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Review Article

Approach to Diabetic Neuropathy

Nitin Kapoor1,2, Kirubah David3, Bharathy Saravanan1
Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore, India, 2Non communicable Diseases Unit, Melbourne School
1

of Population and Global Health, University of Melbourne, Melbourne, Australia, 3Department of Family Medicine, Christian Medical College and Hospital, Vellore, India

Abstract
Neuropathy is the most common symptomatic complication of diabetes mellitus (DM) and accounts for a large share of morbidity and
hospitalization associated with the disease. The symptoms of neuropathy in diabetes may present with somatic, autonomic, motor or sensory
symptoms. Symmetric distal sensory polyneuropathy is the most common form, affecting the distal lower extremities and hands in a “glove
and stocking” pattern. Cardiac autonomic neuropathy can, in particular, contribute to 6% of sudden deaths (painless myocardial infarction)
among those with long‑standing diabetes. Neuropathy whether sensory, motor, or autonomic may lead to the formation of fissures or calluses
which lead to ulceration. Tight glycemic control is the only strategy which has demonstrated to show prevention and progress of diabetic
peripheral neuropathy and autonomic neuropathy. Early treatment of diabetic neuropathy should, therefore, include tight glycemic control.
All patients should be screened for diabetic neuropathy starting at diagnosis of type 2 DM and 5 years after diagnosis of type 1 DM and at
least annually thereafter. An annual comprehensive foot examination is a must for all patients with diabetes and consists of examination of
foot and footwear, neuropathy screening, vascular assessment, and musculoskeletal assessment of feet. This would help in identification of
risk factor predictive of ulcers and amputation.

Key words: Diabetes mellitus, diabetic neuropathy, peripheral neuropathy

Address for correspondence: Dr. Nitin Kapoor, Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore ‑ 632 004, Tamil Nadu,
India. E‑Mail: nitin.endocrine@gmail.com

Case Scenario
A 58‑year‑old female who had poorly controlled type 2 diabetes mellitus for 12 years presented in the outpatient clinic with
a history of fever and swelling of the left foot for 2 days. She had recently returned from a vacation to a distant pilgrimage
center. On examination of the foot, a glass piece was found embedded in the plantar aspect of the left foot, and the surrounding
region showed signs of severe inflammation. The remarkable aspect of this case was that she had never experienced any pain
in the foot.
What do you think was the cause of the loss of sensation and infection in the foot?
How could it have been prevented?

Introduction
Diabetes is a systemic disease, the incidence of which is rising all over the world. The most common symptomatic complication
of diabetes is peripheral neuropathy. It is a microvascular disease that accounts for the most number of hospitalizations among
those with diabetes and is the most common cause of nontraumatic amputations and foot ulcers [Figure 1].1,2 It is also one of
the important causes of mortality (through silent myocardial infarction) among diabetics.

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DOI:
10.4103/cmi.cmi_38_17 How to cite this article: Kapoor N, David K, Saravanan B. Approach to
diabetic neuropathy. Curr Med Issues 2017;15:189-99.

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Kapoor, et al.: Diabetic neuropathy

It is estimated that about 90% of patients with diabetes for more

than 20 years will develop diabetic neuropathy [Figure 1].
What is worrying is that in approximately 40% of these
patients, the diabetic neuropathy may be asymptomatic.3 It is
important therefore for the physician to actively seek evidence
of neuropathy and to make the patient aware of the risk of
developing this complication.
Clinical Pearl a
When should diabetic patients be tested for neuropathy?
All patients with diabetes should be screened for diabetic
neuropathy
• Type 2 diabetes mellitus – starting at the time of the
first diagnosis
• Type 1 diabetes mellitus – starting at 5 years after the
diagnosis and at least once a year thereafter.

The costly sequelae of neuropathy‑like foot ulceration and

amputation are preventable with early detection. The pain
associated with neuropathy severely impairs the quality of life,
physical activity, and productivity of patients.
The important goals as primary care physicians are:
• To screen and diagnose neuropathy at an early stage
• To initiate strict glycemic control which is the main
disease modifying option available for neuropathy4
• Initiate evidence‑based management of painful neuropathy b
and to provide good quality of life to these patients Figure 1: (a) Incidence of diabetic neuropathy among those with diabetes
• Prevent neuropathy‑related sequelae like amputation. for >20 years. (b) Neuropathy, ulceration and amputation.

Definition Box 1: Common causes of peripheral neuropathy to be

Diabetic peripheral neuropathy may be defined as the excluded
“presence of symptoms and/or signs of peripheral nerve • Vitamin B12 deficiency
dysfunction in people with diabetes after exclusion of other • Alcohol-related neuropathy
causes” [Box 1].5 • Hypothyroidism and
The important thing to note in this definition is any patient • Renal insufficiency
with symptoms is also termed to have neuropathy even when • Heavy metal poisoning
signs are absent and vice‑versa. It is not essential to have both • Multiple myeloma
signs and symptoms before terming it neuropathy; therefore,
examination for neuropathy must be done in all long‑standing
diabetic patients to detect loss of sensation even when Box 2: Risk factors for diabetic neuropathy
symptoms are absent. The risk factors for developing diabetic The risk factors for developing diabetic neuropathy are
neuropathy are summarized in Box 2. • Poor glycemic control
• Long duration of diabetes
• Elevated triglycerides
Classification • Elevated blood pressure
Diabetic neuropathy can be classified into symmetrical and • Obesity
asymmetrical neuropathies [Table 1]. Of these, symmetric distal • Smoking or alcohol use
sensory polyneuropathy is the most common form [Figure 2]. • Genetic phenotype
This affects distal lower extremities and hands in a “glove and
stocking” pattern.
Diabetic neuropathy may also be classified according to the Clinical Signs and Symptoms
type of nerve fiber [Table 2] involved into: The symptoms of neuropathy in diabetes may present
1. Small fiber neuropathy and with somatic, autonomic, motor, or sensory symptoms
2. Large fiber neuropathy. [Table 3].

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Table 1: Classification of diabetic neuropathy Somatic sensory symptoms

Diabetic neuropathy can involve both the upper and lower
Symmetric Asymmetric focal/multifocal neuropathy limbs. Symmetric distal sensory polyneuropathy is the most
polyneuropathy
Distal sensory Cranial neuropathies
polyneuropathy Limb mononeuropathy
Autonomic Compression and entrapment
neuropathy neuropathy ‑ femoral, sciatic, ulnar, peroneal
neuropathy
Truncal mononeuropathies
Mononeuropathy multiplex
Asymmetric lower‑limb motor
neuropathy (amyotrophy)

Table 2: Features of small and large fiber neuropathy

Small fiber neuropathy (A
alpha and C fibers)
Pain and paresthesia
Autonomic signs and
symptoms
Temperature loss
No weakness
Normal deep tendon reflexes
Large fiber neuropathy (A delta
fibers)
Impaired vibration
Loss of position sense
Wasting and weakness of muscles
Loss of deep tendon reflexes Figure 2: “Glove and stocking” neuropathy.

Table 3: Symptoms and signs in diabetic neuropathy

Symptoms Signs
Somatic symptoms Autonomic symptoms Motor symptoms/signs
Small fiber neuropathy Cardiovascular Wasting of muscles, Sensory
Paresthesia ‑ burning, pricking, electrical Dizziness on getting up, Tachycardia, Especially in hands and feet loss (touch and
sensations. More severe at night exercise intolerance Weakness of muscle groups temperature)
Heat intolerance Partial or complete
Large fiber neuropathy Loss of deep tendon
Numbness over feet, hands or Genito‑urinary reflexes Loss of vibration
specific sites, sensations of swelling, Incontinence or sensation of partial sense
cotton‑wool‑like sensation or a feeling emptying, erectile dysfunction especially in the
that the limb is “dead” or “asleep.” The extremities
symptoms worsen at night and have a Gastrointestinal
symmetrical distribution Nausea and bloating sensation of
abdomen, diarrhea, constipation, fecal
Pain incontinence
Ill‑defined sharp or deep burning pain
with hyperesthesia or allodynia Sweating
Symptoms of inappropriately increased
sweating, areas of anhidrosis
Metabolic
Hypoglycemia unawareness,
hypoglycemia unresponsiveness
Pupils
Argyll Robertson type pupils
About 6% of diabetics die without any
symptoms, due to “silent” autonomic
dysfunction (E.g., Painless myocardial
infarction)
Keep in mind that 40% of patients with diabetic neuropathy are asymptomatic

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Kapoor, et al.: Diabetic neuropathy
common form. This affects distal lower extremities and
hands in a “glove and stocking” pattern [Figure 2]. Large
fiber neuropathy (A delta fibers) is more common and leads
to symptoms such as electrical tingling sensation or sensation
of a band around the ankles or feet. The patient may have a
sense of imbalance, especially at night with prominent gait
instability. Small fiber neuropathy (A alpha and C fibers) is
less common and results in burning or stabbing paresthesias,
which are more severe at night.
Autonomic symptoms
There is a high prevalence of autonomic neuropathy among
diabetics (50%–60%)5,6 and is associated with significant
mortality and morbidity. Cardiac autonomic neuropathy can,
in particular, contribute to 6% of sudden deaths (painless
myocardial infarction) among those with long‑standing diabetes.
It is important therefore to ask questions to elicit history of
autonomic dysfunction and perform appropriate investigations.
Some of the simple questions that can uncover a hidden
underlying autonomic neuropathy are:
• Cardiac autonomic neuropathy ‑ Do you feel dizzy when
you get up from a lying position (orthostatic hypotension)?
Check for resting tachycardia
• Gastroparesis  ‑  Do you feel full after eating less than
what you normally eat?
• Cystopathy ‑ Decreased/increased urinary frequency and
Figure 3: Pathogenesis of diabetic neuropathy.
192
sensation of incomplete voiding after passing urine
• Gustatory sweating ‑ Is there sweating over the face while
eating?
• Erectile dysfunction.
Clinical Pearl
Screening for signs and symptoms (e.g., orthostasis, resting
and tachycardia) of cardiovascular autonomic neuropathy
should be considered with more advanced disease.
Pathogenesis
There are many hypotheses for the pathogenesis of diabetic
neuropathy. The chronic, more insidious neuropathy is
predominantly due to persistent hyperglycemia while the
acute, usually self‑limiting neuropathy may be due to vascular
causes.
Hyperglycemia results in accumulation of advanced
glycosylated end products and activation of other pathways
ultimately leading to oxidative stress, axonal loss, and
demyelination resulting in nerve dysfunction.7 Excess glucose
also gets converted into sorbitol by the enzyme aldose
reductase. Sorbitol decreases levels of myoinositol nerve
growth factor which leads to diabetic neuropathy [Figure 3].
Optimal glucose control is, therefore, the primary preventive
measure.
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An understanding of the underlying pathophysiology of Quantification of diabetic neuropathy

diabetic neuropathy does help in understanding the treatment
options available as many of the medications available address
the factors involved.
Screening Tests to be Done for Assessing
An objective measurement or quantification of diabetic
neuropathy can help in assessing progress/worsening and
response to treatment. Small fiber neuropathy can be quantified
using a nylon monofilament while large fiber neuropathy is
quantified by assessing vibration sensation.

Peripheral Neuropathy Assessment of sensation using a nylon Semmes–

The following are recommended as screening assessments for
peripheral neuropathy.8
1. Inspection of the feet and the footwear
2. Small fiber function: Pin prick test and temperature test
3. Large fiber function: Vibration perception, monofilament
test, and ankle reflexes
4. Loss of protective sensation test: monofilament test
5. Musculoskeletal assessment for deformity
6. Vascular assessment of the feet
7. Examination of the footwear used, especially at the sites
of ulcer.
Weinstein monofilament
Semmes‑Weinstein Monofilament is a nylon filament which
is available in standard thicknesses. The commonly used
ones are (from thin to thick) the 2 g (purple), 4 g (red), and
10 g (orange). The ten areas of the foot tested are illustrated in
Figure 4 (9 on the plantar aspect and one on the dorsal aspect).
Quantification of diabetic neuropathy using the
semmes‑weinstein monofilament
1. Show the Semmes-Weinstein monofilament to the patient.
Touch it first to the patient’s forehead or sternum so that
the sensation is understood.

Figure 4: Assessment of sensation using a nylon Semmes–Weinstein monofilament.11 (Adapted from Mahesh DM, Paul T, Thomas N. Peripheral
neuropathy. A Practical Guide to Diabetes Mellitus. 7th ed. Jaypee; New Delhi. 2016. p. 171-189.)

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2. Instr uct the patient to say “yes” every time the
monofilament stimulus is perceived.
3. With the patient’s eyes closed, apply the monofilament to
the one of the 10 regions. Use a smooth motion-touch the
skin with the filament, bend the filament for a full second,
then lift from the skin. Perform this stimulus 4 times per
foot in an arrhythmic manner so the patient does not
anticipate when the stimulus is to be applied. [Figure 4]
4. If the individual can perceive 6 out of the 10 touches,
sensation is assumed to the normal. The 2 gram filament
is used first; proceed to the thicker filaments (4 and then
10 gm) if sensation is not perceived.
5. If the 10 gm filament is not perceived, then there is
definitely a loss of protective sensation.
6. Note the filament perceived and the number of regions
perceived for future reference. It is advisable to perform
this test at least once a year.9
Tests for vibration sense
Testing for large fiber neuropathy is done by assessing the
perception of vibration sense using a tuning fork (128 Hz).
Rapid screening for diabetic neuropathy using the 128‑Hz
vibration tuning fork (modified from the Canadian Diabetes
Association guidelines)
1. Strike the tuning fork against the palm of your hand hard
enough that it will vibrate for approximately 40 s
2. Apply the base of the tuning fork to the patient’s forehead
or sternum and ensure that the vibration sensation
(not just the touch sensation) is understood
3. With the patient’s eyes closed, apply the tuning fork to the
bony prominence situated at the dorsum of the first toe just
proximal to the nail bed. Ask if the vibration sensation is
perceived. [Figure 5]
4. Ask the patient to tell you when the vibration stimulus is
stopped and then dampen the tuning fork with your other
hand
5. Repeat this on other toes and bony prominences at the
ankle like the medial and lateral malleolus.10
Figure 5: Tuning fork test for vibration sense.
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Quantification of vibration perception
The perception of vibration can be objective assessed and
quantified using a biothesiometer. This is an instrument that
can be used for the assessment of vibration in a graded manner
using various grades of electric current. If there is neuropathy,
the recording is usually more than 15 mV when it is mild, more
than 25 mV if it is moderate, and more than 40 mV when it
is severe [Figure 6].
Sequelae of Diabetic Peripheral Neuropathy
Neuropathy, whether sensory, motor, or autonomic may lead to
the formation of fissures or calluses which lead to ulceration.
Abnormal pressure over bony prominences is the likely cause
of skin breakdown in patients with diabetes. The pressure can
be long‑standing (as with an ill‑fitted shoe) or sudden (stepping
over a sharp rock or glass piece). Loss of sensation prevents the
patient from being warned of abnormal pressures. This may
result in the formation of blisters in feet and skin breakdown. The
venous edema which often accompanies autonomic neuropathy
causes swelling of the foot and tightness of footwear. Thickened
hypertrophic nails can contribute to increased pressure. This
commonly results in skin breakdown and ulcer formation.
Fissure and foot ulcer
Autonomic neuropathy coupled with loss of sensation in the
predisposes to formation of fissures and foot ulcers. Autonomic
neuropathy results in decreased sweating and dryness in the feet
which may result in the formation of fissures [Figure 7]. A fissure
can get infected and lead to the formation of a foot ulcer.
Callus
Long‑standing abnormal pressure over bony prominences can
result in the formation of a region of thickened skin called callus.
b
Figure 6:  (a) Biothesiometer. (b) Using a biothesiometer.
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The callus may develop a hematoma following an injury which can
get infected, resulting in abscess, and ulcer formation [Figure 8].
The common foot deformities seen are hammer toe and claw
feet both due to motor neuropathy. Extreme deformity in a
neuropathic foot can result in an acute condition termed as
Charcot foot [Figure 9]. Charcot foot or “rocker bottom feet”
is characterized by acute swelling of the foot with warmth
and erythema, bounding pulses and ulcers without much pain.
Management of Diabetic Neuropathy
Treatment of diabetic neuropathy consists of three components:
1. Glycemic control
2. Pain control
3. Foot care.9
Glycemic control
Tight glycemic control is the only strategy which has
demonstrated to show prevention and progress of diabetic
peripheral neuropathy and autonomic neuropathy. Early
treatment of diabetic neuropathy should, therefore, include
tight glycemic control.
In the Diabetes Control and Complications Trial, intensive
therapy slowed the onset of neuropathy by 70% and the
progression of early neuropathy by 57%. 11 In the UK
Prospective Diabetes Study, glucose control was associated
with improved vibratory sensation.12
Treatment should also aim at control of blood pressure,
dyslipidemia, and lifestyle modifications such as exercise and
cessation of smoking and alcohol.
Clinical Pearl
Tight glycemic control is the only strategy convincingly
shown to prevent or delay the development of diabetic
peripheral neuropathy and cardiac autonomic neuropathy in
patients with type 1 diabetes and to slow the progression of
neuropathy in some patients with type 2 diabetes.
Figure 7: Development of fissures in foot.
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Pain control – symptomatic treatment of painful
neuropathy
Pain and paresthesia are distressing symptoms, and optimal
management significantly improves the quality of life of the
individual. The options available for symptomatic treatment
of paresthesia and dysesthesia (discussed below) raise the
threshold for pain and provide some degree of comfort. The
drugs used to treat pain in diabetic neuropathy are summarized
in Table 1.
Agents available for symptomatic treatment of neuropathy
The medications used for the symptomatic treatment of diabetic
neuropathy are discussed below and summarized in Table 4.5
Tricyclic antidepressants (Eg. amitriptyline)
It is probably the most cost‑effective and powerful agent in therapy
of painful neuropathy. Dose: it is started in the doses of 25 mg and
increased by increments of 25 mg usually up to 150 mg. Other
norepinephrine reuptake inhibitors, such as desipramine and
nortriptyline, have also been shown to be beneficial.
Caution: Prostatic hypertrophy – It can worsen symptoms;
Cardiac arrhythmias – can be worsened, so a check
electrocardiogram is recommended; narrow‑angle glaucoma
(in the view of the anticholinergic effect). Anticholinergic
effects, orthostatic hypotension and erectile dysfunction limit
their usage. They can be used in renal failure.
Anticonvulsants
Anticonvulsants have a major impact on pain relief in neuropathy
if used in optimal doses. However, sodium phenytoin should
be avoided since it may worsen hyperglycemia.
a. Carbamazepine is the other drug commonly used in the
symptomatic management of paresthesia. In higher doses,
it can cause ataxia. It rarely causes Stevens‑Johnson
syndrome
b. Gabapentin: Gabapentin has been shown to improve sleep,
which may be impaired in a patient with chronic pain
c. Pregabalin: This agent has been found to be marginally
superior to gabapentin
Figure 8: Development of callus and foot ulcer.
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Table 4: Medications used to treat symptomatic diabetic neuropathy (modified from Canadian Diabetic Association
guidelines)
Class Examples Starting dose Maximum dose for neuropathy
Tricyclic drugs Amitriptyline 10 mg at bedtime 150 mg/day
Nortriptyline 25-75 mg at bedtime
Imipramine 25-75 mg at bedtime
Anticonvulsants Gabapentin 300 mg bd 900 mg/day
Carbamazepine 200 mg tid 800 mg/day
Pregabalin 75 mg od 200 mg/day
5‑HT and norepinephrine Duloxetine 60-120 mg od 120 mg/day
reuptake inhibitor
Substance P inhibitor Capsaicin cream 0.025-0.075% preparation for local application 5-6 applications/day
Antipyretics Paracetamol 500 mg 2500 mg/day
Semisynthetic opioids Tramadol 50-100 mg 400 mg
5‑HT: 5‑hydroxytryptamine

Pregabalin and gabapentin have a similar mechanism of

action in that they bind to a subunit of the voltage‑sensitive
calcium channel and thereby decreasing calcium influx at nerve
terminals modulating neurotransmitter release.
Dizziness, somnolence, and peripheral edema are frequently
reported adverse effects.
d. Topiramate has shown promising results in trials with an
effect on causing growth of intraepidermal nerve fibers
and is used in a dose of 25–50 mg/day.
Fluoxetine has some impact on neuropathic pain. However,
more recently duloxetine has been found to be more
effective. Duloxetine hydrochloride is a selective and potent
norepinephrine and serotonin reuptake inhibitor in the brain
and spinal cord that has been approved in the treatment of
painful neuropathy.
Besides the above list of drugs, analgesics, nonsteroidal
anti‑inflammatory drugs (NSAIDs), and opioids are also used
in addition to treat symptomatic painful neuropathy; however,
no advantage of NSAIDs over paracetamol has been noted.
Deep‑seated pain – treatment options
Deep‑seated, poorly localized pain is experienced by some
individuals with diabetic neuropathy. The following options
may be used in the management of this type of pain.
• Opioid derivatives: Tramadol is an effective semi‑synthetic
opioid. In combination with acetaminophen, it is effective
in curbing deep pain and is less addictive than other opioid
derivatives [Table 1]
• Transcutaneous electrical nerve stimulation: it is effective
in therapy of deep‑seated pain
• Local application of capsaicin ointment: in randomized
trials, it is found to be useful as an adjuvant therapy
[Table 1].
Other medications for diabetic neuropathy
There are several medications that have been used, with
varying levels of success, in the treatment of diabetic
Figure 9: Charcot’s foot with a healing foot ulcer.
neuropathy by targeting different aspects of the pathogenesis
pathway [Figure 10] described earlier. Many of these agents
enlisted below are new, and some are in different phases of
clinical trials.
• Ruboxistaurin  –  This is a protein kinase C inhibitor.
However, it was not found to be clinically effective
• Alpha lipoic acid – This is an antioxidant which reduces
oxidative stress on the neurons that lead to nerve damage.
This agent was not found to be very effective in the oral
formulation in the management of neuropathy
• High‑myoinositol diets  –  A diet rich in   myoinositol
MI (legumes and nuts) has been tried
• Recombinant nerve growth factor
• Topical nitric oxide
• Aldose reductase inhibitors.
Foot care
Care of the foot and the use of appropriate footwear is an
important part of diabetes care. Tight or ill‑fitting footwear
can result in abnormal pressures over bony prominences,
especially in those with foot deformities. The loss of sensation
prevents the patient from appreciating injury due to these
pressures which leads to blister formation and skin breakdown

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Figure 10: Agents used in treatment of diabetic neuropathy.
over time. Fissure and callus formation in the feet leading on to
foot ulcers must be prevented as these may lead to significant
disability. Educating the individual regarding prevention of
these complications of neuropathy is therefore vital [Box 3].
Patient education
Every patient with neuropathy must be educated to take care of
their feet. This can be done either by the physician or a trained
nurse. Some of the general instructions for individuals with
diabetic neuropathy are enlisted below.
Foot Care and Foot Wear
The majority of diabetic foot related complications resulting in
amputation can be prevented by early detection and appropriate
treatment of the ulcers by the primary care giver. Individuals with
Diabetic foot ulcers (DFU) are demonstrating increased incidence
of hospitalization due to infection, and amputations. DFUs
contribute up to 83% of major and 96% of minor amputations
among all amputations associated with a foot wound of any type.
Diabetic foot ulcer may be present in a pre-existing Charcot’s foot
[Figure 4]. So it should be the primary focus of the physicians
to perform routine foot examination for all the diabetic patients.
“Foot problems can be prevented by Simple foot care and
Proper foot wear”
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Box 3: Foot care prescription for diabetic patients with
lower extremity sensory neuropathy
• Never walk barefoot
• Do not apply hot water or heating pads to the feet
• Inspect the feet daily, using a mirror for plantar surfaces
• Wash the feet daily, drying thoroughly between the toes
• Lubricate dry skin to avoid cracking
• Wear clean, soft, cotton socks
• Wear properly fitting, well-cushioned shoes (insoles)
• Break in new shoes slowly
• Consider a second pair of shoes at night (larger size for
dependent edema)
• Cut toenails straight across, to conservative lengths
• Schedule regular visits to a diabetic foot care
Foot care in Small fiber neuropathy (loss of pain and
temperature sensation)
• Daily foot inspection-Use a mirror to inspect the soles of
the feet
• Microcellular rubber (MCR) footwear – distributes weight
evenly, has optimal hardness, has elastic recoil which
maintains shape of foot while walking
• Shoes should fit well
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• Socks - Avoid tight socks, wrinkles in socks. Cotton/wool
is preferred
• Avoid exposure to heat
• Creams may be used to prevent drying and cracking of skin
• After bathing, feet should be dried thoroughly
• Nails should be cut transversely.
Foot care in Large fiber neuropathy
• Gait and strength training: diabetic patients with large
fiber neuropathy have an increased predisposition to
falls due to ataxia, incoordination, weakness, and muscle
wasting. Improving muscle strength by high-intensity
strength training, coordination, and balance techniques
helps to reduce falls and resultant fractures
• Advise use of MCR footwear.
Callus and fissure care
• After shower or bath, soak foot for 10 min to soften the
callus.
• Rub pumice stone over the callus (in one direction)
• Apply 6% salicylic acid to the callus.
• If callus is thick, it may need to be trimmed with scalpel
by a trained nurse/doctor
• Remember to look for cause of the callus– examine the
footwear and make changes if necessary.
Toenail care
• Soak feet 10 min before cutting the nail– this will soften
• Trim the nail straight across– then file the corners
• Leave toenail about 2–3 mm long to avoid cutting close
to the nail bed.
• For Thick toenails: file the nail down with an emery board.
Foot wear
The most important aspect of diabetic foot care is selection
of appropriate foot wear, which protects the neuropathic feet
from uneven plantar pressure, trauma and further preventing
amputation. Microcellular rubber (MCR) is the most common
material used to relieve plantar pressure and can be prescribed
for all diabetic patients. Modifications can be made in the
insole, outsole, and shoes upper portion in order to relieve
pressure in the areas which are at risk for ulceration.
Wound care
Assessing the diabetic wound is important for planning further
management. Description of ulcer characteristic such as size,
depth, location, appearance and odour should be periodically
monitored to assess the wound healing. Wound care involves
daily 0.9% saline dressing, appropriate offloading, good
glycemic control and infection prevention.
Small fiber neuropathy (loss of pain and temperature
sensation)
• Daily foot inspection‑Use a mirror to inspect the soles of
the feet
• Microcellular rubber (MCR) footwear – distributes weight
evenly, has optimal hardness, has elastic recoil which
maintains shape of foot while walking
198
• Shoes should fit well
• Socks ‑ Avoid tight socks, wrinkles in socks. Cotton/wool
is preferred
• Avoid exposure to heat
• Creams may be used to prevent drying and cracking of skin
• After bathing, feet should be dried thoroughly
• Nails should be cut transversely.
Large fiber neuropathy
• Gait and strength training: diabetic patients with large
fiber neuropathy have an increased predisposition to
falls due to ataxia, incoordination, weakness, and muscle
wasting. Improving muscle strength by high‑intensity
strength training, coordination, and balance techniques
helps to reduce falls and resultant fractures
• MCR footwear.
Callus and fissure care
• After shower or bath (soak foot for 10 min.)
• Rub pumice stone over the callus (in one direction)
• Apply 6% salicylic acid to the callus.
• If callus is thick, it may need to be trimmed with scalpel
by a trained nurse/doctor
• Remember to look for cause of the callus– examine the
footwear and make changes if necessary.
Toenail care
• Soak feet 10 min before cutting the nail– this will soften
nails
• Trim the nail straight across– then file the corners
• Leave toenail about 2–3 mm long to avoid cutting close
to the nail bed
• Thick toenails: file the nail down with an emery board.
Conclusions
• All patients should be screened for diabetic neuropathy
starting at the diagnosis of type 2 diabetes mellitus (DM)
and 5 years after the diagnosis of type 1 DM and at least
annually thereafter
• The clinical assessment should include a detailed history
and 10  g monofilament testing and at least one of the
following tests: pinprick test, temperature test, and tests
for vibration sensation
• Symptoms and signs of autonomic neuropathy should be
assessed in patients with microvascular and neuropathy
complications8
• Tight glycemic control is the only strategy which
has demonstrated to show prevention and progress
of diabetic peripheral neuropathy and autonomic
neuropathy
• An annual comprehensive foot examination is a must for
all patients with diabetes and consists of examination
of foot and footwear, neuropathy screening, vascular
assessment, and musculoskeletal assessment of feet. This
would help in the identification of risk factor predictive
of ulcers and amputation.
Current Medical Issues  ¦  Volume 15  ¦  Issue 3  ¦  July‑September 2017
[Downloaded free from http://www.cmijournal.org on Wednesday, February 10, 2021, IP: 202.57.14.18]
Kapoor, et al.: Diabetic neuropathy
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Feldman EL, Stevens MJ, Russell JW, Greene DA. Somatosensory
neuropathy. In: Porte D, Sherwin RS, Baron A, editors. Ellenberg and
Rifkin’s Diabetes Mellitus. 6th ed. New York, USA: McGraw Hill; 2002.
p. 771‑88.
2. Vinik AI, Erbas T, Pfeifer MA, Feldman EL, Stevens MJ, Russell JW.
Diabetic autonomic neuropathy. In: Porte D, Sherwin RS, Baron A, eds.
Ellenberg & Rifkin’s Diabetes Mellitus. 6th ed. New York: McGraw Hill.
2003;789-804.
3. Herman WH, Kennedy L. Underdiagnosis of peripheral neuropathy in
type 2 diabetes. Diabetes Care 2005;28:1480‑1.
4. The effect of intensive diabetes therapy on the development and
progression of neuropathy. The Diabetes Control and Complications
Trial Research Group.Ann Intern Med 1995;122:561‑8.
5. Boulton AJ, Vinik AI, Arezzo JC, Bril V, Feldman EL, Freeman R,
et al. Diabetic neuropathies: A statement by the American Diabetes
Current Medical Issues  ¦  Volume 15  ¦  Issue 3  ¦  July‑September 2017
Association. Diabetes Care 2005;28:956‑62.
6. Nanaiah A, Chowdhury SD, Jeyaraman K, Thomas N. Prevalence of
cardiac autonomic neuropathy in Asian Indian patients with fibrocalculous
pancreatic diabetes. Indian J Endocrinol Metab 2012;16:749‑53.
7. Brownlee M. The pathobiology of diabetic complications: A unifying
mechanism. Diabetes 2005;54:1615‑25.
8. Microvascular Complications and Foot Care. American Diabetes
Association. Standards of medical care in diabetes – 2017. Diabetes
Care 2017;40(Suppl. 1):S88-98.
9. Mahesh DM, Paul T, Thomas N. Peripheral neuropathy. A Practical
Guide to Diabetes Mellitus. 7th ed. Jaypee; New Delhi. 2016. p. 171-89.
10. Canadian Diabetes Association. Clinical Practice Guidelines. Available
from: http://www.guidelines.diabetes.ca/Browse/Appendices/
Appendix8. [Last accessed on 2016 Jun 10].
11. Diabetes Control and Complications Trial Research Group, Nathan DM,
Genuth S, Lachin J, Cleary P, Crofford O, et al. The effect of intensive
treatment of diabetes on the development and progression of long‑term
complications in insulin‑dependent diabetes mellitus. N Engl J Med
1993;329:977‑86.
12. Intensive blood‑glucose control with sulphonylureas or insulin compared
with conventional treatment and risk of complications in patients with
type diabetes (UKPDS). UK Prospective Diabetes Study (UKPDS)
Group. Lancet 1998;352:837‑53.
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