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Diabetic Nerve Pain: Symptoms And Treatment

Medically reviewed by Carmen Fookes, BPharm. Last updated on Oct 5, 2022.

Diabetic Nerve Pain: Causes

Diabetes is a condition characterized by abnormally high blood sugar levels. Diabetic nerve pain (also called diabetic neuropathy) is a complication of diabetes that is more common in people who have had diabetes for more than 25 years. Researchers are still trying to elucidate how prolonged exposure to high blood sugar levels contributes to diabetic nerve pain. However, the exact cause of diabetic nerve pain is probably the result of a combination of factors, including:

  • damage to the blood vessels that supply oxygen and other nutrients to the nerves
  • nerve inflammation as a result of an overreactive immune system
  • nerve damage as a result of trauma or a coexisting medical condition such as rheumatoid arthritis
  • other metabolic factors such as abnormally high blood lipid levels, low insulin levels, or high blood pressure
  • an inherited susceptibility to nerve damage
  • lifestyle choices such as obesity, smoking or excessive alcohol use.

Symptoms Of Diabetic Nerve Pain

60 to 70 percent of people with diabetes develop some form of neuropathy, although some may experience no symptoms at all. Nerve damage occurs slowly, over a number of years, and almost every organ system can be affected, including the digestive tract, heart, and sex organs.

Pain and tingling, a numbness or a loss of feeling in the hands, arms, feet or legs is the most commonly reported symptom. Gastrointestinal symptoms, such as nausea, vomiting, indigestion, diarrhea or constipation may signal nerve damage to the gut but be wrongly attributed to some other cause. Other symptoms may include:

  • a wasting of the muscles in the feet or hands
  • dizziness or feeling faint when going from lying down or sitting to standing
  • erectile dysfunction in men or vaginal dryness in women
  • urination problems
  • feeling generally weak or tired all the time.

Weight loss and depression often accompany diabetic neuropathy but are not caused by it.

Types Of Diabetic Nerve Pain

There are four main types of diabetic neuropathy.

  • Peripheral neuropathy: the most common type. Causes pain or numbness in the toes, feet, legs, fingers, hands or arms.
  • Autonomic neuropathy: affects the nerves that are not under voluntary control. Causes changes in blood pressure, digestion, perspiration, bowel, and bladder control and sexual response.
  • Proximal neuropathy: the nerves of the thighs, hips, or buttocks are affected leading to weakness in the legs.
  • Focal neuropathy: damage is localized to one nerve or a particular group of nerves resulting in sudden weakness or pain to a certain area of the body.

Peripheral Neuropathy: Should Be Taken Seriously

Peripheral neuropathy is the most common type of diabetic nerve pain. The feet and legs are usually the first to be affected, but with time, the hands and arms may also show signs. Symptoms include:

  • Numbness or an inability to distinguish between different temperatures
  • Pins and needles, tingling, or burning sensation in the affected areas
  • Cramps or sharp pains
  • An extreme sensitivity to even the lightest touch
  • Coordination or balance problems.

Because the condition happens gradually over time, your doctor may pick up on signs or symptoms of peripheral neuropathy before you do. Left unmanaged, the condition may affect the muscles, causing weakness and a loss of reflexes. Eventually, this may affect your ability to walk.

One of the biggest concerns with peripheral neuropathy is the lack of awareness of injury to the foot. Any break in the tissue caused by sharp toenails, tight-fitting shoes, or as a result of trauma, becomes a potential entry point for bacteria and there is a high risk of an infection spreading to the bone. Diabetes is a leading cause of lower limb amputation. Recognizing and treating minor foot problems early in people with peripheral neuropathy is the best way of preventing amputations.

Autonomic Neuropathy: Outside Of Our Control

Many muscles and organs inside our body are not under our conscious control. The nerves that control them form part of the autonomic nervous system and autonomic neuropathy is a diabetic nerve disorder that occurs when the nerves that supply these involuntary muscles are damaged.

Symptoms of autonomic neuropathy reflect the part of the body that is affected; several areas may be affected at once. Symptoms may include:

  • Dizziness or fainting when going from a lying or sitting position to standing. This reflects damage to the nerves in the cardiovascular system making it difficult for the body to adjust blood pressure in response to changes in body position.
  • A lack of awareness of hypoglycemia (low blood sugar levels). Most diabetics feel shaky, sweat or develop heart palpitations when their blood sugar levels drop below 70 mg/dL. These symptoms may not occur in people with autonomic neuropathy.

Autonomic Neuropathy: Gastrointestinal and Urinary Symptoms

Our gastrointestinal (GI) tract is also under the control of the autonomic nervous system. Constipation is typically the first sign that the nerves that supply the GI tract have been damaged. Gastroparesis - a condition characterized by a significant slowing of the muscle contractions of the stomach - can also occur, leading to persistent nausea and vomiting, bloating and a loss of appetite. People may also experience weight loss, diarrhea, and difficulty swallowing.

Recurrent urinary tract infections (UTI) may be a sign of damage to the nerves that control urination and sexual function. Bacteria are more likely to grow in urine that is allowed to sit for long periods of time in people unable to empty their bladders completely. Urinary incontinence and erectile dysfunction (ED) typically occur in people with autonomic neuropathy of the genitourinary tract.

Antibiotics may be needed to clear up a UTI, and scheduling urination at regular intervals (for example every three hours) may reduce bladder 'accidents'. Further investigations may be needed to determine other contributing causes of ED before prescribing oral medications, or other, more suitable treatments.

Proximal Neuropathy

Proximal neuropathy is characterized by severe, usually asymmetric leg pain and weakness, which mainly affects the muscles near the hip and knee, such as the buttocks, thighs, and lower leg. Help is usually needed when going from a sitting to a standing position.

Proximal neuropathy usually comes on suddenly, with most people able to recall the exact day the symptoms began. Typically the condition reaches a plateau and then gradually improves with time. At the peak of their illness, confinement to a wheelchair is not uncommon. Despite an improvement in the condition, some residual weakness tends to remain.

People with type 2 diabetes or older adults are more likely to develop proximal neuropathy.

Focal Neuropathy

Focal neuropathy is a painful and unpredictable diabetic nerve disorder that appears suddenly and affects a small localized area of the body, most commonly in the region of the head, torso or leg.

Symptoms may include:

  • Abdominal pain that may be mistaken for appendicitis
  • Bell's palsy - a paralysis down one side of the face
  • Chest pain that may be mistaken for a heart attack or heart disease
  • Eye problems, including double vision, an inability to focus the eye, pain or aching behind the eye
  • Moderate-to-severe pain in one particular area of the body, such as the lower back, pelvis, at the front of the thigh, instep of the foot, stomach or side.

Seniors with diabetes are more likely to develop focal neuropathy but the disorder is short-lived and tends to improve by itself within a few weeks or months. Diabetics are also more prone to developing entrapment syndromes, such as carpal tunnel syndrome.

How Are Diabetic Neuropathies Diagnosed

A typical cluster of symptoms or a physical examination of the feet may be all that is needed for a diagnosis of diabetic peripheral neuropathy. Sometimes other tests may be ordered as well.

Nerve conduction studies check how fast and how well nerves can transmit electrical signals (called impulses) to the muscles. Electromyographies measure how responsive the muscles are to those nerve signals. A poor result in any one of these tests suggests a neuropathy.

Doctors can also measure how well the heart responds to deep breathing and changes in blood pressure and posture. An ultrasound of the bladder may be used to determine how well the bladder empties after urination.

Treatment Of Diabetic Neuropathies

Further nerve damage can be prevented by bringing the blood glucose levels back within the normal range. Regular monitoring, meal planning, exercise, and strict adherence to recommended medications and/or insulin schedules is vital to help control blood glucose levels. In some people, the symptoms may worsen initially, before improving.

Oral medications may be used to relieve painful diabetic neuropathy. Finding the right medication may take some trial and error, and some medications may work better in combination. The American Diabetes Association recommends starting with pregabalin. Several antidepressants also work well for diabetic neuropathy, regardless of whether or not the person is depressed. Common medications used include:

  • Tricyclic antidepressants (eg, amitriptyline, desipramine, imipramine)
  • SSRIs or SNRIs (eg, citalopram, duloxetine, paroxetine, venlafaxine)
  • Bupropion
  • Anticonvulsants (eg, carbamazepine, gabapentin, lamotrigine, pregabalin)
  • Opioid and opioid-like drugs (eg, oxycodone, tramadol) may also be used; however, pain-relieving benefits must be weighed up against risk of dependance and tolerance.

Other Treatments For Peripheral Neuropathy

Some other treatments may also help with nerve pain in the feet; however, discuss the pros and cons thoroughly with your doctor before using.

Capsaicin cream and patches contain an ingredient derived from chili peppers (the substance that makes them hot) and reduce chronic nerve pain by depleting the amount of a neurotransmitter called substance P that sends pain messages to the brain. Initially, capsaicin may cause intense burning or stinging, until all the substance P has been depleted. One review of 25 trials found the benefits of the 8% patch were similar to those of orally acting agents, with less systemic side effects.

Lidocaine patches and nitrate sprays or patches may also provide some relief. More evidence of a beneficial effect is needed before traditional Chinese medicine or supplements such as acetyl-l-carnitine, alpha-lipoic acid, or primrose oil can be recommended.

Bed cradles may be used to keep sheets and blankets from touching sensitive feet and legs. Acupuncture and treatments such as electrical nerve stimulation, magnetic therapy, and laser or light therapy may also help, but further research is needed.

Keep An Eye On Your Feet

Everybody with diabetes should take good care of their feet. This means inspecting them every couple of days for cuts, blisters, redness, swelling, ingrown or fungal toenails, or athletes foot. Use a mirror if it is difficult for you to bend over or ask a friend to inspect them for you. Your doctor should also check them at every appointment, and at least once a year, visit a podiatrist for a comprehensive foot examination.

Clean your feet every day but avoid soaking them. Always dry them thoroughly and gently with a towel; pay particular attention to between your toes to discourage fungal growth. Moisturize your heels to prevent cracking and always trim your toenails straight across and file carefully so there are no sharp edges.

Wear socks made of cotton or other moisture-wicking materials without tight bands or thick seams. Shoes should fit well and cushion your feet without restricting toe movement. Never go bare feet. People who qualify for Medicare may be entitled to one free pair of shoes per year.

Treatments For Gastrointestinal Problems Caused By Diabetic Neuropathies

Eating small and frequent meals that are low in fat and fiber may help relieve symptoms such as belching, indigestion, flatulence, nausea or vomiting caused by damage to the nerves supplying the gastrointestinal tract.

Medications such as erythromycin and metoclopramide may help speed the passage of food through the gastrointestinal tract and metoclopramide can also help relieve nausea. Other medications may be prescribed to reduce stomach acid secretion or control diarrhea.

Preventing Diabetic Nerve Disorders

Keeping your blood glucose (sugar) levels as close to the normal range as possible is the BEST way to prevent neuropathy. And it is important to be aware of this fact from the moment you are diagnosed with diabetes, because symptoms of diabetic neuropathies usually take years to manifest. By then the damage has already been done.

Regular monitoring and good medication taking is the key to maintaining consistent blood glucose levels. Large shifts in blood glucose are thought to accelerate the damage to nerve fibers.

At least twice a year, your doctor should ask for a blood test called the A1C test. This gives an idea of your average blood glucose readings over the past two to three months.

Other Self-Help Measures

To compensate for the fact that your heart rate and blood pressure do not respond quickly to changes in posture, always get out of bed or up from a chair slowly. This is particularly important if you have been lying down for long periods of time or when needing to use the bathroom in the middle of the night.

If you sweat a lot, drink more water during the day and try to avoid places with high humidity or intense heat. If you don't sweat enough, apply a moisturizer daily to dry or cracked skin.

Keep exercising; exercise helps with blood circulation and weight control and is important for your overall health. Talk with your doctor about what type of physical activity is the most suitable for you.

Join a support group, such as the Diabetic Peripheral Neuropathy Support Group. Here you can share your story with people who have the same condition, and gain insight into which treatments have worked for them, and which haven't.

Finished: Diabetic Nerve Pain: Symptoms And Treatment

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