting 10% of those with diabetic neuropathy. Some with focal neuropathy may develop carpal tunnel syndrome or a similar type of nerve compression in the wrist.

Is It Possible To Have Prediabetic Neuropathy?

Yes, diabetic neuropathy is possible in those with prediabetes, with most studies reporting a prevalence of more than 10%.^[2] Prediabetes is a condition where blood sugar is abnormally elevated but not high enough to be diagnosed as diabetes. Neuropathy and related symptoms associated with prediabetes are clinically similar to the early stages of diabetic neuropathy.

Symptoms of Diabetic Neuropathy

Diabetic neuropathy symptoms vary depending on the type and severity of nerve damage. Some people may not have any symptoms at all, while others may experience mild to severe discomfort or disability.

Peripheral neuropathy symptoms include: tingling, burning, sharp shooting pain, numbness, or loss of sensation in the affected areas, such as the feet or hands.

Autonomic neuropathy symptoms include: nausea, vomiting, diarrhea, constipation, bladder problems, erectile dysfunction, or abnormal heart rhythms.

Other signs and symptoms of diabetic neuropathy are:

• Blurred vision or eye problems
• Foot problems such as ulcers, infections, deformities, or fractures
• Balance problems or difficulty walking
• Muscle weakness or wasting in the feet or legs

The symptoms of diabetic neuropathy may worsen at night or during periods of stress. They may also change over time as the condition progresses.

It is important to recognize early warning signs of diabetic neuropathy. If experiencing any of the above symptoms, seek medical attention as soon as possible. Early detection and treatment can help prevent further nerve damage and complications.

The Progression of Diabetic Neuropathy

Diabetic neuropathy does not develop overnight. It usually takes years for high blood sugar levels to cause noticeable nerve damage. Some people may develop symptoms sooner than others, depending on the severity and duration of diabetes, comorbidities and other risk factors, genetics, and their lifestyle. Symptoms of diabetic neuropathy can also come and go, especially in the early stages.

Diabetic neuropathy stages are classified according to severity:

• Stage 1: Subclinical Neuropathy. This is the earliest stage where there is no obvious symptom, but there is evidence of nerve damage on tests such as nerve conduction studies (NCS) or quantitative sensory testing (QST).
• Stage 2: Clinical Neuropathy. In this stage, symptoms such as pain, numbness, or tingling start to appear.
• Stage 3: Complicated Neuropathy. In stage 3, complications such as foot ulcers, infections, or deformities occur due to nerve damage and loss of sensation.
• Stage 4: End-stage Neuropathy. This is the stage where nerve damage is so severe that it causes irreversible disability or organ failure.

Can Diabetic Neuropathy Be Reversed?

The course of diabetic neuropathy can be slowed down or stopped by maintaining good blood sugar control and managing other risk factors. Once nerve damage has occurred, it is usually irreversible, and the longer one has the condition, the higher the likelihood of nerve damage.

The effectiveness of treatments for diabetic neuropathy varies, yet medications, lifestyle interventions, and complementary therapies can be highly beneficial and are known to improve outcomes. It is not certain at this point whether improvements seen in response to treatment are permanent or long-lasting. Some treatments can pose side effects or interactions with other medications that can interfere with the outcome and even lead to complications.

It is important to consult a doctor before starting any treatment for diabetic neuropathy.

Causes and Risk Factors

The main cause of diabetic neuropathy is blood sugar level fluctuations over a long period of time. Extremely low or high blood sugar can give rise to chronic low-grade inflammation and energy deficits.^[3] This can eventually damage blood cells and the small blood vessels that serve oxygen and nutrients to the nerves.

When nerves are starved of oxygen and nutrients, it creates nerve injury (including demyelination and degeneration), deformity and/or death. These events can also interfere with nerve transmission and repair, causing neurons in the brain and body to become hyper-excitable and far more sensitive to pain.^[4]

Other factors that can contribute to the development or worsening of diabetic neuropathy are:

• Hypertension (high blood pressure)
• Dyslipidemia (faulty fat metabolism)
• Iron overload and related blood problems
• Smoking
• Obesity
• Genetics and aging
• Malignancy and chemo toxicity
• Hypothyroidism
• Autoimmune conditions

Diagnosis

Diabetic neuropathy diagnosis involves a neurologist assessing your medical history, conducting a physical examination and potentially running a few tests. They will test your reflexes, muscle strength, sensation in the affected area, and coordination.

Common tests for diabetic neuropathy include:

• Nerve conduction studies (NCS)
• Electromyography (EMG)
• Quantitative sensory testing (QST)

These tests evaluate the electrical activity and sensation of nerves in the symptomatic area. A skin biopsy may also be required to assess nerve density and the degree of nerve damage.

If neuropathy is suspected in the absence of a diabetes diagnosis, you may need to get blood tests to confirm whether you have diabetes or not. It is more common to be referred to a neurologist when neuropathy symptoms are present after being diagnosed with diabetes.

Medical Treatments for Diabetic Neuropathy

While there is no cure, there are treatments for diabetic neuropathy that can help manage symptoms and prevent complications.

Diabetic Neuropathy Medication

When seeing a doctor, a patient with diabetic neuropathy is likely to be given medication for diabetes and comorbidities such as heart disease, hypertension and hypercholesterolemia. Common prescriptions for these conditions include metformin, statins and antihypertensives.^[5]

There are also various medications that can help relieve pain, numbness, tingling, or other symptoms of diabetic neuropathy. The type and dose of medication depend on the severity and type of nerve damage, as well as the patient’s preference and tolerance.

OTC Medication: Before making a more serious prescription, a doctor may suggest getting over-the-counter diabetic neuropathy medication. These are topical preparations that numb or warm the skin where they are applied. Common topical creams or patches used for diabetic neuropathy are lidocaine (Lidoderm), capsaicin (Zostrix), and menthol (Aspercreme).

Prescription Medication: If these are unsuccessful at managing painful symptoms that get in the way of daily activities, a doctor may prescribe stronger pain-relieving medications that improve nerve function and reduce symptom severity.

The effectiveness of medications for diabetic neuropathy varies and may decrease over time as the body gets used to them. Side effects of anti-neuropathic medications include drowsiness, dizziness, nausea, constipation, dry mouth, weight gain, or addictIon.

It is important to follow instructions and see your doctor if you begin to experience any additional symptoms.

Medical Procedures

Medical procedures for diabetic neuropathy are usually reserved for people who have severely painful symptoms and those who don’t respond to usual treatment after a prolonged period of time.

Procedures commonly involve the surgical implantation of devices that inhibit signals of pain and improve the quality of life. Examples include:

• Spinal Cord Stimulation, which involves a surgically implanted device that delivers mild electrical pulses to the spinal cord.
• Intrathecal Drug Delivery, in which an inserted device delivers pain-relieving medication directly into the fluid around the spinal cord.
• Nerve Decompression Surgery helps release the pressure on compressed nerves. It is often used to treat those with focal neuropathy or carpal tunnel syndrome.
• Limb Amputation may be required if nerve damage is advanced or if the affected organ deteriorates or develops diabetic ulcers.

Risks or complications of such procedures include infection, bleeding, nerve damage, or device malfunction. It is essential to consult a doctor beforehand and to weigh the benefits and risks carefully.

Diabetic Neuropathy Self-Care and Management

Besides medical treatment, self-care and management are also essential for coping with diabetic neuropathy and preventing its complications. The self-care and management practices for diabetic neuropathy include:

Blood Sugar Control

Blood sugar control is the cornerstone of preventing and managing diabetic neuropathy, as it can help protect the nerves from damage and reduce symptoms.

Here are a few tips for optimal blood sugar control:

• Following a balanced diet that is low in sugar, fat, and salt and high in fiber, protein, and vitamins.
• Regulating one’s carbohydrate intake by avoiding meals with a high glycemic load or that may spike one’s blood sugar levels erratically. Food pairing for one’s metabolism can help lower the glycemic load of meals consumed.
• Eating smaller portions of balanced meals at steady intervals throughout the day.
• Minimizing stress, including emotional or mental stress, physical stress or shock, and injuries.
• Exercising moderately and regularly to improve blood circulation, hormonal stability and glucose metabolism. One ought to create a routine that emphasizes aerobics as well as balance, resistance and strength training.
• Ensuring one gets enough quality sleep from a set time every night.

Foot Care

Diabetic neuropathy foot care is another important aspect of managing the condition, as it can help prevent foot problems such as ulcers, infections, or amputations.

This is especially pertinent if symptoms of peripheral neuropathy are experienced in the feet. The feet should be inspected daily for signs of injury, infection, or abnormality. Keep them clean, moisturized, at a stable temperature and protected, making use of comfortable shoes and padded socks. Greater care needs to be taken when trimming toenails or walking barefoot to avoid injuries.

Consult with your doctor if your feet look infected, don’t heal properly or if any other problem persists.

Home Remedies and Alternative Therapies

Home remedies and alternative therapies for diabetic neuropathy may help provide symptom relief and improve nerve function or repair.

They don’t work for everyone and should not replace medical treatment or advice. It is recommended to ask your doctor before starting any other therapy for diabetic neuropathy, just to make sure it does not interfere with your main treatment protocol.

Alternative therapies or home remedies for diabetic neuropathy include:

Compression Socks are tight-fitting socks that apply gentle pressure to the legs and feet. They can help improve blood flow and reduce swelling, pain, or numbness in some people with diabetic neuropathy.

Herbal Remedies may be able to lower inflammation, help regulate blood glucose, improve oxygenation, balance nerve transmission and lower pain. There are many supplements available that can help in this respect, although it is best to consult with a specialist to find which ones work best for your specific profile. Foods that may be of use include antioxidant herbs and spices such as mint, turmeric, ginger, nutmeg and saffron.

Massage can help relax the muscles, improve blood circulation, stimulate the nerves, and reduce pain or stress in some people with diabetic neuropathy.

Acupuncture is a traditional method in Chinese medicine involving the insertion of thin needles into specific points on the body. It can help balance the energy flow in the body, improve nerve transmission, release endorphins (natural painkillers), and reduce inflammation. Some studies suggest it is more effective than diabetic medication with respect to blood sugar control^[6], while others show varying results.^[7] Variations that may also be of benefit include electroacupuncture and acupuncture used with injectables.

Transcutaneous Electrical Nerve Stimulation (TENS) is a technique that involves applying mild electrical currents to the skin through electrodes attached to a device. Preliminary studies suggest it to be effective for enhancing the effectiveness of medications for diabetic neuropathy patients, substantially lowering pain and extending the benefits by several months, especially at higher frequency ranges.^[8]

Prevention Tips

The best way to prevent diabetic neuropathy is to avoid or delay diabetes itself by maintaining a healthy lifestyle and managing risk factors such as obesity, smoking, or severe stress.

For people who already have diabetes, keeping blood sugar levels within a healthy range and avoiding fluctuations is vital. It is advisable to follow the blood sugar control tips (under self-care), which include avoiding stress, getting good sleep, consuming a nutritious diet, and exercising regularly.

Other tips that can help prevent or delay the onset and progression of diabetic neuropathy include:

• Making use of supplements such as probiotics, zinc, vitamin D3 and K2, vitamin B12, alpha-lipoic acid, omega-3 fatty acids or others as advised by the doctor.
• Being strict about adhering to your protocol.
• Going for regular checkups that aim to monitor blood sugar levels, cholesterol and blood pressure. Your doctor will adjust your medications or diet accordingly.
• Seeking medical attention promptly if any symptoms or problems occur.

Conclusion

Diabetic neuropathy is a common yet serious complication of diabetes that can cause nerve damage, pain, numbness, weakness, and disability in different parts of the body. While challenging, diabetic neuropathy is not impossible to overcome and is potentially reversible if lifestyle changes and treatment are implemented early on. With the help of medical professionals, family members, friends, support groups, and other resources, individuals with diabetic neuropathy can navigate their nerve pain and live a fulfilling life.

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