Published in "Panorama"
When you have Diabetic Neuropathy
50% of diabetics have some form of neuropathy, but not all with neuropathy have symptoms. Worldwide, 50% of all leg amputations are of diabetics and in 85% of these cases, it begins with a foot ulcer. While usually it takes 5-10 years of diabetes before patients start feeling symptoms of neuropathy, the highest rates of neuropathy are among people who have had the disease for at least 25 years, reveals Dr.K.R.Suresh, Director, Jain Institute of Vascular Sciences, Bhagwan Mahavir Jain Hospital, Bangalore.
Dr.Suresh explains the disorder, “Diabetic neuropathy is a condition where there is damage to nerves caused by diabetes. Since diabetes affects all the end organs, it can cause nerve damage anywhere in the body but we that most of the neuropathy in diabetes, occurs in the legs.”
Any diabetic should be considered at risk of neuropathy, emphasizes Dr.Sharmila Changkakoti, Physician and Neurologist, Zulekha Hospital, Sharjah. The disorder is more common in people who have elevated blood glucose levels which they find difficult to control, in individuals who have abnormally high levels of blood fat and blood pressure, in overweight and obese individuals and generally, in people over the age of 40. Though diabetics can develop nerve problems at any time, the risk is greater, the longer a person has had diabetes. Besides these factors, hereditary factors, smoking and alcoholism also contribute to neuropathy in diabetics.
Also, mechanical injury to nerves and autoimmune factors which cause inflammation in nerves, may contribute to the problem.
Symptoms depend on the type of neuropathy and upon the nerves which are affected. While some diabetics may have no symptoms at all, others experience numbness, tingling, or pain in their feet. This is often the first sign of neuropathy, explains Dr.Suresh. A person can experience both pain and numbness. The symptoms, often, are very minor initially and since it may take a number of years before nerve damage actually occurs, mild cases may go unnoticed for a long time. Symptoms may involve the motor, sensory or autonomic nerves or combinations of all three types of nerves in varying degrees. The onset of pain may be sudden and severe in focal neuropathy where specific nerves involving the legs, head or torso, get affected. This may result in paralysis on one side of the face, inability to focus the eye and double vision with pain behind one eye, pain in the pelvic region, abdominal region, chest.
Problems may also arise involving systemic organs like the heart, sex organs and digestive organs with diarrhoea, constipation, nausea and vomiting. There may be bladder and bowel dysfunction. Weight loss and depression may accompany diabetic neuropathy though they are not in themselves symptoms of the disorder.
Diabetics also tend to develop nerve compressions or what are called entrapment syndromes, explains Dr.Suresh. Carpal tunnel syndrome is one of the commonest wherein the patients experience tingling and numbness of the hand, sometimes accompanied by muscle weakness or pain.
Dr. Suresh elaborates on the complications that untreated diabetic neuropathy can cause to the patient’s feet, “In sensory neuropathy that affect the feet, all the sensations in the region are gone and these patients, they don’t feel the ground when they walk. The worst part is that if they get injured with a cut or if there’s a foreign body – a stone, nail, in their shoes, they don’t feel it and keep walking on it. It will be 3-4 days before they realize they are injured unless they start seeing pus, swelling, or get fever. Even then they would not know when they were hurt!
Many of these injuries, at least in the Third World countries, happen at home because of the habit of walking bare feet. Also, in these countries, the infection rate is high. These factors, coupled with the fact that healing is anyway slower in diabetics, the whole problem is aggravated.”
Bent or claw toes, again, are associated with motor neuropathy, explains Dr.Suresh. “In a healthy individual, the feet are structured to walk in a certain way. So when you walk, the first stress is on the heel, following which, the body’s weight is transferred along the sides of the feet and then to the first and second toes. In this sequence of events, the arch of the feet do not touch the ground. However, in diabetics, this balancing function of the feet may develop dysfunction or even paralysed. The result is an abnormal looking claw or bent toes. So when a diabetic develops this abnormal foot, the weight is transferred all over the foot instead of the sequential heel-side-toe distribution of weight. They almost stamp their foot down and the pressure points are redistributed, making the foot out of shape, with every area of the foot taking weight. Then infection from injury spreads more easily, often leading to loss of legs.”
Similarly when the autonomic nerves are affected, there may be swelling of the leg, warm dry feet and no sweating. These conditions make the diabetic more prone to sores, cracks, fissures and infections of the foot there from, cautions Dr.Suresh. “And the combination of these three types of neuropathy can be lethal, not just for the foot, but for the leg itself. Once there’s a minor injury which goes unnoticed and it becomes infected, it can spread very rapidly along the foot and patients can lose their leg, even life, in a very short span of time, in a few days.”
Dr.Sharmila adds, Charcot joint or neuropathic arthropathy is another result of diabetic neuropathy, wherein the joints are deprived of pain and position sense. This condition, yet again, makes the individual susceptible to injury. Also, nourishment for the joint is diminished since the blood circulation in a diabetic foot is abnormal. These factors together can cause severe damage in the joints in the foot. These joints may have to be surgically repaired.
How is neuropathy in diabetics diagnosed, especially if there are no symptoms to suspect the disorder? Dr.Suresh emphasizes, “Every diabetic is at potential risk of developing the disorder. Hence a routine check of the feet are anyway in order. For those exhibiting symptoms, clinical examination of the feet is a starting point. A comprehensive foot examination is done to assess skin, circulation and sensation. A nylon monofilament weighing about 10 gm, which resembles a bristle on a hair brush is used to touch the foot, to check for sensation. Simple pinprick tests are also used for the purpose, without causing injury to the foot. Nerve conduction studies are made to observe the transmission of electric current through a nerve. If the nerve impulse is slower or weaker than normal, it might indicate possible nerve damage. Electromyography indicates the response of muscles to electrical signals transmitted by nearby nerves.
Again, slower or weaker response, is suggestive of nerve or muscle damage. Other tests to diagnose neuropathy include using response to stimuli such as temperature, pressure and vibration.”
How is diabetic neuropathy treated? Dr.Suresh emphasizes, “You cannot cure it. You cannot stop neuropathy, but blood sugar control is a must if you need to check further progression of the condition. There are no medicines for the purpose but what you can do is control and prevent the damages that can occur by taking measures to control the causative or risk factors, in this instance, diabetes. Besides, there are various drugs including vitamin B complex and anti-convulsants which control the symptoms of diabetic neuropathy, but they cannot diminish the neuropathy itself.”
The doctors elaborate on the preventive and treatment modality.There is no doubt that individuals who are diabetic, should take special care of the feet and footwear since the nerves of the feet are the longest in the body and also the ones most affected by neuropathy. Almost most of the times, loss of a leg in diabetes, starts with a small ulcer in the foot. And this is very much preventable to taking certain simple measures:
• Wash your feet clean with warm water and soap at least three times a day.
• Dry the feet well after washing them and after a bath, especially between the toes.
• Inspect your feet and toes for sores, cuts, blisters, ulcers or any abnormalities, using a mirror. Else, involve family members to inspect them.
• Apply moisturizing lotion on the feet.
• Make sure to trim your toe-nails regularly.
• Use appropriate footwear that fit you well and allow your toes free mobility.
• Always use your footwear while walking, to prevent feet from getting hurt.
• Before getting into your shoes, check them inside for any tears, or objects like stone, that might have got into them and might hurt you.
• Use thick, soft socks to prevent skin irritation.
It is very common for people to use hot water fomentation for pain in their feet. Do not do this since your feet may have no sensation and this can cause you to burning your feet with the hot water. Should you need to use such fomentation, first feel the water with your elbow which has normal sensation, or get someone else to feel the water for you.