Neuropathy

Question 1

what are the types of neuropathy?

Answer 1

peripheral: pain/loss of feeling in feet and hands
autonomic: changes in bowel, bladder function, sexual response, sweating, heart rate, blood pressure
proximal: pain in thighs, hips, buttocks - leading to weakness in the legs (amyotrophy)

focal neuropathy: sudden weakness in one nerve or groups of nerves causing muscle weakness or pain e.g. carpal tunnel, ulnar mono-neuropathy, foot drop, bells palsy, CN palsy

Question 2

risk factors

Answer 2

increased length of diabetes 
poor glycaemic control 
more common in T1DM 
high cholesterol/lipids
smoking 
alcohol 
genetics
mechanical injury

Question 3

what is peripheral neuropathy?

Answer 3

distal symmetric/ sensorimotor neuropathy

Question 4

how does peripheral neuropathy present?

Answer 4

glove stocking distribution 
numbness/insensitivity 
tingling/burning 
sharp pains or cramps 
sensitivity to touch 
loss of balance and coordination

Question 5

what are the consequences of peripheral neuropathy?

Answer 5

charcot foot
painless trauma
foot ulcer

Question 6

what is diabetic foot?

Answer 6

peripheral neuropathy: neuropathic ulcer, clawing of toes, glove and stocking neuropathy, dry cracked skin, callus
peripheral vascular disease: proximal arterial occlusion, digital gangrene, Charcot foot, loss of leg hair, absent pulses, cold feet

Question 7

what is charcot arthropathy?

Answer 7

a destructive inflammatory process causing fractures/ bony destruction and deformity of the foot

Question 8

how does charcot arthropathy present?

Answer 8

hot swollen foot in someone with neuropathy

Question 9

how is charcat arthropathy diagnosed?

Answer 9

hard to differentiate from infection

MRI can be useful

Question 10

how is Charcot arthropathy managed?

Answer 10

non-weight bearing (total contrast cast or airiest boot)

Question 11

natural history of Charcot arthropathy?

Answer 11

3 months of active destruction
1-4 months of healing (months 4-8)
then chronic phase after 8 months

Question 12

how is Charcot arthropathy screened for?

Answer 12

podiatrist annually assess at risk patients

refer to specialist if active disease

Question 13

what is the usual development of loss of sensation?

Answer 13

usually get pain before loss of sensation

Question 14

how to treat painful neuropathy?

Answer 14

amitriptyline 
duloxetine 
gabapentin or pregabalin 
titrate up as needed
if localised neuropathic pain and pain doesn't want/ can't tolerate oral treatments - can give topical capsaicin cream

Question 15

what is diabetic amyotrophy?

Answer 15

amyotrophy = muscular atrophy
starts with pain in the thighs, hips, buttocks or legs - usually on 1 side of the body
more common in elderly patients with T2DM
proximal muscle weakness
associated with marked weigh loss

Question 16

what is autonomic neuropathy?

Answer 16

affects the nerves which regulate heart rate and blood pressure
they also control internal organs
- gastric motility, respiratory function, urination, sexual function and vision

Question 17

autonomic neuropathy in the digestive system can cause?

Answer 17

constipation (gastric slowing) or diarrhoea (frequent gastric emptying) - sometimes both
Gastroparesis (slow stomach emptying) - persistent N&V, bloating and loss of appetite, can cause wide fluctuation in BG levels because of abnormal food digestion
Oesophagus nerve damage - makes it hard to swallow and can lead to weight loss

Question 18

how is gastroparesis managed?

Answer 18

improve glycaemic control
smaller and more frequent food portions - low fat, low fibre
may need liquid meals if severe
promotility drugs - metoclopramide, domperidone, erythromycin)
may need NSAIDs/analgesics (low dose tricyclic antidepressants, gabapentin, tramadol and fentanyl) for abdominal pain
botulinum toxin (works on pyloric sphincter)
gastric pacemaker

Question 19

autonomic neuropathy of the sweat glands can cause?

Answer 19

profuse sweating at night or while eating (gustatory sweating)
prevent the sweat glands from working possibly
stop the body from being able to regulate temperature properly
Anhidrosis = inability to sweat normally
Hyperhidrosis = excessive sweating

Question 20

how is sweat gland neuropathy managed?

Answer 20

topical glucopyrrolate
clondine
botulinum toxin

Question 21

affect of nerve damage in the CV system?

Answer 21

disrupts body’s ability to adjust BP and heart rate

• postural hypertension
• persistent high heart rate (despite change in activity)