Neuropathy
Recommendations
| Identify and Treat the Cause | ||
|---|---|---|
| 1 | Conduct a foot inspection and examine for decreased sensation. Correct (if possible) risk factors for ulcer formation/amputation:  Vascular supply  Infection  Pressure (including bony deformity) Remember the mnemonic VIP | Level of Evidence Not Assessed |
| 2 | Perform neurologic testing, even in patients with no symptoms, to diagnose or rule out diabetic neuropathy. | Level of Evidence Not Assessed |
| 3 | Identify risk of foot ulceration based on results of neurologic testing, including increased vibration threshold and inability to feel pressure of a 10-g monofilament. | Level of Evidence Not Assessed |
| Address patient-centered Concerns | ||
|---|---|---|
| 4 | Provide individualized education to enhance Glycemic control, Adherence to treatment, Plantar pressure redistribution/daily foot inspection. (GAP) | Level of Evidence Not Assessed |
| Provide Local Wound Care | ||
|---|---|---|
| 5 | Follow recommended strategies to maintain a healthy foot in all patients with diabetic neuropathy. | Level of Evidence Not Assessed |
| Provide Organizational Support | ||
|---|---|---|
| 6 | Establish and empower an interprofessional team to work with Persons With Diabetes (PWD) and neuropathy. | Level of Evidence Not Assessed |
Background
The definition of diabetic neuropathy used for this summary is the following:• The presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes, after exclusion of other causes.
Sensory neuropathy, present in 30 to 50% of people with diabetes, is the most important common cause of foot ulceration, and 45 to 60% of ulcerations are entirely neuropathic in origin. Motor and autonomic neuropathy may also contribute to the risk of ulceration. Distal symmetric sensorimotor neuropathy is the most common clinical presentation.
Presenting symptoms vary and may include various types of pain, altered temperature perception, paresthesia, hyperesthesia, allodynia or insensitivity. Nocturnal exacerbation may be present. Motor symptoms, such as weakness, may also be present. Some patients report no symptoms.
Neuropathy cannot be excluded without a neurologic examination. Various scoring measures exist, including the Neuropathy Disability Score and the Michigan Neuropathy Screening Instrument. The ankle reflex is often reduced or absent in people with diabetic neuropathy. Absent ankle reflexes are a useful predictor of ulceration risk.
Electrophysiologic testing is the most sensitive, reproducible and reliable method of evaluating nerve function, and such testing can also detect subclinical neuropathy. Electrophysiology does not diagnose the cause of the neuropathy.
Vibration perception threshold can be evaluated using a tuning fork (128Hz) or a biothesiometer, which can quantify and measure progressive sensory loss. A decreased vibration threshold is highly predictive of foot ulceration, with a threshold above 25V increasing risk tenfold compared with lower thresholds.
Semmes Weinstein monofilaments can identify loss of pressure sense. Absent protective threshold is diagnosed if an individual cannot feel at least seven of 10 tested pedal sides. A sensitive predictor of ulceration and amputation risk is inability to feel pressure of a 10-g monofilament.
Treatment of neuropathy is focused on maintaining a healthy foot and preventing ulceration. Treatment measures include management of any foot deformities, appropriate footwear, frequent professional monitoring and patient education about the importance of proper foot care and footwear and effective diabetes management.
References
| Essential Publications |
|---|
| 1 | Prevention and Management of Diabetic Neuropathy |
Quality Indicator
|
Type: Narrative Review |
| Unger J, Cole BE. Recognition and management of diabetic neuropathy. Prim Care. 2007 Dec;34(4):887-913, viii. | |||
| This publication provides a thorough and comprehensive summary of information relevant to diabetic neuropathy. It is a good source of information for researchers and practitioners who wish to learn about diabetic neuropathy. | |||
| 2 | Detection of Diabetic Foot Neuropathy |
Quality Indicator
|
Type: Prospective Correlation study |
| Forouzandeh F, Aziz Ahari A, Abolhasani F, Larijani B. Comparison of different screening tests for detecting diabetic foot neuropathy. Acta Neurol Scand. 2005 Dec;112(6):409-13. | |||
| This publication compares the effectiveness of different screening methods in detecting diabetic foot neuropathy. The results are inconclusive in determining the optimal screening method, so further research is deemed to be necessary. | |||
| 3 | Vascular Endothelial Growth Factor in Diabetic Neuropathy |
Quality Indicator
|
Type: Case-control study (2 groups) |
| Quattrini C, Jeziorska M, Boulton AJ, Malik RA. Reduced vascular endothelial growth factor expression and intra-epidermal nerve fiber loss in human diabetic neuropathy. Diabetes Care. 2008 Jan;31(1):140-5. Epub 2007 Oct 12. | |||
| This publication examines the relationship between Vascular Endothelial Growth Factor (VEGF) and peripheral nerve integrity in diabetic patients. 53 diabetic patients and 12 non-diabetic patients underwent neurological evaluation, electrophysiology, quantitative sensory, and autonomic function testing. The results showed that progressive endothelial dysfunction, a reduction in VEGF expression, and loss of intra-epidermal nerve fibers occurs in the foot skin of diabetic patients with increasing neuropathic severity. | |||
| 4 | Frequency-Modulated electromagnetic neural stimulation in treatment of diabetic neuropathy |
Quality Indicator
|
Type: RCT |
| Bosi E, Conti M, Vermigli C, Cazzetta G, Peretti E, Cordoni MC, Galimberti G, Scionti L. Effectiveness of frequency-modulated electromagnetic neural stimulation in the treatment of painful diabetic neuropathy. Diabetologia. 2005 May;48(5):817-23. Epub 2005 Apr 15. | |||
| This RCT examines the effect of Frequency-Modulated electromagnetic neural stimulation (FREMS) on diabetic neuropathy. By comparing its effects with the effects of a placebo in a randomized clinical trial with 31 total patients, it was demonstrated that FREMS decreases pain (p<0.02) and increases motor conduction velocity (p<0.01). As a result, FREMS can be used clinically as an effective management technique for patients with diabetic neuropathy. | |||
| 5 | Frequency-Modulated electromagnetic neural stimulation in treatment of diabetic neuropathy |
Quality Indicator
|
Type: Cohort study (2 groups) |
| Bevilacqua M, Dominguez LJ, Barrella M, Barbagallo M. Induction of vascular endothelial growth factor release by transcutaneous frequency modulated neural stimulation in diabetic polyneuropathy. J Endocrinol Invest. 2007 Dec;30(11):944-7. | |||
| This publication examines the effect of FREMS in the release of vascular endothelial growth factor (VEGF). In a comparison with treatment with TENS, treatment with FREMS demonstrates a release of VEGF, which can be used to explain the increase in motor conduction velocity that is associated with FREMS treatment. | |||
| 6 | Neuropathy in the Diabetic Foot |
Quality Indicator
|
Type: Correlation study |
| Boyko EJ, Ahroni JH, Stensel VL. Skin temperature in the neuropathic diabetic foot. J Diabetes Complications. 2001 Sep-Oct;15(5):260-4. | |||
| The purpose of this study was to examine the validity of the common clinical assumption that neuropathy is associated with a higher foot temperature. The results demonstrate that diabetic patients with neuropathy do not have higher foot skin temperature. | |||