1. Diabetes and Nerve Problems

2. 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.

3. Diabetes
“Mild Disease”
Serious consequences

4. 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

5. 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

6. 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

7. 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

8. 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

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. Outro