PERIPHERAL NEUROPATHY

DISORDER

Gia K. Sharma #2013-02-95

Srikanth Shanmuk #

CASHU, Belize

Instructor : Dr. M.MEDINA M.D.

2 August 2014

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.

TYPES & KINDTHE 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.

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

STRANGE FACTS

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

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 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.

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

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.

STAGING

• No-no symptoms or signs of neuropathy

• N1-asymptomatic,signs of neuropathy

• N2-symptomatic neuropathy

• N3-disabling polyneuropathy.

??? THINK ???

Is it “ Diabetic Neuropathy “

or

“ Neuropathy in a Diabetic patient “

SRIKANTH WILL TAKE OVER NOWAND EXPLAIN PATHOGENESIS

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.

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)

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.

• 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

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

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/dayGabapentin:900-3600 mg/dayPregabaline:75-300 mg/day

A MISALIGNED HINDFOOT LEADS TO CONSTANT COMPRESSION

AND OVERSTRETCHING OF THE NERVES

WHILE STANDING.

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.

The fact is - we really don’t know.

At that point the case is closed.

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.

KEEP WALKING …

WITH JOHNNY WALKER …