Diabetic neuropathy

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The term diabetic neuropathy encompasses a wide range of conditions with diverse clinical manifestations (see Figures 5.8 and 5.9). The most common clinical presentation is with chronic sensorimotor DPN and autonomic neuropathy. Although DPN is a diagnosis of exclusion, complex investigations to exclude other conditions are rarely needed.

Patients with diabetes should be screened annually for DPN using tests such as pinprick sensation, temperature and vibration perception (using a 128 Hz tuning fork), 10 g monofilament pressure sensation at the dorsal surface of both great toes, just proximal to the nail bed, and ankle reflexes (see Figure 5.10). Combinations of more than one test have >87% sensitivity in detecting DPN. Loss of 10 g monofilament perception and reduced vibration perception predict foot ulcers. A minimum of one clinical test should be carried out annually.

Figure 5.8 Pathophysiology of diabetic neuropathy

Figure 5.8 Pathophysiology of diabetic neuropathy

Neuropathy Pathophysiology

Nerve dysfunction

Q NCV, Q Regeneration, Structural damage

Nerve dysfunction

Q NCV, Q Regeneration, Structural damage

DAG, diacyclglycerol; LDL, low-density lipoprotein; NCV, nerve conduction velocity; PKC, protein kinase C.

Key points: distal symmetric polyneuropathy

• All patients should be screened for distal symmetric polyneuropathy (DPN) at diagnosis and at least annually thereafter, using simple clinical tests. Electrophysiological testing is rarely ever needed.

• Once the diagnosis of DPN is established, special foot care is appropriate for insensate feet to decrease the risk of amputation.

• Simple inspection of insensate feet should be performed at 3- to 6-month intervals. An abnormality should trigger referral for special footwear, preventive specialist, or podiatric care.

• Education of patients about self-care ofthe feet and referral for special shoes/inserts are vital components of patient management.

• Medications for the relief of specific symptoms related to autonomic neuropathy are recommended.

Figure 5.9 Symptoms of diabetic peripheral nephropathy

Typical neuropathic symptoms

Positive Negative

Burning pain Asleep

Knife-like 'Dead'

Electrical sensations Numbness

Squeezing Tingling

Constricting Prickling Freezing Throbbing Allodynia

Peripheral and symmetric stocking glove distribution

Negative symptoms are often perceived as unimportant

Symptoms may occur intermittently

Time tr


Symptoms and signs progress from distal to proximal over time

Figure 5.10 Assessment of chronic sensorimotor diabetic neuropathy

Annual examination of sensory function in feet and ankle reflexes

Assessment of sensory function with one or more tests

• Temperature

• Vibration perception (128 Hz tuningfork)

• Pressure sensation (10 gmonofilament) History of neuropathic symptoms Visual inspection

• Deformities

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