Nurses frequently care for patients with one or more type of diabetic neuropathy. Approximately 50% of diabetics have some degree of nerve damage and the greatest rates occur in people who have been diagnosed with diabetes for over 25 years. The most commonly recognized symptoms of neuropathy are numbness, tingling and pain in the arms and legs. However, depending on the affected nerves, diabetic neuropathies can lead to more severe problems and even organ damage. The impact of neuropathy on quality of life is significant and may include anxiety, depression and loss of mobility. This will provide a review of not only peripheral neuropathy but will help give you an understanding of all four types of diabetic neuropathy- peripheral, autonomic, proximal and focal.
High blood glucose sustained over a long period of time is the most common cause of diabetic neuropathy. Other contributing factors include damage to blood vessels caused by high cholesterol levels, mechanical injury (i.e. carpal tunnel syndrome) and lifestyle factors, such as alcohol use or smoking.
Peripheral neuropathy, also known as distal polyneuropathy, is the most common form of diabetic neuropathy. Nerves branch off of the spinal cord in the lumbar region and form a long network to the arms and legs. This type of neuropathy causes nerve damage typically in the legs first and then arms as the disease progresses. It is not unusual for diabetics to have no symptoms of neuropathy, but signs are evident upon assessment.
Peripheral neuropathy symptoms
Numbness, tingling, burning or prickling sensations
Sharp pains or cramps
Decreased ability to feel pain or temperature changes
Increased sensitivity to touch
Loss of reflexes (especially in the ankle)
Loss of balance/coordination
Serious foot problems- ulcers, infections and joint pain
These symptoms are usually worse at night. Muscle weakness may cause gait issues, increasing fall risk. Hammertoes and collapse of the midfoot, as well as other foot deformities, may occur as the disease progresses. Decreased sensation in the feet increases risk of blisters and sore that may cause infection. The infection risk is increased when foot injury is not treated promptly and may spread to the bone and foot leading to amputation. It is estimated that 50% of all such amputations if treated in time could be avoided.
This type of neuropathy damages the nerves that control involuntary body functions and interferes with messages sent from the brain to other organs and the autonomic nervous system. Presenting symptoms will depend on the severity of nerve damage and where it has occurred.
Autonomic neuropathy symptoms
Orthostatic hypotension- dizziness or faintness when standing
Bladder problems- hesitancy, incontinence, retention and increased urinary infections
Sexual problems- erectile dysfunction and ejaculation problems in men, vaginal dryness, low libido and difficulty reaching orgasm in women.
Poor appetite, difficulties with food digestion, nausea, vomiting, diarrhea, swallowing problems and heartburn
Inability to recognize hypoglycemia
Difficulty regulating body temperature due to sweating abnormalities
Slow pupil reaction with difficulty adjusting to light
Activity intolerance due to nerve messages not received to adjust heart rate to activity level
People who chronic poorly managed hyperglycemia are at the greatest risk of autonomic neuropathy.
Proximal Neuropathy (diabetic amyotrophy)
Proximal neuropathy begins with pain in the thighs, hips, buttocks or legs. The pain is typically on one side of the body and more common in type 2 diabetes and in older people. Proximal neuropathy causes weakness in the legs leading to difficulty going from sitting to standing without assistance of another person. Treatment and recovery time depends on the type of nerve damage.
Symptoms of proximal neuropathy
Difficulty standing without assistance
Sudden, severe pain in the hip, thigh or buttock on one side of the body
Overtime- weak thighs with loss of muscle
Abdominal swelling if abdomen affected
Focal Neuropathy (Mononeuropathy)
Focal Neuropathy is unpredictable, occurs suddenly and affects specific nerves. The affected nerve usually causes pain in the head, torso or leg and may last weeks to months. Fortunately, focal neuropathy usually resolves on its own with no long-term effects. Older individuals are at higher risk, although diabetics at any age can have focal neuropathy.
Symptoms of focal neuropathy
Difficulty focusing the eye and/or double vision
Pain behind one eye
Bell’s palsy (paralysis on one side of face)
Severe pain in lower back or pelvis
Pain in front of thigh
Pain in chest, stomach or flank
Pain on the inside of the foot or outside of the shin
Chest or abdominal pain
The chest and abdominal pain may be mistaken for other conditions (heart disease, appendicitis etc). Entrapment syndromes, such as carpal tunnel syndrome, are also common in people with diabetes.
Treatment of Diabetic Neuropathies
First line treatment of diabetic neuropathies is long-term and consistent blood glucose management. Additional interventions for prevention, delaying or treating diabetic neuropathies may include treating and managing high blood pressure, weight control and healthy lifestyle changes. Prescribed medications are often used to relieve pain and may include:
Anti-seizure drugs- pregabalin (Lyrica), gabapentin (Neurontin) and carbamazepine (Tegretol)
Antidepressants- Tricyclics imipramine (Tofranil), desipramine (Norpramin)
SNRIs- duloxetine (Cymbalta), venlafaxine (Effexor XR)
Managing complications and restoring function
Management of complications will depend on the specific neuropathy present and may require referrals to medical specialists, physical and occupation therapists. Complications requiring treatment may include:
Urinary tract problems
The cause of diabetic neuropathy is multifactorial with high blood glucose being the most common. The effects on the body range from mild to severe with the potential to significantly impact quality of life
All four types of diabetic neuropathies can be delayed, prevented and treated with consistent management of blood glucose. The damage caused to nerves can affect areas throughout the body, significantly impacting mobility and quality of life. Patient education is important to promote good foot care and prompt follow-up with any problems. Lifestyle changes, such as smoking, alcohol intake and exercise are also important in the prevention and treatment of neuropathy.
How do you approach diabetic neuropathy in your practice?
American Academy of Neurology, Evidence-based practice guidelines for painful chronic neuropathy.
National Diabetes Education Initiative, Diabetes management guidelines.
American Diabetes Association- Resources for professionals