Diabetic Nerve Pain Symptoms! Mrs. H (65 years old) comes to the practice room of a neurologist. Mrs. H complains of pain in the foot-tips since 3 months ago. Pain is felt like burning and stabbing. Pain is heavy at night, and very disturbing to sleep.
Pain does not improve with the anti-pain medication purchased at the stall. Pain is felt increasingly heavier over time. Mrs. H is a diabetic since 8 years ago.
Sugar levels are often uncontrolled due to irregularity of treatment. The doctor checks out Mrs H, and after checking out Mrs. H the doctor explains ‘it seems your diabetes has caused nerve damage’.
The above story is the true story of a patient with diabetes mellitus that comes with symptoms of peripheral nerve damage due to diabetes, called diabetic neuropathy.
Complications of diabetes may vary from the retina (diabetic retinopathy), the kidneys (diabetic nephropathy), bowel movements (diabetic gastropathy), blood vessels (angiopathy), to the cerebral nerves.
The illustration above shows a clinical picture of diabetic neuropathy. Diabetic neuropathy generally appears slow and has a slow progressivity as well. Symptoms that appear is the loss of sensation or a sense of dominance in the fingertips.
Diabetic neuropathy is one of the major complications of diabetes. An Australian study of 2,436 patients with diabetes showed that 13.1% of patients had peripheral neuropathy / damage to peripheral nerves (Tapp, et al, 2003).
Symptoms of pain are common complaints in patients with diabetic neuropathy. Several epidemiological studies have shown that pain is present in 7-13% of diabetic neuropathy cases at the time of diagnosis.
The prevalence of pain and paresthesia or tingling increases with the duration of diabetes mellitus. Pain that is often described is a burning pain, such as punctured, paroxysmal. Hyperalgesia (severe pain due to mild pain stimulus) and allodinia (pain caused by excitatory rather than pain).
Research in the United States shows that 10-20% of patients when diagnosed with diabetes have neuropathy, and the prevalence increases to 50% in patients who have suffered DM> 25 years (Partanen, et al, 1995). The prevalence of diabetic neuropathy is approximately 30% of all DM patients (De Cherney, 1997, Echeverry and Sherman, 2003).
Of all diabetic cases, diabetic neuropathy as a diabetic complication is also said to be a major cause of hospitalization, as well as a major cause of patients undergoing amputation beyond trauma.
Each year, in the United States there are 80,000 cases undergoing amputation due to diabetic neuropathy or 1 amputation every 2 minutes (Vinik, 2002). Pain Neuropathy (pain due to nerve damage) is estimated to be suffered by 1% of the total population and 1/3 of them are ND (Bennet, 1997).
Of the total diabetics, 7.5% of them suffer from neuropathic pain (Nash, 1997). Description of diabetic neuropathy pain characterized by burning, stabbing, electric shock, tearing, tied, numbness, and tingling.
Positive symptoms or negative symptoms
Damage to nerve fibers in general starts from the distal / end to the proximal / base, while the repair process from proximal to distal. Therefore, patients generally complain of numbness or pain in the tips of the toes (Vinik, 2002). Compared with large diameter nerve fibers, it appears that initially lesions are small nerve fibers (De Cherney, 1999).
Patients with neuropathic pain with severe pain complaints (especially in the legs) generally exhibit mild neurologic abnormalities of distal sensory disturbances of the feet whereas reflexes are still within normal limits. Patients with painless nerve damage often present with neurologic symptoms such as negative reflex (Scadding, 1999). This means that the patient’s nerve damage with pain is milder than the patient without pain.
Whether it is in accordance with the dynamics of the degeneration process is still a question. The function of nerve fibers is as a conductor of impulses. The presence of impulse duty impairment impedes or activates survival or death programs. Thus it can be understood, if the lesions suffered by the patient is severe then the active death program is a neuron.
Neuronal death causes negative symptoms of the nervous system such as sensory disturbance with manifestations of numbness, thickness, anesthesia, motor impairment in the form of paralysis or autonomic disorder of impotence.
However, if the lesion is mild, there will be degeneration of the axon (survival response). This response causes phenotypic changes to prepare the regeneration process. The regeneration process causes distortion of the signal, such as the emergence of receptors, new ion channels, sprouting nerve endings
What can be done?
The main principle of management of diabetic neuropathy pain is the control of blood sugar levels. Control of blood sugar levels will inhibit the progression of diabetic neuropathy. Research on 1,441 patients with type 1 diabetes showed that controlling blood sugar levels was effective to slow the progression of diabetic neuropathy.
Another therapy commonly used to overcome the pain is the anti-depressant and anti-convulsant / anti-epilepsy drugs. Anti-convulsants have the ability to suppress the abnormal sensitivity of neurons in the central nervous system on which epilepsy is generated (Chong and Smith, 2000).
Epilepsy and neuropathic pain are both due to abnormal activity of the nervous system. Epilepsy is triggered by central nervous system hipereksitabilitas which can lead to paroxysmal spontaneous generation, and this is similar to the occurrence of paroxysmal spontaneous pain in neuropathic pain.
Stress and anxiety will make the pain inhibition system not working properly. Depression will increase the pain and intensity of pain. Behavior modification and consolation is one form of therapy that must also be done.