Types of Neuropathy and Treatment

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There are many types of nerve damage. Our nervous systems are so complex, it's often hard to decide exactly what type of neuropathy is present. Complicating this is the fact that high blood glucose levels can damage nerves in two ways: directly and by slowing down or stopping their flow of blood. Sometimes it's hard to know whether a problem is caused by nerve damage or by circulation problems.

Distal Symmetric Polyneuropathy. This type of neuropathy, also called peripheral neuropathy, can strike the nerves in many parts of your body. Sensation can be either decreased or increased with neuropathy. The treatment is determined by the symptoms. If sensation is decreased, your feet can feel numb, or you can lose the ability to determine temperature or the position of your feet. If you have lost sensation, you need to pay special attention to care for your feet and protect them from injury. You can step on something and not feel it or burn your feet with your bath water. If you don't realize it and treat it, you can get an infection.

Dealing with the pain of neuropathy can be difficult. Many people find that their pain gets better when their glucose levels are lower. Some even notice that their pain will be worse when their blood glucose levels go up temporarily. Walking may also help to decrease calf pain.

Several types of medications can be used for pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) are generally the first medications that are tried. Others include low doses of antidepressants, antiseizure medications, and drugs designed specifically for neuropathy pain. Medicines that contain narcotics are generally not used unless the pain is very severe. Lidocaine patches can be used to numb the area, and a high-potency cream (capsaicin) can be rubbed on the area.

If these therapies aren't effective, ask for a referral to a pain clinic. There are also less conventional methods to treat the pain. Biofeedback training, hypnosis, relaxation exercises, acupressure, acupuncture, and use of a TENS (transcutaneous electrical nerve stimulation) unit have all been effective for some people.

Focal Neuropathy. This is a condition due to damage to a single nerve or group of nerves. It may develop when the blood supply to a nerve is shut off because of a blockage in the blood vessel that supplies the nerve. Or it could result from a nerve being pinched. Focal neuropathy can injure nerves that sense touch and pain as well as nerves that move muscles. Fortunately, it is not usually a permanent condition. It usually goes away within 2 weeks to 18 months.

Carpal tunnel syndrome, a type of focal neuropathy, occurs about three times more often in people with diabetes than in the general population and more often in women than in men. It occurs when the median nerve of the forearm is squeezed in its passageway, or tunnel, by the carpal bones of the wrists. It can cause tingling, burning, and numbness and can make you drop things you are holding without even realizing it. Suspect carpal tunnel syndrome if you have tingling in your hands or fingers that goes away when your arms are relaxed down at your sides. Carpal tunnel syndrome is often treated with splints, medication, or surgery to remove the pressure on the nerve.

Autonomic Neuropathy. Some of your nerves control parts of your body that you don't move voluntarily. These are called autonomic nerves, and when they become damaged, autonomic neuropathy can result. Autonomic neuropathy can take many different forms:

Gastroparesis: Your stomach and intestines slow down or become less efficient at emptying, leading to feeling full after a few bites of food, erratic glucose levels, nausea and vomiting, constipation, or diarrhea. Nerves to the bladder can become damaged, causing diminished sensation of bladder fullness and an inability to completely empty the bladder. Because urine can then stay in the bladder for long periods, you are at high risk for developing urinary tract infections.

Erectile dysfunction: Men may find that they cannot have an erection even though they may still have sexual desire. Women may experience vaginal dryness and a decreased sexual response.

Autonomic neuropathy can also affect blood pressure. You may find yourself feeling lightheaded or dizzy when you stand because of a drop in blood pressure. This is called orthostatic hypotension. Or when you exercise, your blood pressure may go way up.

Nerves to the skin may cause too much or too little sweating or very dry skin.

Nerves to the heart may fail to speed up or slow down your heart rate in response to exercise. That is one of the reasons it is important to get a checkup before starting any exercise program. If your heart rate doesn't respond as it should to exertion, you won't be able to use a standard method, such as counting your pulse, to find your target heart rate during and after a workout.

Treatment. Different types of autonomic neuropathy call for different treatments. Feeling full or bloated may be helped by eating small frequent meals instead of three large ones. Medications, such as metoclopramide, can help food to move through your stomach. There are other medications and dietary adjustments that you can use to treat constipation or diarrhea.

Incontinence, or urine leakage, can be treated by training in bladder control and timed urination using a planned bladder-emptying program. Rather than waiting until your bladder feels full, you can try urinating every 2 hours. Men sometimes find it easier to urinate sitting down. Applying pressure over the bladder may also be helpful. If these steps don't work, oral medication may be needed. Or you may need to use a catheter or have surgery. Fecal incontinence (passing stool involuntarily) is treated in a similar way, with medicine for diarrhea and biofeedback training.

If you are experiencing a sudden drop in blood pressure when you stand up, there are several treatment options. If you drink alcohol or take medications, such as diuretics, ask your provider about stopping them. Other options include medications for low blood pressure, raising the salt content of your diet, or raising the head of your bed. However, low blood pressure in itself is not unhealthy. It only becomes a problem if it makes you dizzy or disoriented. Try to stand up more slowly and avoid staying still for long periods to prevent fainting. When you get up in the morning, sit on the edge of the bed before you stand up.

Sometimes neuropathy can trigger a cascade of diabetes-related complications. For example, many people who have had diabetes for a long time develop a condition known as Charcot's foot. This disorder usually affects weight-bearing joints, such as the ankles. It may start with a loss of feeling and thinning of bones in the feet. This can lead to a painless frac-

ture. Because the injury doesn't cause pain, it can go unnoticed and untreated. You may continue walking on the fracture, making matters worse. Muscle shrinking (atrophy) and joint damage can occur and add to the damage, which can become severe enough to deform the foot. The key to treating Charcot's foot is early non-weight-bearing. This involves keeping weight off the joint and wearing special footwear. If you notice any swelling in a joint, especially in your ankle or foot, see your provider right away.

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