Diabetes - Padda Institute Center for Interventional Pain Management

Diabetes and Neuropathy

Diabetic Peripheral Neuropathy (DPN) is the most common complication of diabetes, and often presents as a distal, symmetric, sensorimotor neuropathy. In the United States, 26.8 million people are affected by diabetes; by the year 2030, that number is predicted to increase to approximately 35.9 million people.

In the U.S. alone, the annual total direct medical and treatment costs of diabetes were an estimated $44 billion in 1997, representing 5.8 percent of total personal healthcare expenditures during that year. When it comes to diabetic peripheral neuropathy and its complications, management is resource intensive and long-term, accounting for a large proportion of this total expenditure. In 2001, the total annual cost of diabetic peripheral neuropathy and its complications in the U.S. was estimated to be between $4.6 and $13.7 billion. Up to 27 percent of the direct medical cost of diabetes may be attributed to diabetic peripheral neuropathy.

More than half of patients who have type 1 or 2 diabetes develop DPN. Diabetes is associated with both macrovascular and microvascular complications, in which the major microvascular complication is diabetic neuropathy (DN) with a prevalence of 50–60%. The neuropathy progresses with decreasing nerve functionality and nerve blood perfusion which may result in malnourished nerve and leads to permanent nerve damage. The clinical manifestations of diabetic neuropathy include numbness, burning and tingling sensation, and intractable pain.

 

Many patients with neuropathy simply don’t now they have it

You may have nerve damage well before you experience its symptoms. The first time you may notice diabetic nerve pain symptoms is when the nerve damage has already progressed. Neuropathy is known to develop well before the patient has any symptoms, and the literature states unequivocally that the sooner treatment can be initiated, the greater the chances of reversal of the symptoms. Microvascular circulatory deficiencies, caused by errors in glucose metabolism, for example, have direct effects on the circulation to the nerves, and there are direct effects on the nerves themselves. Pain signals, in turn, trigger secondary peripheral and central hyperalgesia which enhance the body’s response to the microvascular insult. On a local level, microinflammation and edema around the nerves also contribute to the neuropathy. While this nerve damage can cause pain, it can also result in a loss of feeling in the feet and hands. Numbness can cause cuts and foot ulcers to go unnoticed. These cuts can lead to an infection. In severe cases, an untreated infection can even result in amputation.

 

DPN affects the nerves in the hands and feet, causing numbness, tingling, and pain. Clinical symptoms associated with DPN involve poor gait and balance associated with large sensory fibers and abnormal cold and/or heat sensation associated with small sensory fibers. Chronic pain associated with diabetes is represented by hyperalgesia, allodynia, paresthesias, and spontaneous pain. Symptoms are described as tingling, “pins and needles,” burning, itching, and an abnormal sensation to pain and temperature. Over time, these symptoms may advance from the toes to the foot and up the leg, and these symptoms may occur in the fingers and hands.

Tingling and Numbness

Scientists aren’t sure exactly how diabetes damages nerves. Some theorize that the excess blood sugar affects the protective coating on nerves. Others believe decreased blood flow to the nerves can cause damage.

Either way, as the disease progresses, patients may feel a tingling or numbness in the fingers, toes, hands, and feet. Patients may also report a “pins and needles” feeling, or even a burning sensation.

 

Shooting Pain

A nerve that’s pinched or suffering from damage may send out signals that cause shooting pains. People also described this sensation as an electric shock, or a sharp, stabbing pain. The sensations usually come and go, but they may also remain more constant at times.

These types of pains are most common at night, and can disturb sleep. They may also be the result of damaged nerves that are sending out mistaken signals to the brain (misfiring).

 

Inability to Feel Hot and Cold

Our nerves help us to sense the world around us. They are how we notice when we’re feeling hot or cold. They also tell us when we’ve stubbed a toe or suffered a paper cut.

When nerves are severely damaged, they can actually die off. Suddenly, you may no longer be able to tell when you’ve stepped on a tack or suffered a blister. That means small injuries can go unnoticed and untreated. This can cause more problems down the road.

 

Foot Problems

Once a person loses function in some of the nerves in the feet, they may not notice a blister, infection, or wound until it becomes infected, swollen, and inflamed. Nerve damage can also lead to changes in the shape of the toes. This can require shoe-fitting adjustments. Doctors always recommend that people with diabetes check their feet and hands daily for injuries, especially those who’ve suffered nerve damage and lack feeling in the fingers or toes.

 

Difficulty Walking and Performing Other Daily Tasks

It’s because of our nerves we can button up a shirt, create a hairstyle for ourselves, or even open a doorknob. Nerve damage in the hands and feet can make these everyday tasks more difficult or even impossible. But there are tools available that can help. Specialized orthotic inserts, diabetic shoes, and gripping tools are just a few examples.

 

Autonomic Symptoms

Did you know that nerves control the digestive system? They are also involved in perspiration, sexual function, heart rate, urinary function, and more. If diabetes affects any of these nerves, patients may experience the following symptoms:

  • stomach upset (constipation, diarrhea, nausea, vomiting)
  • urinary problems (incontinence or urinary tract infections)
  • erectile dysfunction or vaginal dryness
  • inability to stay warm or cool
  • difficulty focusing your eyes
  • dry, cracked skin

 

Nerve Pain and Sleep

Some nerve pain is worse at night and as a result, the individual can have difficulty sleeping. This loss of sleep can cause additional problems so people with this type of nerve pain need to discuss the problem with their doctor to receive early treatment.

 

Coping with Nerve Damage

To avoid or limit any of these symptoms, concentrate on controlling your blood sugar levels. The more you can keep your levels in the normal range, the slower any nerve damage will progress. Exercise regularly, manage your weight, and take steps to reduce stress.

Talk to your doctor about lifestyle changes and tools that can help you cope once nerve damage has occurred. Medications and specific treatment methods are also available to help reduce symptoms. Your doctor is your partner in controlling nerve pain. By answering all questions asked (pain type, duration, and how it has changed your lifestyle), you help your doctor to determine the cause of the pain and how to treat it.

 

Treating diabetic nerve pain requires a specific treatment:

Diabetic nerve pain, or painful diabetic peripheral neuropathy, is a separate condition from diabetes that is caused by high blood sugar related to diabetes. This nerve damage may cause foot pain and hand pain. If you suffer from diabetic nerve pain, you can’t undo the damage that has already occurred but it’s very important that you don’t ignore your pain either. The pain, which may get worse over time, can be treated.

Control of your blood sugar

If you have diabetes, it is important to control your blood sugar. Your doctor has probably tested your A1C level before. This measures your average blood sugar level over the past 3 months. The American Diabetes Association recommends a goal of 7% or lower.

Do something about your diabetic nerve pain

Controlling your blood sugar can prevent further nerve damage. However, that won’t reverse the damage or relieve your diabetic nerve pain. And since nerve pain isn’t like other kinds of pain, you may need to receive a specific diabetic nerve pain treatment.

 

What treatment options are available for diabetic nerve pain?

The most common approach is oral medications that only mask the symptoms.

  • 50 percent of patients with diabetic peripheral neuropathy receive treatment with opioids
  • 40 percent take anti-inflammatory drugs
  • 20 percent use serotonin selective reuptake inhibitors (SSRI)
  • 11 percent take tricyclic inhibitors
  • 11 percent take anticonvulsants (Neurontin and Lyrica).

 

Although there is a range of pharmacological agents available for treating the pain associated with diabetic neuropathy, only duloxetine and pregabalin are approved by US Food and Drug Administration (US FDA) for the treatment of diabetic neuropathic pain. The “gold standard” in treating peripheral neuropathy, pregabalin (Lyrica, Pfizer), helps 39 percent of patients achieve a 50 percent reduction in their discomfort and pain, but causes at least 38 percent to have complications. These medications have drawbacks and major adverse effects.

 

Over-the-counter pain relief pills are not approved by the FDA to treat this specific pain. Diabetic nerve pain is a form of nerve pain, a unique type of pain that is different than other types of pain, like pain from a headache, muscle ache, arthritis or sprained ankle. Over-the-counter pain relief pills are not approved by the FDA for the treatment of diabetic nerve pain.

 

What is Combined Therapy?

Combined therapy incorporates two well established procedures that have been combined into a protocol that is showing great promise as an effective treatment solution for diabetic and idiopathic neuropathies. Combined therapy consists of two procedures, an ankle block performed with local anesthetic, and Electronic Signal Treatment (EST), as delivered by a unique sophisticated electroanesthetic wave generator.

 

Ankle Block

The ankle block targets five nerves responsible for sensory supply distal to the ankle. The nerves consist of four branches of the sciatic nerve (the superficial peroneal, the deep peroneal, the sural, and the posterior tibial nerve) and one cutaneous branch of the femoral nerve (the saphenous nerve). The sciatic nerve gives off two terminal branches, the common peroneal and the tibial nerve.

 

Electronic signal treatment

EST is an electrical signal wave treatment that regenerates nerves and increases blood flow by using electrical waves to simulate nerve function in the damaged areas. Electronic signal treatment utilizes computer-controlled, exogenously delivered specific parameter electronic cell signals using both varied amplitudes (AM) and frequencies (FM) of electronic signals. This

digitally produced electronic sinusoidal alternating current with associated harmonics produces scientifically documented and/or theoretical physiological effects when one applies them to the human body. The electronic signal treatment medical device uses sophisticated communications technology to produce and deliver higher frequency signal energy in a continually varying sequential and random pattern via specialty electrodes. This alternation of sequential and random electronic signal delivery eliminates neuron accommodation.

With the help of 0.25% Marcaine, which is a vasodilator (opens the blood vessels for a short time to increase blood flow) and a local anesthetic. The more blood flow that your nerves get while stimulated the faster your regeneration takes place.

 

Combined therapy is believed to:

  • Increases cellular growth
  • Increases Metabolic Activity
  • Reduces swelling around the nerve
  • Stimulates nerve function
  • Increases oxygen and blood directly to the nerve
  • Promotes wound healing
  • Anti-inflammatory action
  • Reduces scar tissue development

The patient has the ability to attain increased movement once again with an effective and favorable pain management treatment plan.