Peripheral neuropathy (PN) is a common condition related to living with diabetes, with almost 50% experiencing it as part of their diabetes journey.

The term peripheral means that it affects the parts of our bodies furthest from our hearts. These are your hands and lower limbs below the knees, including the feet. Neuropathy means nerve dysfunction; it means your nerves aren’t working as they should.

The jury is still out on the exact cause of PN; however, ongoing research reveals both large and small nerves are affected. Damage to large nerves is related to loss of sensation, numbness, and muscle weakness. When smaller nerves are involved, it can lead to pain and ulcers.

Prevention, diagnosis, and treatment strategies are difficult because there are so many mechanisms involved. Some affect the whole body such as infections or chemical exposure, for example chemotherapy. Others are on a cellular level, perhaps how our bodies use glucose or fats, or there may be confusion of the immune response to differing stimuli. These pathways then lead to inflammation, gene damage, signalling failure, or compromise of the protective layer around the nerves known as the myelin sheath. There are many possible pathways to PN, and this article can’t cover all of them. There is much still yet to be understood, and research is ongoing.

Signs and symptoms

• Pain on one or both sides of the body – sensations such as aching, stabbing and throbbing
• Numbness
• Pins and needles
• The sensation of insects crawling on your skin
• Hot areas or a burning sensation
• Cold areas which are difficult to warm up
• Muscle weakness
• Lower leg or foot ulcers.

Risk factors for PN are as varied as the signs and symptoms

Here’s what we know so far: diabetes is a risk factor. This is different for each individual and related to factors such as age, blood glucose time in range, average HbA1c levels, duration of diabetes, type of diabetes and so on. But living with diabetes is not the only possible risk factor.

Other possible causes of PN include alcohol consumption, side effects of certain medications, deficiency of certain vitamins such as thiamine (vitamin B1) and cobalamin (vitamin B12), exposure to specific toxins, some autoimmune conditions, and associated inflammation and immune responses, smoking related oxidative stress, genetics and gene mutations, some conditions of the nervous system such as CIPD (Chronic Inflammatory Demyelinating Polyneuropathy), HIV, having a heavier than recommend weight, or compromised thyroid function. This is not an exhaustive list. Sometimes we just don’t know why PN develops.

So why might you care?

We all deserve to live our best lives. As well as the signs and symptoms listed earlier, you may also experience:

• Damage to feet, lower limbs or hands
• Altered gait, with discomfort or ongoing mobility issues
• Compromised balance increasing falls risk
• Development of ulcers – with possible pain and infection
• Reduced independence
• Less ability to keep up with the grandchildren
• Limits to work around the house or paid employment
• Questioned eligibility of driving license
• Disturbed sleep
• Associated anxiety, depression, and diabetes burnout
• Possible amputation when wounds do not heal.

Investigations

Due to the large number of risk factors for PN, several testing avenues might be offered including:

• A clinical picture such as family history, physical examination for signs and symptoms, duration, and severity
• Exposure to toxins for example in the workplace, or alcohol consumption
• Medications both current and historical
• Imaging or biopsy
• Nerve testing
• Blood pathology.

Prevention and treatments options

Prevention and treatment involve an inter-disciplinary approach, where a range of health providers work together to support you with your self-management of diabetes and related PN. Prevention is always the best path forwards. Some risk factors you can’t do anything about such as genetics. However, there are many lifestyle, dietary and other factors that can be modified.

• Daily foot monitoring and care performed by yourself or your carer.
• Your general practitioner may prescribe specific supplements or medications, provide advice, answer questions and also be the central contact point for your diabetes and PN healthcare team. He or she can request pathology or other investigations and refer you to health professionals and specialists. Some referrals may be subsidised under a Medicare Care Plan.
• A comprehensive podiatry assessment can check function and risk factors and can include advice about footwear and foot care.
• An accredited practising dietitian assessing and advising around diet, particularly if your doctor identifies deficiencies.
• The practice nurse assists your general practitioner answering your questions, and monitoring aspects such as weight, blood glucose and blood pressure.
• An accredited exercise physiologist can prescribe physical activity and exercises to help improve balance and fitness, based on your individual health issues and needs.
• A psychologist may provide psychological wellbeing strategies.
• A credentialled diabetes educator supports, answers questions and provides education relating to managing diabetes.  He or she can offer insight into modifiable and non-modifiable risk factors, and what’s happening in your body.
• Physiotherapy may be required if, for example, you experience a fall or other injury.
• Your pharmacist is your go-to for all information related to medications including side effects and interactions.

Treatment generally depends on symptoms, but often involves capsicum-based cream to distract from pain or tingling. These creams are available from pharmacies.

Next treatment options include a range of medications which include anti-depressants and anti-epileptics which as a side effect, decrease nerve pain.

And, lastly, spinal cord stimulation, which requires surgery to place an electrode in the spinal cord. This allows an electrical current to be applied to confuse pain signals to the brain.

Find out more

Take this two minute quiz to assess the health of your feet, or head to FootForward for more information.

The National Diabetes Services Scheme (NDSS) has good quality information on their website about self-assessment and care of hands, feet, and lower limbs. There are also face-to-face and virtual (online) programs available, such as FootSMART.

Peripheral neuropathy is the most common condition related to living with diabetes. The resulting compromise to quality of life can be profound. Diabetes Australia, the NDSS, and your healthcare team are here to help. Download a fact sheet, make a call on 1800 177 055, or set up an assessment appointment today.

Constance Russell, RN CDE