Diabetic neuropathy: a question and an answer

One of the readers of my blog emailed me this query. A very good question and I wanted to reproduce it here, my answer follows.

Bree Johnson on November 28, 2008 said: Edit Link

I am very confused about whether I have diabetic neuropathy or not. I have been a diabetic for 21 years. A podiatrist confiremd recently that I have VERY good sensation in the feet & there is no evidence of neuropathy. I do not experience any numbness, pins & needles as such but I do have signficant pain at times in the my feet. The pain is largely due to a heightenend sensitivity at skin level. For example having things brush against my skin is unbearable, or putting on my shoes is also uncomfortable or walking on rough surfaces. But applying direct pressure on my feet – as in reflexology – is not painful. The podiatrist could not explain what this heightened sensitivity is due to.

I am however prone to occasional bouts of deep aching pain the feet & legs – which seems to always be the case now when I am a bit rundown & tired.

I also do have electrical type of stabbing pains that come & go – they can be quite painful stabs. Again they seem to be apparent only when rundown & tired.

Can you please offer any comments on the above? It would be greatly appreciated.

Bree

Dear Bree,

Thank you for writing in. You ask a very good question and that is what I shall attempt to answer. First at the onset let me tell you that most diabetics (especially those who have had long standing diabetes, in your case for over 21 years) shall have clinical evidence of diabetic neuropathy if one subjects them to a thorough clinical examination and electrodiagnostic testing (we use tests like nerve conduction velocities (NCV) and electromyogram (EMG) to unearth evidence of nerve damage/ neuropathy).  

Diabetes can cause different kinds of neuropathies depending upon what kind of nerves are preferentially involved:

(large nerves that carry sensations like joint sense and vibration versus smaller nerves that carry sensations of crude touch, pain and temperature)

(motor nerves that help in moving muscles and joints versus sensory nerves which carry sensation)

THE MOST COMMON NEUROPATHY THOUGH IN DIABETES IS A MIXED MOTOR SENSORY POLYNEUROPATHY WHICH USUALLY INVOLVES THE SMALL NERVES WHICH CARRY SENSATIONS LIKE PAIN, CRUDE TOUCH AND TEMPERATURE. MEANING THAT AT LEAST INITIALLY IN THE DISEASE COURSE THE MOTOR NERVES AND THE LARGE SENSORY NERVES (CARRY SENSATIONS OF VIBATION, JOINT SENSE AND POSITION SENSE) MAY BE SPARED OR AT LEAST WE DO NOT SEE EVIDENCE OF THEIR DEGENERATION ON NERVE CONDUCTION TESTING.

Patients who have small nerve fiber involvement commonly have what we refer to as allodynia and hyperpathia. What is allodynia you may ask?

Well allodynia is when a normally non-painful stimulus becomes painful. Let me explain with the aid of an example. You are lying in the bed, settling down to sleep. You pull the sheets over your bare legs. The sheets touch your legs, now they are silk sheets that is not a painful stimulus. But a patient with diabetic neuropathy may find it excruciatingly painful. THERE THAT IS ALLODYNIA.

They also have hyperpathia. What is hyperpathia? Well lets take another example. I take a pin and stab you with it. Now that is a painful stimulus and everyone shall find it so.  A normal person may say “ouch”, a patient with diabetic neuropathy though may jump out of his seat. SO HYPERPATHIA IS WHEN YOU FEEL A GREATLY EXAGGERATED PAIN SENSATION TO A PAINFUL STIMULI.

So in conclusion, it is more that likely that you have diabetic neuropathy. My advise to you would be to see a neurologist. If you do indeed have diabetic neuropathy, there are many good medicines out there that can treat the pain and more over prevent the progression of this painful and disabling condition.

Personal Regards,

Nitin Sethi, MD

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3 thoughts on “Diabetic neuropathy: a question and an answer

  1. Hi;

    This complaint is actually quite common. Having diabetes does not necessarily mean that any nerve-related pain is ‘diabetic neuropathy.’ What is quite common, however, is B-12, B-6, D-3, thiamine and magnesium deficiencies. Diabetics have notoriously poor absorbance of micronutrients, and these are the most commonly encountered vitamin/mineral deficiencies in diabetes.

    Before you proceed much further, it would be inexpensive and fairly easy to take these supplements, and see if the symptoms abate over a week or so.

    David S. Klein, MD

    1. Thank you Dr. Klein for writing in. I agree with your comments. In my experience, I too have found patients to be deficient in B1, B6, B12, carnitine and magnesium. Vitamin supplementation is relatively easy and cheap and should be attempted in all patients. There is some evidence to suggest that neuropathies such as diabetic and alcoholic neuropathies are nutritional to some extent, due to either marginal diets or malabsorption.

      Personal Regards,
      Nitin Sethi, MD

  2. Dear Bryan,
    thank you for writing in. Some of the negative symptoms of neuropathy can be particularly distressing and notoriously difficult to treat. These include feeling of numbness, legs feel dead or wooden and a cold clammy feeling in the affected limbs.
    As I mentioned above these symptoms are harder to treat as compared to positive symptoms of neuropathy such as pain, tingling and pins and needle sensation.

    Personal Regards,
    Nitin Sethi, MD

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