Importance of early detection of peripheral neuropathy in diabetic patients.
diabetic neuropathy This may include different types of neuropathies: symmetric polyneuropathy, autonomic neuropathies and other mononeuropathies and polyradiculopathies. This article will focus on Diabetic Distal Symmetric Polyneuropathy (PND) in adults with diabetes. PND affects 26–50% of people with diabetes, one third of whom will have painful PND.
Symptoms develop peripherally in the feet and toes (reflecting widespread damage in long sensory nerves) and may progress to the classic “gloves and stockings” distribution. PND can impair quality of life due to pain. Symptoms that affect and limit function, and loss of protection associated with decreased sensitivity, can lead to foot ulceration and amputation.
PND often manifests with microvascular complications including retinopathy and albuminuria.
The likelihood of PND and these other complications increases with the duration of diabetes. The course of PND can be altered by addressing modifiable risk factors such as hyperglycemia, hypertension, and dyslipidemia.
Optimization of blood glucose provides the best protection against the development of PND, as it is not currently a reversible condition. PND can often progress without symptoms, or it may be so subtle with symptoms that without testing, PND may go unnoticed.
People with PND are at risk for developing foot ulcers due to a reduced ability to detect painful stimuli. The absence or reduced ability to feel injury from chronic trauma, such as ill-fitting shoes or walking on a bone spur, leads to hyperkeratosis, tissue destruction and ulceration.
when you lose protective sensitivity, burns from heaters or hot water, ingrown or thickened nails, and fungal infections may go unnoticed and lead to ulcers. Once a foot ulcer develops, the risk of new ulcers increases in the future. Peripheral artery disease and foot deformities, such as stiff claw toes, represent the other 2 most important ulceration risk factors.
|Peripheral Neuropathy Related to Multimorbidity and Diabetes|
Most management of type 2 diabetes is done in primary care, where evidence-based treatment can improve outcomes. Over 90% of people with type 2 diabetes attending general practice in Australia live with multimorbidity.
People with type 2 diabetes and comorbidities spend up to 80 hours per month on self-management. Multimorbidity is also common in people with type 1 diabetes, spending more of their time on daily self-care. People with multimorbidity may prioritize health problems based on their quality of life, for example, prioritizing analgesia for painful PND over glycemic optimization.
It is especially important to consider patient preferences in multimorbidity, including assessing treatment burden and exploring how health conditions affect the patient’s quality of life. The problem areas in the diabetes scale allow a structured approach to identify areas of concern related to diabetes management. High levels of diabetes distress impair diabetes and blood glucose self-management, which are essential factors in preventing high-risk foot disease.
People with multimorbidity visit general practice more frequently than people without multimorbidity. This provides opportunities to carefully evaluate PND and other microvascular changes (including annual changes in urine albumin/creatinine ratio and estimated glomerular filtration rate, as well as at least biennial assessment of diabetes-related retinopathy) for the purpose of developing personalized management. Is.
While long-standing diabetes is a risk factor for neuropathy, there are other factors that can co-exist and contribute to peripheral neuropathy, such as age, alcohol consumption, vitamin B12 deficiency. and thyroid disease.
|Causes of peripheral neuropathy in people with and without diabetes|
|To. Alcohol use, autoimmune conditions (e.g., rheumatoid arthritis, sarcoidosis, systemic lupus erythematosus)|
|B. Vitamin B12/B6 deficiency|
|C. chronic kidney disease|
|D. Medications (for example, metronidazole, nitrofurantoin; amiodarone; phenytoin; colchicine; chemotherapy agents: vincristine, cisplatin, and paclitaxel).|
the risk of Vitamin B12 deficiency When metformin is used this increases to about 20% after 5 years. Further study of vitamin B12 is needed for worsening of peripheral neuropathy in people with type 2 diabetes taking metformin.
|Diagnosing diabetes-related peripheral neuropathy|
One-fifth of people with type 2 diabetes will have symptoms of diabetes-related distal symmetric polyneuropathy (DNP) at the time of diabetes diagnosis.
PND is a clinical diagnosis, and the extent and progression of the neuropathy should be documented. Since PND is often asymptomatic, guidelines recommend annual screening to find evidence of PND diagnosing type 2 diabetes. Recently, the National Diabetes Service Scheme has launched learning modules that can help assess diabetes practice. Foot health.
Symptom assessment and relevant test findings, specific to the diabetic foot, are summarized in the table below. A history of foot ulcers, inability to feel a 10-G monofilament, or absence of a pedal pulse reliably identifies future risk of foot ulcers.
|Symptoms and signs of distal symmetric polyneuropathy|
|symptoms||, Asymptomatic (50%)
, Numbness, tingling, lack of balance (large myelinated fibers)
, Pain, burning, electric shock, shooting (small myelinated fibers)
|significant medical history||, hind leg ulcer
, lower extremity amputation
, peripheral artery disease or intermittent claudication
, History of chronic kidney disease
, smoking history
|guided examination||, inspection: Hair loss, atrophy, ulcers on toes and metatarsal heads, any pressure areas, calluses, superficial infections, fungal nail infections, wasting of intrinsic muscles of the foot associated with claw toes, anhidrosis, cracks in the skin
, vascular status: Touching the pulses of the feet;
, pressure sense: 10 grams monofilament to test sensitivity
, vibration sense:128Hz tuning fork behind the big toe
, ankle and knee reflexes
, move evaluation
|Patient-reported outcome measures to support the assessment of diabetes-related peripheral neuropathy.||, Symptom Score for Diabetic Neuropathy|