Neurology topic presentation on diabetic neuropathy

1. PERIPHERAL NEUROPATHY
DISORDER
Gia K. Sharma #2013-02-95
Srikanth Shanmuk #
CASHU, Belize
Instructor : Dr. M.MEDINA M.D.
2 August 2014

2. UNDERSTANDING PERIPHERAL NEUROPATHY -
THE BASICS
Knowing Peripheral Neuropathy :
Peripheral : Beyond (in this case, beyond the brain and the spinal cord.)
Neuro : Related to the nerves
Pathy : Disease
Peripheral neuropathy refers to the conditions that result when nerves that carry
messages to the brain and spinal cord from the rest of the body are damaged or
diseased.

3. TYPES & KIND
THE SIGNS AND SYMPTOMS OF DIABETIC NEUROPATHY VARY, DEPENDING ON THE TYPE OF
NEUROPATHY AND WHICH NERVES ARE AFFECTED.
Mononeuropathy – Pain, Tingling, Burning in the arms and shoulder.
Polyneuropathy - Tingling, Numbness, Loss of Sensation in the arms and legs
There are three kinds of diabetic neuropathy.
1. Peripheral neuropathy is damage to peripheral nerves. These are the nerves that sense pain,
touch, hot, and cold. They also affect movement and muscle strength. The nerves in the
feet and lower legs are most often affected. This type of nerve damage can lead to serious
foot problems. The damage usually gets worse slowly, over months or years.
2. Autonomic neuropathy is damage to autonomic nerves. These nerves control things like your
heartbeat, blood pressure, sweating, digestion, urination, and sexual function.
3. Focal neuropathy affects just one nerve, usually in the wrist, thigh, or foot. It may also
affect the nerves of your back and chest and those that control your eye muscles. This type
of nerve damage usually happens suddenly.

4. DIABETIC PERIPHERAL NEUROLOGY
BEING NUMB AND IN PAIN AT THE SAME TIME
• It is the most common type of disorder of peripheral neuropathy
• Nerve damage in the feet
• Most common symptoms : Loss of Sensation ( numbness ) and Pain
• The leading cause is diabetes
• The exact cause is unknown, nerve damage combined with hyperglycemia an Ischemia is
believed to be the main cause
• In the nerve tissue the capillary is damaged and reduced blood supply to neural tissues
that leads to nerve impairment
• Effects Sensory : Pain, Touch, Temperature , Motor : Muscle control and Autonomic
nerves : sweating and digestion

5. STRANGE FACTS
The unfortunate
fact is that once a
patient presents to a
doctor with nerve
symptoms the first
thought the doctor
has
is:

6. Type I diabetics don’t
usually develop
signs/symptoms of
peripheral neuropathy until
they are in their 40s/50s.
The average age of diagnosis
of Type I DM is 14 years old
Type II diabetics aren’t
usually diagnosed until they
are middle age or older (50
years +)
Unfortunately, that number
is getting younger due to an
increase in type II pediatric
diabetes.
It is estimated that
someone loses a leg
every 18 minutes as
an ultimate
complication from
neuropathy
Did you know there is
one main nerve
collecting all of the
sensations from the
bottom of the foot?
Type I diabetics are
potentially affected with
this nerve condition after
decades of chronic
uncontrolled blood sugar
levels,
while
Type II diabetics can have
signs/symptoms of
neuropathy after only a few
years of diagnosis.

7. 7 CLASSIC SYMPTOMS
1) Feeling Numbness : A common symptom of diabetic peripheral neuropathy is
numbness.
2) Shooting Pain : Sometimes pain will feel sudden and sharp, like an electrical
current.
3) Loss of Balance : Loss of coordination is a common sign of diabetic peripheral
neuropathy.
4) My Foot Looks Funny : One type of deformity is called hammertoe.
5) Why Am I Sore : Sores or blisters on your feet that you can't explain.
6) Hot and Cold : Exaggerated sensations.
7) When Pain Affects Sleep : A bed sheet feels extremely heavy and painful.

8. WHAT CAUSES DIABETIC NEUROPATHIES?
• Metabolic Factors : such as High Blood Glucose, long duration of diabetes,
Abnormal blood fat levels and possibly low levels of Insulin.
• Neurovascular Factors : leading to damage to the blood vessels that carry
Oxygen and Nutrients to nerves.
• Autoimmune Factors : that cause inflammation in nerves.
• Mechanical Factors : injury to nerves.
• Lifestyle Factors : such as Smoking or Alcohol use

9. COMPLICATIONS
• Loss of a limb : The risk of infection is high because diabetes reduces blood flow to your feet.
• Charcot joint : It is marked by loss of sensation, as well as swelling, instability and sometimes
deformity in the joint itself.
• Urinary tract infections : Allows bacteria to multiply in your bladder and kidneysHypoglycemia
unawareness. Normally, when your blood sugar drops too low
• Low blood pressure : Damage to the nerves that control circulation
• Digestive problems : Damage to the nerves in the digestive system can cause a range of
problems, including severe constipation or diarrhea.
• Sexual dysfunction : Autonomic neuropathy often damages the nerves that affect the sex
organs,
• Increased or decreased sweating : When the sweat glands don't function normally, (anhidrosis)
• Social isolation : Isolated and depressed.

10. STAGING
• No-no symptoms or signs of neuropathy
• N1-asymptomatic,signs of neuropathy
• N2-symptomatic neuropathy
• N3-disabling polyneuropathy.

11. ??? THINK ???
Is it “ Diabetic Neuropathy “
or
“ Neuropathy in a Diabetic patient “

12. SRIKANTH WILL TAKE OVER NOW
AND EXPLAIN PATHOGENESIS

14. PATHOGENESIS
• Increased Aldose Reductase activity.
• Auto oxidation of glucose
• Non enzymatic glycation of protein (AGE)
• Activation of protein kinase C : PKC is implicated in the pathology of diabetic
neuropathy. Increased levels of glucose cause an increase in intracellular
diacylglycerol, which activates PKC. PKC inhibitors in animal models will increase
nerve conduction velocity by increasing neuronal blood flow.
• Oxidative stress
• Decrease essential fatty acid
• Reduced serum levels of nerve growth factor
• Nerve ischemia/hypoxia.

16. TEST & DIAGNOSIS : INVESTIGATION.
• Quantitative sensory testing. This noninvasive test is used to assess how your
nerves respond to vibration and changes in temperature.
• Autonomic testing. If you have symptoms of autonomic neuropathy, your doctor
may request special tests to look at your blood pressure in different positions and
assess your ability to sweat.
• Diabetic neuropathy is usually diagnosed based on your symptoms, your medical
history and a physical exam. During the exam, your doctor is likely to check your
muscle strength and tone, tendon reflexes, and sensitivity to touch, temperature
and vibration.
• The American Diabetes Association recommends that all people with diabetes have
a comprehensive foot exam — either by a doctor or by a foot specialist (podiatrist)

17. CONT.
• Filament test. Sensitivity to touch may be tested using a soft nylon fiber called a
monofilament. If you're unable to feel the filament on your feet, it's a sign that
you've lost sensation in those nerves.
• Nerve conduction studies. This test measures how quickly the nerves in your arms
and legs conduct electrical signals. It's often used to diagnose carpal tunnel
syndrome.
• Electromyography (EMG). Often performed along with nerve conduction studies,
electromyography measures the electrical discharges produced in your muscles.

18. • Urinalysis for
protein/glucose/microscopy-for
evidence of nephropathy.
• HbA1c/glucose
• Urea and electrolytes
• LFT including GGT
• Thyroid function tests
• Serum protein electrophoresis
• Vitamin B 12 levels.
• Assess symptoms - muscle weakness,
muscle cramps, prickling, numbness or
pain, vomiting, diarrhea, poor bladder
control and sexual dysfunction
• X-ray
• Ultrasound
INVESTIGATIONS
RECOMMENDED

19. TREATMENT
• Glucose control
• Pain control
• Tricyclic antidepressants
• Topical creams
• Anticonvulsants
• Foot care
• Physiotherapy
• Acupuncture
• Acupressure
Treatment for diabetic neuropathy
focuses on:
• Slowing progression of the disease
• Relieving pain
• Managing complications and restoring
function

21. ALPHA LIPOIC ACID
ALDOSE REDUCTASE
INHIBITOR
ANTIDEPRESSANTS
Antioxidant
600 mg/day iv for 5 days ×14 days.
Improves neuropathic symptoms
including pain.
Clinical trials has consistently shown
benefit over placebo.
Tolrestat , epalrestat , ranirestat,
fidarestat are available.
Potentially slow or reverse progression
of neuropathy.
Clinical trials fail to show any benefit
over placebo.
Amitriptyline, nortriptyline, imipramine,
paroxetine, duloxetine are commonly used.
Efficacy is similar within the class.
Useful when secondary depression coexists.
Side effects are bothersome in elderly.
Duloxetine hydrochloride
-dual uptake inhibitor
-dose:20-60 mg/day
-nausea , sedation &sleepiness
ANTICONVULSANTS
Carbamezipine , Gabapentin ,
pregabaline are often used.
Used alone or as add on therapy
to tricyclics.
Well tolerated.
Carbamezipine:200-600 mg/day
Gabapentin:900-3600 mg/day
Pregabaline:75-300 mg/day

23. A MISALIGNED HINDFOOT LEADS TO CONSTANT
COMPRESSION
AND
OVERSTRETCHING OF THE NERVES
WHILE STANDING.

24. HYPROCURE®
is a titanium stent that is inserted into a naturally occurring space (sinus
tarsi) in between the ankle & heel bones. This minimally invasive soft tissue
procedure instantly maintains the natural opening of the sinus tarsi while
restoring the normal motion and alignment of the hindfoot bones.

25. The fact is - we really don’t know.
At that point the case is closed.

26. Keep coming back for check-ups so that we can monitor
how bad it is getting.
It will only get worse.
Sure, you can try to keep
your blood sugar under
control.
You can take vitamin supplements and wear cushioned
shoes.
Have you ever taken a look
at the possible side-effects of
those pills?
You might be surprisYou can
take vitamin supplements
and wear cushioned
shoes.ed.
If you develop painful neuropathy
we will offer you pills to mask the
pain.

28. KEEP WALKING …
WITH JOHNNY WALKER …