Diabetes and Nerve Problems

What is Diabetes? Diabetes is a condition in which there is too much sugar (glucose) in the blood. Although sugar is needed to provide energy for the body, when in excess, it causes problem. Persons with diabetes have excess sugar because they lack or have deficient supply of insulin.

Diabetes “Mild Disease” Serious consequences

Diabetes Mellitus A Serious Disease Leading cause of new cases of blindness 25 times more prone to eye problems 6 times higher risk for Paralysis (stroke) 2-3 times higher risk for heart attack 5 times more prone to Kidney failure 20 times more prone to lower limb amputation Nerve damage causes loss of sensation

The Nervous System The nerves in our body serve as a communication system. The nervous system conveys messages from the brain to our legs, hands, feet and other parts of the body (peripheral nervous system) internal organs such as heart, stomach and bladder (autonomic nervous system) The nervous system sends sensations to the brain so that appropriate actions can be taken in response touch, pain, pressure, vibration and temperature smell, taste, sound, and sight

The Nervous System Long periods of high blood sugar can damage nerve fibers, impairing their ability to carry messages to and from the brain Damaged nerve fibers relay signals (sensations) slowly or don’t relay them at all Restoration of the blood sugar level quickly to with-in target range may allow damaged nerve fibers to heal and function properly again

Cause of Nerve Damage High blood sugar can harm nerve cells in two ways: High sugar level in blood causes high amount of sugar to enter the nerve cells. As the nerve cells cannot use all of it, toxic substances accumulate and affect the nerves' ability to transmit signals High blood sugar also damages the small blood vessels that carry oxygen and nutrients to the nerves

Diabetes and Nerve Problems Diabetic Neuropathy is a common complication of diabetes It does not always cause obvious symptoms. When it does, you may experience: Loss of sensation in your feet and hands Pain and other kind of discomfort These symptoms are more likely to occur during periods of poor blood sugar control

Diabetes and Nerve Problems Diabetic foot ulcers (common accompaniment to neuropathy) are a common cause of prolonged hospitalizations

Diabetes and Nerve Problems Parts most often affected Parts of the body most commonly affected by nerve problems in people with diabetes: Leg, feet and hands Genitals Eye muscles Heart Stomach Intestines Bladder

Symptoms of Diabetic Neuropathy Feet and Hands Symptoms include various types of uncomfortable feelings such as: Tingling, like a feeling of “ants crawling” or “pins and needles.” Numbness and heaviness “feeling of walking on cotton” Reduced ability to sense heat and cold Stabbing or burning pain A persistent “restlessness” in the feet and legs Extreme sensitivity to touch, even light touch Loss of balance and coordination Dry skin susceptible to cracks and infections

Symptoms of Diabetic Neuropathy Feet and Hands Most serious consequence of nerve problem is the loss of protective sensation in the feet Without an intact “pain-alarm-system,” minor injuries may occur and go unnoticed until they develop into serious foot ulcers Poorly fitted shoes can led to painless lesions that quickly develop into ulcers

Symptoms of Diabetic Neuropathy Feet and Hands Serious burns or foreign body impaction (thorns; pebbles) may occur without pain Never walk barefoot. Sharp objects can cause injury at work or home when you least expect them Don’t underestimate the importance of daily foot inspection and care – especially if you have nerve problems in your feet

Symptoms of Diabetic Neuropathy Eye Muscles Six pairs of eye muscles work together to turn both eyes in the direction of your choice. These muscles are controlled by three pairs of nerves. If blood sugar control has been poor, one or more of these nerves can be affected and can paralyse one or more eye muscles causing double vision. This can occur suddenly without warning. Severe unexplained pain behind the eye may also be due to diabetic neuropathy

Symptoms of Diabetic Autonomic Neuropathy Stomach and Intestines Nausea, vomiting, feeling of bloating and lack of appetite, because of delay in emptying of stomach Difficulty in swallowing Diarrhoea or constipation because stagnation due to poor bowel movement Weight loss Urinary Tract and Genitals infection and incontinence of the bladder due to retention of urine impotency and loss of libido (sexual response) in men and women

Symptoms of Diabetic Autonomic Neuropathy Heart and blood vessels Sudden fall in blood pressure on standing and sitting suddenly Silent heart attacks as the perception of pain of heart attack may be affected Abnormal heart beats and irregular pulse Other Profuse sweating and inability of the body to control temperature as the nerves to the sweat gland may get affected Hypoglycaemia unawareness -the body's normal response to low blood sugar is impaired, making it difficult for the person to recognize the symptoms

Symptoms of Diabetic Neuropathy You may also have serious nerve damage without any symptoms Insist on your doctor examining your nervous system when you are diagnosed or as soon as possible See a neurologist (nerve specialist) regularly for examination if and when advised by your doctor

When to Check for Nerve Problems The overall health of your nervous system should be checked as part of your regular visits to the clinic Children >10 years and adults < 30 years within 3-5 years of diagnosis and thereafter once a year Adults > 30 years at the time of diagnosis and thereafter once a year Those already diagnosed with abnormal findings need to be tested more frequently as advised by their doctor

Preventing Nerve Damage Keep blood sugar levels as close to normal as possible to slow the onset and progression of diabetic neuropathy Avoid smoking as it worsens circulatory problem increasing the risk of neuropathy Reduce alcohol drinking as it can worsen neuropathy Take Insulin, if advised

Testing for Nerve Problems Your doctor should ask you about: Vision problems Any tingling, unusual pain or numbness Any change in your ability to sweat Heart palpitations Bowel problems, such as constipation or diarrhea Difficulty emptying your bladder Problems with impotence

Testing for Nerve Problems Your doctor will examine you to check for sensations Pressure and deep sensation threshold test using a monofilament – the doctor will apply a thin sharp plastic filament to the skin on the feet and hands Vibration perception threshold using a tuning fork – the doctor will apply a vibrating tuning fork on bony prominences to check for vibration sensation Light touch sensation – using a cotton swap- doctor will lightly touch the skin of the legs and hands to check presence of light touch sensation

Testing for Nerve Problems Your doctor will examine you to check for sensations Thermal threshold to check for warm and cold sensation – using test tubes filled with hot and cold water Check reflexes – Strike parts of body with a small rubber hammer or touch parts of body to examine for reflex reactions Cold pressor test – doctor may ask you to dip your hands in ice cold water and check for changes in your pulse or heart rate Blood pressure response on standing – doctor will check BP in lying down and while standing to see if blood pressure suddenly falls on standing

Testing for Nerve Problems Other Tests Biothesiometry – to check for sensations. Biothesiometer is an electrical device that varies the intensity of vibrations Electromyography (EMG) - to check muscles response to electrical impulses transmitted by nearby nerves. A slower or weaker response suggests damage to the nerve or muscle Nerve conduction studies – to check the flow of electrical current through a nerve. Impulses that seem slower or weaker than usual indicate possible damage to the nerve ECG – to check regularity of heart rate Ultrasound - to check functioning of the bladder and other parts of the urinary tract

Treatment For Neuropathy To prevent further damage and reverse the changes of neuropathy - bring the blood sugar levels under control Take Insulin, if advised The aim of treatment is to relieve discomfort and reduce pain Appropriate medication to help relieve pain; usual pain-killers may not work well. Imipramine, Amitriptyline (anti depressants) are more efficient in such cases Insulin treatment improves painful neuropathy

Treatment For Neuropathy To reduce problems related to foot take special care of the feet Follow the rules of foot care To reduce muscle weakness Physiotherapy and physical exercise may be advised Insulin treatment is also reported to improve weakness

Treatment For Neuropathy To reduce GI symptoms – such as indigestion, bloating, nausea and vomiting Stop some types of anti diabetes medications Small frequent meals, with low intake of fat and fibre In severe cases medication may be prescribed To reduce diarrhoea Suitable medication for diarrhoea is prescribed

Treatment For Neuropathy To reduce dizziness and weakness related to postural hypotension Sit or stand slowly from lying down position Wear elastic stockings Medication may be prescribed

Treatment For Neuropathy To reduce problems affecting the urinary tract Drink more fluids Pass urine regularly every 3-4 hours Antibiotics to treat urinary infections To reduce sexual problems Counselling to help relieve stress Medication to help improve impotence in men Medication to reduce vaginal dryness and urinary tract infections in women Suction devices or Surgery for men

Conclusion It has now been proven that prevention of nerve damage- like prevention of other long term complication of diabetes- is best achieved through tight blood sugar control Take Insulin, if advised Strive to keep your blood sugar with in your target < 120 mg/dl Fasting and < 180 mg/dl PP You are in the best position to accomplish this goal through regular blood sugar testing and appropriate adjustments in your medication,diet and exercise

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