Findings on neurological examination vary from no abnormalities to sensory loss and hyperaesthesia in a complete dermatomal pattern; sometimes just the ventral and dorsal rami are involved. Again, the pathogenesis of diabetic truncal radiculoneuropathy is not well understood.
Painful Diabetic Neuropathy in Clinical Practice : Andrew Boulton :
The acute onset of symptoms suggests a vascular cause, whereas its occurrence in patients with poorer glycaemic control indicates a metabolic basis. This diagnosis is often overlooked and the patient simply labelled as having diabetic amyotrophy or polyneuropathy, which, unlike CIDP, has no specific treatment.
Autonomic Neuropathy 19 By contrast, progressive symmetric or asymmetrical motor deficits, progressive sensory neuropathy in spite of optimal glycaemic control, together with typical electrophysiological findings and an unusually high cerebrospinal fluid protein level all suggest the possibility of an underlying treatable demyelinating neuropathy.
A variation of the peripheral diabetic polyneuropathies, diabetic autonomic neuropathy can involve the entire autonomic nervous system. It may be either clinically evident or subclinical, and is manifested by dysfunction of one or more organ systems e. Clinical symptoms generally do not arise until long after the onset of diabetes. It results from damage to the nerve fibres that innervate the heart and blood vessels, and results in abnormalities in heart rate control and vascular dynamics.
The earliest indicator of CAN is reduced heart rate variation; later manifestations include silent myocardial ischaemia and sudden death Figs.
Diabetic Peripheral Neuropathy Associated With Increased Health Care Costs
Neuropathic pain: aetiology, symptoms, mechanisms, and management. Diabetic neuropathies: a statement by the American Diabetes Association. Merskey H, Bogduck N. Seattle: IASP; Neuropathic diabetic foot ulcers. The role of muscle spindles in ankle movement perception in human subjects with diabetic neuropathy. Exp Brain Res. Clinically apparent eating disorders in young diabetic women: associations with painful neuropathies and other complications. The natural history of acute painful neuropathy in diabetes.
J Neurol Neurosurg Psychiatry. Diabetic peripheral neuropathy and depressive symptoms: the association revisited. Pain severity in diabetic peripheral neuropathy is associated with patient functioning, symptom levels of anxiety and depression, and sleep.
J Pain Symptom Manage. Predictors of depressive symptoms in patients with diabetic peripheral neuropathy: a longitudinal study. Diabetes Res Clin Pract. Vileikyte L. Psychological aspects of diabetic peripheral neuropathy. Diabetes Rev. Classification and Clinical Features A natural history of chronic painful neuropathy in a community diabetes population. The development and validation of a neuropathy — and foot ulcer — specific quality of life instrument. Depression predicts first but not recurrent diabetic foot ulcers.
Focal entrapment neuropathies in diabetes. Wilbourn AJ. Diabetic entrapment and compression neuropathies.
Diabetic Neuropathy. Philadelphia: WB Saunders; Characteristics of cranial nerve palsies in diabetic patients. Chronic demyelinating polyradiculoneuropathy in diabetes. Curr Diab Rep. Freeman R. Diabetic autonomic neuropathy. Oxford Clinical Handbook of Diabetic Neuropathy. Oxford: Oxford University Press; ; Autonomic neural dysfunction in recently diagnosed diabetic subjects. Historytaking can also be confounded by the inability of some patients to communicate unusual sensations see below and difficulty in separating out multiple symptoms.
The patient history should include an assessment of multiple dimensions of quality of life including mood, physical and social functioning, and social support. Diabetic neuropathy is a diagnosis of exclusion and the initial step is to eliminate non-diabetic causes. The main non-diabetic causes of symptomatic neuropathy are summarised in Fig. Patient Description of Pain 25 Non-diabetic causes of symptomatic neuropathy Malignancy e. Pain is a very individual sensation and patients with similar pathological lesions may describe their symptoms in markedly different ways.
Salient clinical features of neuropathic pain are listed in Fig.
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See also Chap. All neuropathic pains are projected, and the simplest way for the patient to indicate the location of their pain is by making it on a simple chart, such as that in Fig. It is often useful to relate pain distribution to a standard diagram of dermatomal and segmental distribution because, in most cases, pain distribution matches the level of the lesion. Positive symptoms arise spontaneously or in response to a stimulus, whereas negative symptoms represent decreased responsiveness to stimuli e.
This grouping is somewhat arbitrary but may be useful for certain purposes. However, the MPQ was not designed for quantitative evaluation of distinct pain qualities and the considerable overlap between descriptors of neuropathic and nociceptive pain limits its usefulness as a diagnostic tool. It also asks the patient about pain relief, pain quality and their perception of the cause of pain.
Impact of comorbidities on pharmacotherapy of painful diabetic neuropathy in clinical practice.
The BPI is a powerful tool and has demonstrated both reliability and validity across cultures and languages. It is used in clinical pain assessment and epidemiological studies, and to gauge the efficacy of pain treatment. Most NPS items have been shown to be sensitive to treatment effects,11 and may be useful for mechanism-led diagnosis.
It also includes an item for skin discoloration. The examination comprises two simple bedside tests: allodynia to light touch and altered pin-prick threshold. One is a simplified neuropathy symptom score that was used in European prevalence studies and may also be useful in clinical practice. Signs of nervous system dysfunction may manifest as either positive or negative phenomena, as discussed earlier. Sensory signs include increased or decreased perception of stimuli, whereas motor signs might include abnormal tone, power or coordination.
These signs can be indicative of widespread central nervous system involvement. Autonomic signs tend to be localised and include changes in skin temperature or colour, swelling and sweat production. A simple clinical examination can be carried out using easily available instruments. As with neuropathic symptoms, clinical signs can be assessed using composite scores such as the Neuropathic Disability Score NDS. A modified version of the NDS has been shown to be an excellent predictor of outcomes and can be used in the community by trained non-specialists Fig.
The maximum score is 10, with a score of 6 or more indicating a high risk of foot ulcers.
Reproduced with permission from the American Diabetes Association of perception thresholds for different sensations. QST measures can be used to identify the sensory modalities affected and to estimate the magnitude of the deficit Fig. Among patients with diabetes, vibration, thermal and pain thresholds have proven valuable in the detection of subclinical neuropathy, in tracking the progression of disease in large cohorts and in predicting which patients are at risk of foot ulceration.
Diagnosing Cardiovascular Autonomic Neuropathy 33 However, the panel warned that QST should not be used as the sole criterion to define diabetic neuropathy. They are objective, parametric, noninvasive and highly reliable measures. An appropriate battery of electrophysiological tests allows the clinician to measure the speed of sensory and motor conduction, the amplitude of the propagating neural signal, the density and synchrony of muscle fibres activated by maximal nerve stimulation, and the integrity of neuromuscular transmission.
However, the tests measure only large afferent and motor nerve function , and are therefore of limited use in neuropathic pain. Based on expert consensus and clinical experience, screening should be instituted at diagnosis of type 2 34 Chapter 3. Healthy subjects develop tachycardia and peripheral vasoconstriction during strain and an overshoot bradycardia and rise in blood pressure with release.
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The patient stands, and the systolic blood pressure is measured after 2 minutes. Screening should comprise a history and an examination for signs of autonomic dysfunction. The battery of tests for assessing CAN, as recommended by the American Diabetes Association, is readily performed in the average clinic or hospital with widely available technology Fig. A staging system for chronic sensorimotor DPN was agreed by an international consensus panel in and is shown in Fig.
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Reproduced with permission from the American Diabetes Association 36 Chapter 3. Psychological assessment and treatment of patients with neuropathic pain. Curr Pain Headache Rep. Pain assessment and evaluation of patients who have neuropathic pain. Neurol Clin. Huskisson EC.