It's 11 p.m., the end of a long day. As you climb gratefully into bed, you are suddenly caught in the grasp of excruciating pain in your legs.
Unfortunately, this scenario is all too real for people who struggle with diabetic neuropathy, a debilitating complication of diabetes mellitus.1 Nightly leg and foot pain, an inability to tolerate the pressure of bedding on the lower extremities, and subsequent sleep deprivation may become as routine as turning back the covers each night.
Peripheral neuropathy is a disease that causes damage to the nerves outside the brain and spinal cord. In people with diabetes, this nerve damage is thought to be a direct result of high blood sugar. Diabetic neuropathy affects the nerves that carry information about sensation to the brain and thus influences the ability to distinguish hot from cold, the feel of textures or even the pain caused by sharp objects. Peripheral neuropathy is a form of sensory neuropathy that affects the hands and feet. It is the most common type of neuropathy and is largely responsible for the increased risk of serious foot problems in patients with diabetes.2
Approximately 45 percent of people with diabetes experience some form of neuropathy and, of these, 10 percent have associated pain.3
The pathophysiology of diabetic neuropathy includes interneuronal accumulation of byproducts from abnormal sugar and fat metabolism, as well as ischemia in the blood vessels that supply the peripheral nerves.3 While this may explain the painful form of diabetic neuropathy, additional pathophysiologic processes not fully understood may be responsible for the non-painful forms.
Since there are no absolute diagnostic tests to confirm that the signs and symptoms of neuropathy are definitely a result of diabetes, exclusion of other causes is the recommended course.4 When a patient with diabetes presents with a complaint of pain, burning, tingling or numbness in the extremities (usually lower) in the presence of decreased glycemic control, diabetic neuropathy is the obvious cause. Clinical diagnosis can often be made using a simple monofilament test to assess lower extremity sensitivity, or the knee jerk and ankle jerk reflex tests. Indications of neuropathy are inability to correctly respond to monofilament touch on the soles of the feet and decreased reflex response.
For patients with a diagnosis of diabetic peripheral neuropathy, treatment should focus on helping the patient achieve relief. The Diabetes Control and Complications Trial demonstrated that improved glycemic control can retard the onset and progression of diabetes complications including peripheral neuropathy.5
The importance of tight glycemic control cannot be overemphasized, and it is the first line of defense against the unrelenting pain of neuropathy. Diet, exercise, medication and weight control are still the mainstays of treatment, but for patients struggling with the pain of peripheral neuropathy, pain relief measures must also be implemented. Conventional and alternative therapies are available.
Nonconventional therapies for neuropathy include acupuncture, massage, biofeedback, yoga and meditation.
Biofeedback teaches patients to use their own body signals to control physiologic processes including pain. Meditation uses the mind to send "feel good" messages to the body, thus altering perception of pain and releasing endorphins into the body. Therapeutic massage increases circulation, stimulates the skin and soothes the nervous system, thus quieting neuropathic pain. In acupuncture, an acupuncturist inserts hair-thin needles under the skin to stimulate specific points in the body to block pain signals from the brain.
Direct nerve stimulation can also be used to modify pain signals. Transcutaneous electronic nerve stimulation (TENS) sends small electrical impulses through the skin to nerve centers to block the pain signals normally sent through nerve fibers to the brain.
Alternative therapies avoid the side effects of drugs while providing an effective means of controlling pain.6