Diabetic neuropathy

Question 1

Diabetic neuropathy

Answer 1

• common complication associated with DM
• progressive disorder with nerve fiber loss, atrophy, manifested by deteriorating neural function, progressively decreasing sensation and strength

-neuropathies can be focal or diffuse and involve the ANS or somatic PNS

Question 2

Diabetic neuropathy incidence

Answer 2

• can occur in type I (54%) or Type II diabetes (30%).

- 50% of people with diabetes never develop S/S of neuropathy

Question 3

Diabetic neuropathy : etiology

Answer 3

• individual with good glycemic control can still develop neuropathies, although a clear relationship does exist between the length of time that the individual has diabetes and development of neuropathy
• there may be a genetic predisposition
• caused by chronic metabolic dstrubances that affect nerve cells and schwann cells

Question 4

Diabetic neuropathy Pathology

Answer 4

• loss of both myelinated and unmyelinated axons associated with exposure of nerves and schwann cells to glucose. the nerves are affected more distally than proximally

Question 5

diabetic neuropathy: hyperglycemia

Answer 5

• chqracterized by increased sorbital and fructose
• coincide with deficiencies in ATP that alter peripheral nerve function
• excess sorbital also damages schwann cells
• leads to abnormalities in microcirculation creating endothelial capillary changes and local ischemia

Question 6

diabetic neuropathy: pathology vascular changes

Answer 6

• vascular changes can also aaffect the peripheral nerves
• endoneurial and microvascular thickening is present with closed capillaries that are associated with multifocal regions of ischemia and hypoxia to the nerve
• decreased blood supply leads to axonal degeneration

Question 7

diabetic neuropathy: pathology impaired nerve nutrition

Answer 7

• the nerve may also be nutrionally deprived
• the concentration of nerve growth factor is similar molecularly to insulin and is reduced which reduces the nutrition to the nerve

Question 8

Summary of pathophysiology

Answer 8

• metabolic disturbances affect nerve cells and schwann cells
• hyperglycemia coincides with deficiencies in ATP that alter peripheral nerve function
• excess sorbital also damages Schwann cells
• hyperglycemia leads to abnormalities in microcirculation
• the nerve may also be nutritionally deprived

Question 9

diabetic neuropathy : diagnosis

Answer 9

• at leasttwo abnormalities have been recommended for diagnosis
• electrodiagnotic studies

Question 10

diabetic neuropathy: clinical manifestations

Answer 10

• stocking and glove distribution of sensory loss
• progression of disease moves distal to proximal
• insidious onset
• loss of ankle reflexes
• muscle wasting
• loss of sensation and thermal awarenes

Question 11

Rapidly reversible neuropathy

—Hyperglycemic neuropathy

Answer 11

• occurs in individuals with uncontrolled DM or newly diagnosed cases
• presents with sensory changes, paresthesias, tenderness of the feet and legs
• symptoms disappear when blood sugar is controlled although nerve conduction may be abnormal

Question 12

acute sensory neuropathy

Answer 12

• rapid onset of severe burning pain, deep aching a sudden sharp “electric shock” sensation and hypersensitivity of the feet
• sx are often worse at night
• sensory loss may be mild
• motor exams are normal
• DTRs are normal or reduced at the ankles

Question 13

chronic sensorimotor neuropathy

Answer 13

• most common type of diabetic polyneuropathy
• 50%of patients may develop this
• insidious onset
• S/S include sensory loss, burning pain and paresthesias because of small fiber loss.
• large fiber loss results in non-painful paresthesias decrease proprioception, impaired vibration, loss of touch sensation, diminished DTRs

Question 14

autonomic neuropathy

Answer 14

• sympathetic and parasympathetic involvement
• after 10-15 years 30% of patients have subclinical manifestations of autonomic involvement
• cardiovascular: tachycardia, exercise intolerance, orthostatic hypotension, dizziness
• gastrointestinal: esophageal motility dysfunction, diarrhea, constipation
• genitourinary: neurogenic bladder, bladder urgency, incontinence, erectile dysfunction

Question 15

mononeuropathy

Answer 15

• single neuropathy in the limb
• occur less often than symmetric patterns
• median , ulnar and peroneal nerves are the most commonly affected
• somatic division of the oculomotor nerve can be affected

Question 16

diabetic neuropathy: management

Answer 16

• control of hyperglycemia and measures to address sympotomatic management of the disorder
• physical therapy for strategies to compensate for sensory loss and balance training

Question 17

diabetic neuropathy medications

Answer 17

• gangliosides
• NGFs
• angiotensin-converting enzyme inhibitors
• antidepressants
• gabapentin: focal neuropathies
• topical capsaicin: allodynia
• b12- for pain & parasthesias

Question 18

diabetic neuropathy Prognosis

Answer 18

• metabolic disorder and multiple organs are affected

- strict preventative procedures and early detection can greatly alter the progression of the disease

Question 19

alcoholic neuropathy: etiology

Answer 19

• peripheral neuropathy that appears after years of chronic alcohol abuse.
• patients without a co-existing thiamine deficiency tend to have a slower progressing course
• nutritional deficiencies

Question 20

alcoholic neuropathy: pathology

Answer 20

• segmental demyelination progressing to axonal degeneration

- changes occur distally at first and become more marked and proximal

Question 21

alcoholic neuropathy: clinical manifestation

Answer 21

• mild forms are associated with minor loss of muscle bulk, sensory impairment, diminished ankle reflexes, aching in calves
• distal sensory changes include pain, paresthesia, and numbness in stocking glove pattern
• begins insidiously, most cases involve all four extremities. occasionally the onset may be more acute
• weakness and atrophy of distal musculature should be anticipated
• foot drop and wrist drop. peripheral muscle weakness
• LE are more affected that UE

Question 22

compression neuropathies

Answer 22

• may develop from prolonged positions of nerve compression when patients passs out in awkward positions after intoxication

Question 23

Rhabdomyolysis

Answer 23

• characterized by proximal muscle wasting, swelling, pigmented urine, result of renal failure

Question 24

chronic renal failure

Answer 24

• uremic encephalopathy characterized by recent memory loss, inability to concentrate, perceptual errors and decreased alertness

Question 25

alcoholic neuropathy anemia

Answer 25

• decreased hemoglobin in blood levels, moderate to severe is 7-8g/dl. normal is 11-12 g/dl for females and 13-14 g/dl for males

Question 26

alcoholic neuropathy: diagnosis

Answer 26

• made by clinical presentation and history
• nerve biopsy demonstrates greater small fiber axonal loss inpatient w/o a thiamine deficiency. greater large fiber loss with segmental demyelination in those with a deficiency
• electrodiagnostic testing shows loss of action potential amplitude

Question 27

alcoholic neurpathy: management

Answer 27

• quit drinking
• treatment is symptomatic
• recovery depends on demyelination or degeneration
• equipment evaluation
• orthotic evaluation for AFOs and wrist splints
• medication for management of paresthesias

Question 28

alcoholic neuropathy: prognosis

Answer 28

• if the individual abstains from alcohol, mild improvement can be expected
• recovery is slow and dependent on whether demyelination or degeneration has occurred. careful review of EMG studies are needed