What is paresthesia in diabetic polyneuropathy. Dysmetabolic (autonomous, hereditary, distal, sensorimotor, amyloid) polyneuropathy

Diabetes mellitus, which lasts more than 15 years, causes the destruction of many internal organs and leads to oxygen deficiency in the peripheral nervous system. Diabetic polyneuropathy is diagnosed in 50% of diabetics.

The disease affects patients with types 1 and 2 equally. Damage to nerve tissue can cause serious complications, including foot deformity and death.

Etiology and causes of the disease

Diabetes mellitus is an endocrine disorder accompanied by an increased concentration of sugar in the bloodstream. 150 million people in the world have diabetes. If the patient controls the glucose concentration, not allowing it to rise above 8 mmol/l, then the risk of developing polyneuropathy (neuropathy) will be minimal.

To understand what diabetic polyneuropathy (DPN) is, you need to understand that an increase in blood sugar leads to the destruction of vascular walls. Because of this, nerve tissues do not receive the required amount of oxygen, blood supply and metabolism are disrupted. Ischemia gradually develops and impulse transmission is blocked.

The peripheral nervous system is divided into autonomic and somatic. The somatic task is to control the functioning of the body. The autonomic system regulates the functions of internal organs. Diabetic neuropathy disrupts both systems. Pathology (ICD 10 code: G63.2) is one of the most dangerous conditions.

Note! The disease may appear several years after diabetes is diagnosed.

The dominant cause of diabetic polyneuropathy of the lower extremities is increased sugar concentration and prolonged lack of insulin. The deterioration of metabolism at the cellular level has a detrimental effect on peripheral nerve areas.

Other factors influencing the development of pathology are:

endocrine disorders;
kidney and liver diseases;
infectious attacks;
decreased immune status;
depressive states;
alcohol abuse;
intoxication with chemical compounds;
tumor neoplasms.

The disease appears when blood sugar rises to its maximum. Diabetes mellitus provokes disruptions in metabolic processes, which is the cause of disorders in the peripheral nervous system. The brain begins to experience a lack of oxygen, the deficiency of which leads to deterioration of blood supply and damage to nerve tissue. Sharp painful attacks occur, patients note muscle weakness and numbness of the limbs.

Symptoms

Neuropathy in diabetes manifests itself in several stages: subclinical and clinical. At the first stage, the person feels completely healthy, there are no complaints. But the neurologist reveals a deterioration in the threshold of temperature and pain sensitivity, a decrease in the Achilles reaction.

At the clinical stage, signs of the disorder clearly appear. The functioning of many nerves is impaired. The patient loses sensation. Ulcerative inclusions form on the lower extremities.

Initially, diabetic polyneuropathy is expressed in numbness, pain and “pins and needles” in the extremities. The painful syndrome is felt even at rest. Later, discomfort begins to bother you during stressful situations and at night, and a burning sensation in the feet increases. A person suffers from insomnia and anxiety. The threshold for pain and temperature sensitivity decreases.

Other signs include weakness of the muscles and toes. The limbs take on a red tint and dark spots appear. Deformation of the nail plates occurs: the nails become significantly thicker or thinner. The shape of the foot changes: it increases in the transverse direction, flat feet are formed, and the ankle joint is deformed.

As the disease progresses, some areas of the foot become necrotic, leading to gangrene.

Initially, the long muscles running to the feet and hands are affected. The feet are the first to be affected. Due to damage to thick nerve endings, the skin becomes hypersensitive. Allodynia is diagnosed - a condition in which the patient feels acute pain from touch.

Fingers lose sensitivity. After damage to small nerve tissues, temperature sensitivity disappears, burning and tingling appear. There is swelling of the feet, the skin on which dries and peels. Calluses, cracks, and ulcers are actively forming.

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Polyneuropathy of the lower and upper extremities - symptoms and methods of treating damaged nerve endings

Tendon reactions gradually fade away, muscle weakness develops, and the functioning of internal organs is disrupted - visceral polyneuropathy is diagnosed. The disease is accompanied by hypotension, urinary incontinence, erectile dysfunction, and digestive problems.

When the optic nerve is damaged, cataracts and other visual disturbances form. Unbearable pain occurs in the liver and pharynx. Numbness and stiffness of the limbs becomes permanent. The irreversibility of the situation is indicated by the patient's gait: since the patient does not feel his legs, he walks strangely and unnaturally, as if falling.

All muscles gradually atrophy. This leads to a change in speech skills. The diabetic begins to speak incomprehensibly, distorting the correct pronunciation of words.

Classification

The peripheral systems give their name to types of diabetic polyneuropathy. The somatic type leads to trophic formations on the lower extremities, the vegetative type leads to difficulty urinating, impotence, and irreversible heart attacks.

Based on the location of the lesion, the following types of polyneuropathies are distinguished:

sensory, which manifests itself as a painful syndrome in the limbs, loss of sensory susceptibility;
motor, accompanied by difficulties with movement, muscle dystrophy;
sensorimotor, combining the features of the described types.

The latter type of neuropathy can cause destruction of the peroneal nerve fiber. This manifests itself in the absence of a reaction to thermal irritation; the diabetic does not feel pain in some areas of the foot and leg. Patients cannot regulate the movements of their feet, which provokes an unnatural “cock” gait.

Diagnostic methods

To identify polyneuropathy in diabetes mellitus, it is necessary to conduct a comprehensive examination of the patient. The doctor collects anamnesis, interviews the patient, assessing the functionality of organs and systems.

Sensitivity to vibration is assessed using a tuning fork, placing the device against different parts of the foot. The neurologist uses monofilament to determine tactile sensitivity. To do this, you need to press on the skin and wait for the results. The study must be repeated three times.

The temperature sensitivity threshold is determined using a two-sided device, which consists of plastic and metal. The doctor alternately applies the cylinder to the skin with different sides. With neuropathy, the patient does not feel the difference between plastic and metal. Sensitivity to pain is assessed using a special needle or gear.

Note! The determination of the knee and Achilles reflex is of great diagnostic importance.

It is necessary to draw blood to determine the glucose concentration. You will also need to conduct an ultrasound scan, an electrocardiogram and an electromyography. The latest examination reveals the speed of impulse transmission between the brain and muscles.

Therapeutic measures

Treatment of diabetic polyneuropathy of the lower extremities should include a large range of therapeutic methods. The effectiveness of therapy depends on the correct impact on all factors that caused the pathology. To cure damaged peripheral nerve fibers, you must follow these rules:

Regulate the amount of sugar in the bloodstream. The patient must maintain values at an acceptable level and avoid sudden jumps in values.
Use antioxidant medications that reduce the concentration of free radicals. These elements harm the peripheral nervous system.
Use vascular and metabolic means to restore damaged fibers. The drugs prevent the destruction of new nerves.
Use painkillers.

Sugar concentration control

Since increased glucose levels are the main cause of polyneuropathy in diabetes, symptomatic treatment is required to stop the development of the disease. For type 1 diabetes, insulin is required, for type 2, various pharmacological drugs in tablet form are required.

Choosing the dosage of tablets or insulin is not an easy task, since it is necessary to ensure that there are no sharp jumps in values. Fluctuations in indicators are dynamic, and this affects different dosages of medications. The change in values depends on the diet of the diabetic, the length of pathology, and concomitant diseases.

Even with normal sugar levels, it is not possible to eliminate the signs of destruction of nerve tissue. Degenerative processes are stopped, but additional medications must be used to get rid of painful symptoms.

– a complex of diseases of the nervous system that occur slowly and arise as a result of excess sugar in the body. In order to understand what diabetic polyneuropathy is, you need to remember that diabetes mellitus belongs to the category of serious metabolic disorders that negatively affect the functioning of the nervous system.

In the event that competent medical therapy has not been carried out, elevated blood sugar levels begin to inhibit the vital processes of the entire body. Not only the kidneys, liver, and blood vessels suffer, but also the peripheral nerves, which is manifested by a variety of symptoms of damage to the nervous system. Due to fluctuations in blood glucose levels, the functioning of the autonomic and autonomic nervous system is disrupted, which is manifested by difficulty breathing, heart rhythm disturbances, and dizziness.

Diabetic polyneuropathy occurs in almost all patients with diabetes; it is diagnosed in 70% of cases. Most often, it is detected in the later stages, but with regular preventive examinations and careful attention to the condition of the body, it can be diagnosed in the early stages. This makes it possible to stop the development of the disease and avoid complications. Most often, diabetic polyneuropathy of the lower extremities is manifested by impaired skin sensitivity and pain, often occurring at night.

Due to excess sugar in the blood, oxidative stress increases, which leads to the appearance of a large number of free radicals. They have a toxic effect on cells, disrupting their normal functioning.
An excess of glucose activates autoimmune processes that inhibit the growth of cells that form conductive nerve fibers and have a destructive effect on nerve tissue.
Impaired fructose metabolism leads to excess production of glucose, which accumulates in large volumes and disrupts the osmolarity of the intracellular space. This, in turn, provokes swelling of the nervous tissue and disruption of conduction between neurons.
A reduced content of myoinositol in the cell inhibits the production of phosphoinositol, which is the most important component of the nerve cell. As a result, the activity of energy metabolism decreases and the process of impulse conduction is completely disrupted.

How to recognize diabetic polyneuropathy: initial manifestations

Disorders of the nervous system that develop against the background of diabetes are manifested by a variety of symptoms. Depending on which nerve fibers are affected, there are specific symptoms that occur when small nerve fibers are damaged, and symptoms that occur when large nerve fibers are damaged.

1. Symptoms that develop when small nerve fibers are damaged:

numbness of the lower and upper extremities;
tingling and burning sensation in the limbs;
loss of sensitivity of the skin to temperature fluctuations;
chills of extremities;
redness of the skin of the feet;
swelling in the feet;
pain that bothers the patient at night;
increased sweating of the feet;
peeling and dry skin on the legs;
the appearance of calluses, wounds and non-healing cracks in the foot area.

2. Symptoms that occur when large nerve fibers are damaged:

balance disorders;
damage to large and small joints;
pathologically increased sensitivity of the skin of the lower extremities;
pain that occurs with a light touch;
insensitivity to finger movements.

In addition to the listed symptoms, the following non-specific manifestations of diabetic polyneuropathy are also observed:

urinary incontinence;
bowel disorders;
general muscle weakness;
decreased visual acuity;
convulsive syndrome;
sagging skin and muscles in the face and neck;
speech disorders;
dizziness;
swallowing reflex disorders;
sexual disorders: anorgasmia in women, erectile dysfunction in men.

Classification

Depending on the location of the affected nerves and symptoms, there are several classifications of diabetic polyneuropathy. The classical classification is based on which part of the nervous system is most affected by metabolic disorders.

The following types of disease are distinguished:

Damage to the central parts of the nervous system, leading to the development of encephalopathy and myelopathy.
Damage to the peripheral nervous system, leading to the development of pathologies such as:
— diabetic motor type polyneuropathy;
— diabetic sensory polyneuropathy;
— diabetic polyneuropathy of sensorimotor mixed form.
Damage to the nerve pathways leading to the development of diabetic mononeuropathy.
Diabetic polyneuropathy, which occurs when the autonomic nervous system is damaged:
- urogenital form;
- asymptomatic glycemia;
- cardiovascular form;
- gastrointestinal form.

Diabetic alcoholic polyneuropathy, which develops against the background of regular alcohol consumption, is also distinguished. It also causes burning and tingling sensations, pain, muscle weakness and complete numbness of the upper and lower extremities. Gradually, the disease progresses and deprives a person of the ability to move freely.

The modern classification of diabetic polyneuropathy includes the following forms:

Generalized symmetrical polyneuropathies.
Hyperglycemic neuropathy.
Multifocal and focal neuropathies.
Thoracolumbar radiculoneuropathy.
Diabetic polyneuropathy: acute sensory form.
Diabetic polyneuropathy: chronic sensorimotor form.
Autonomic neuropathy.
Cranial neuropathy.
Tunnel focal neuropathies.
Amyotrophy.
Inflammatory demyelinating neuropathy, occurring in a chronic form.

What forms are most common?

Distal diabetic polyneuropathy or mixed polyneuropathy.

This form is the most common and occurs in approximately half of patients with chronic diabetes mellitus. Due to excess sugar in the blood, long nerve fibers suffer, which provokes damage to the upper or lower extremities.

The main symptoms include:

loss of the ability to feel pressure on the skin;
pathological dryness of the skin, pronounced reddish tint of the skin;
disruption of the sweat glands;
insensitivity to temperature fluctuations;
lack of pain threshold;
inability to feel changes in body position in space and vibration.

The danger of this form of the disease is that a person suffering from the disease can seriously injure his leg or get a burn without even feeling it. As a result, wounds, cracks, abrasions, ulcers appear on the lower extremities, and more serious injuries to the lower extremities are also possible - joint fractures, dislocations, severe bruises.

All this further leads to disruption of the musculoskeletal system, muscular dystrophy, and bone deformation. A dangerous symptom is the presence of ulcers that form between the toes and on the soles of the feet. Ulcerative formations do not cause harm, since the patient does not experience pain, however, a developing inflammatory focus can provoke amputation of the limbs.

Diabetic polyneuropathy sensory form.

This type of disease develops in the later stages of diabetes mellitus, when neurological complications are pronounced. As a rule, sensory impairments are observed 5-7 years after the diagnosis of diabetes mellitus. The sensory form differs from other forms of diabetic polyneuropathy by specific, severe symptoms:

persistent parasthesias;
feeling of numbness of the skin;
disturbances of sensitivity in any modality;
symmetrical pain in the lower extremities that occurs at night.

Autonomic diabetic polyneuropathy.

The cause of autonomic disorders is excess sugar in the blood - a person experiences fatigue, apathy, headache, dizziness, and attacks of tachycardia, increased sweating, and darkening in the eyes with a sharp change in body position also often occur.

In addition, the autonomous form is characterized by digestive disorders, which slows down the flow of nutrients into the intestines. Digestive disorders complicate antidiabetic therapy: it is difficult to stabilize blood sugar levels. Heart rhythm disturbances, often occurring in the autonomic form of diabetic polyneuropathy, can be fatal due to sudden cardiac arrest.

Treatment: main areas of therapy

Treatment of diabetes mellitus is always comprehensive and aims to control blood sugar levels, as well as neutralize symptoms of secondary diseases. Modern combination drugs affect not only metabolic disorders, but also concomitant diseases. Initially, you need to normalize your sugar level - sometimes this is enough to stop the further progression of the disease.

Treatment for diabetic polyneuropathy includes:

The use of drugs to stabilize blood sugar levels.
Taking vitamin complexes that necessarily contain vitamin E, which improves the conductivity of nerve fibers and neutralizes the negative effects of high blood sugar concentrations.
Taking B vitamins, which have a beneficial effect on the nervous system and musculoskeletal system.
Taking antioxidants, especially lipoic and alpha acids, which prevent the accumulation of excess glucose in the intracellular space and help restore damaged nerves.
Taking painkillers - analgesics and local anesthetics that neutralize pain in the extremities.
Taking antibiotics, which may be needed if leg ulcers become infected.
Prescribing magnesium supplements for seizures, as well as muscle relaxants for spasms.
Prescription of drugs that correct heart rhythm for persistent tachycardia.
Prescribing a minimum dose of antidepressants.
The purpose of Actovegin is a drug that replenishes the energy resources of nerve cells.
Local wound healing agents: capsicam, finalgon, apizartron, etc.
Non-drug therapy: therapeutic massage, special gymnastics, physiotherapy.

Timely, based on regular preventive examinations, competent therapeutic therapy and compliance with preventive measures - all this allows you to smooth out the symptoms of diabetic polyneuropathy, as well as prevent further development of the disease. A person suffering from such a serious metabolic disorder as diabetes must be extremely attentive to his health. The presence of initial neurological symptoms, even the most minor ones, is a reason to urgently seek medical help.

Bolgova Lyudmila Vasilievna

Moscow State University named after. M.V. Lomonosov

Diabetic polyneuropathy: symptoms, classification and directions of treatment therapy

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Diabetic polyneuropathy is one of the most common complications of diabetes. It is believed that diabetic polyneuropathy develops in more than 70-90% of all people with diabetes for over 5 years. At the initial stages, asymptomatic forms prevail, which can only be detected with a thorough neurological examination and/or during instrumental research methods.

Information for doctors. To encrypt the diagnosis of diabetic polyneuropathy, you should use code G63.2* according to ICD 10. In this case, you should indicate the type of disease (sensory, motor, autonomic, or a combination thereof), and the severity of the manifestations. The first diagnosis must indicate diabetes mellitus directly (according to ICD 10 codes E10-E14+ with a common fourth character of 4).

Causes

The development of the disease is associated with a chronic hyperglycemic state, lack of insulin (absolute or relative), and microcirculation disorders in peripheral nerves. Damage to nerve axons usually develops, but segmental demyelination may also occur. The combination of polyneuropathy and angiopathy of the extremities is the leading cause of trophic disorders in diabetes mellitus, in particular the cause of the development of diabetic foot.

Classification

Based on the type of manifestations and localization of symptoms, the following forms of diabetic polyneuropathies are distinguished:

Proximal symmetrical polyneuropathy (amyotrophy).
Asymmetrical proximal neuropathy of large nerves (usually femoral, sciatic or median).
Neuropathies of the cranial nerves.
Asymptomatic polyneuropathies.
Distal types of polyneuropathy.

Distal polyneuropathy is the most common type of diabetic polyneuropathy. It accounts for more than 70% of all types of this disease. The word distal indicates damage to parts of the extremities remote from the body (hands, feet). The lower extremities are more quickly affected. Depending on the nature of the lesion, the following forms are distinguished:

Sensory.
Motor.
Vegetative.
Mixed (sensorimotor, motor-sensory-vegetative, sensory-vegetative).

Symptoms

The clinical picture of the disease depends on the form of polyneuropathy, the degree of nerve damage, and blood sugar levels.

Proximal polyneuropathies are characterized, first of all, by the development of impaired muscle trophism, weight loss of the entire limb, and a decrease in its strength. Autonomic and sensory functions are affected to a lesser extent.
Diabetic cranial nerve neuropathies vary depending on the extent of the affected pair. Thus, the most common lesion is the oculomotor nerve, which often manifests itself in the form of acutely developing painful ophthalmoplegia. Damage to the optic nerve is characterized by a pronounced decrease in vision, blurred vision, and impaired twilight vision. Less commonly, the trigeminal, trochlear, and facial nerves are affected. The most common cause of cranial nerve damage is acute ischemia, and timely therapy usually leads to good results.
Asymptomatic polyneuropathies are usually discovered incidentally during a routine neurological examination. They manifest themselves as a decrease in tendon reflexes, most often knee reflexes.
Distal forms of polyneuropathy usually manifest themselves quite clearly. Thus, the presence of sensory disorders manifests itself in the presence of a crawling sensation in the patient, a painful burning sensation, and numbness in the limb. A person may also notice a pronounced disturbance of sensitivity, may notice a feeling of “walking on a pillow”, in which he does not feel support and his gait is disturbed. In the distal form of diabetic polyneuropathy of the lower extremities, painful cramps often develop. Gait disturbances can lead to the development of foot deformities and, subsequently, the development of diabetic foot.

Autonomic disorders can lead to the development of tachycardia, hypotensive orthostatic reactions, dysfunction of the intestines and bladder, decreased potency, and impaired sweating. The risk of sudden cardiac death also increases.

Motor disturbances in the distal form of polyneuropathy are rare, especially in the isolated form. They are characterized by the development of hypotrophy of distal muscle groups and a decrease in their strength.

Diagnostics

Diagnosis of the disease is based on the clinical picture and the documented fact of the presence of diabetes mellitus for a long time. In difficult situations, it is necessary to conduct electroneuromyography, which allows identifying initial changes in the conduction of nerve impulses along the fibers, and additional consultation with an endocrinologist.

The mechanism of development of diabetes complications - video material by the author

Video about diabetic polyneuropathy

Treatment

Treatment of diabetic polyneuropathy should be comprehensive and carried out jointly with an endocrinologist and therapist. The first thing you need to do is control your blood sugar levels. Correct diet and basic therapy for diabetes. It is also imperative to exclude the presence of micro- and macroangiopathies and, if necessary, carry out appropriate treatment.

To relieve neurological manifestations, thioctic (alpha-lipoic) acid preparations (berlition and its analogues) are most widely used. Drug therapy is carried out in adequate dosage (the initial dose should be at least 300 mg per day) and in long courses (at least 1.5 months). Symptomatic therapy can also be supplemented with ipidacrine hydrochloride drugs (Axamon, Ipigrix, Neuromidin). B vitamins are also widely used.

Exercise therapy, physiotherapy, and massage play an important role in the treatment of diabetic polyneuropathy. If there are signs of foot deformation, orthopedic selection of insoles and shoes is necessary. In all cases, the most important role is played by careful skin care and prevention of microdamage.

In this article we will consider in detail the most common form of late neurological complication of diabetes mellitus - distal, symmetrical, sensory or sensorimotor polyneuropathy.

The main symptoms of diabetic neuropathy are paresthesia, numbness, chilliness and pain in the lower extremities, as well as in the hands. There are symmetrical disturbances of all types of sensitivity (pain, temperature, tactile and vibration) in the so-called "socks" and "gloves" area. In some patients, these manifestations may be mild. In severe cases, paresthesia, pain, and burning sensation in the feet and hands become worse at night. If left untreated, the pathology worsens.

Initial symptoms of neuropathy are determined in the toes; with proximal progression of the process, signs of decreased sensitivity appear in the fingers. The distal parts of the upper extremities are rarely involved first.

In distal, symmetrical, sensorimotor polyneuropathy, thin unmyelinated (C), weakly myelinated (Aσ) and thick myelinated nerve fibers (Aα, Aβ) are affected. Neuropathy predominantly affecting small fibers is characterized by loss of pain and temperature (heat and cold) sensitivity. When predominantly thick fibers are involved in the process, the speed of nerve impulse conduction is disrupted and tactile and vibration sensitivity is reduced or lost, which in severe cases can lead to sensory ataxia. But it should be noted that signs of damage to thin nerve fibers are observed earlier than thick ones.

Symptoms of diabetic neuropathy are recorded in more than 40% of people with diabetes and about half of them have pain. The period of occurrence of pain is characteristic: at rest, during overwork, during stress and mainly at night; when walking, the pain intensity decreases, while changing the position of the limb has no effect. Acute pain syndrome due to neuropathy is described as an independent clinical entity. It is characterized by hypersensitivity and hyperalgesia. In this case, motor nerve fibers are preserved, and sensory functions are slightly affected. A similar phenomenon was called “diabetic cachexia” by Ellenberg. Acute neuropathic pain syndrome is observed with insulin therapy and normalization of glycemia, which Caravati describes as “insulin neuritis.” In this case, pain symptoms are associated with nerve regeneration.

The progression of diabetic polyneuropathy leads to damage to motor fibers - muscle atrophy and weakness in the distal lower extremities. When autonomic nerve fibers are involved, sweating decreases, the skin becomes dry and prone to hyperkeratosis. A so-called “risk stop” is formed. The knee and Achilles reflexes are reduced, and typical bone deformities appear: protruding heads of the metatarsal bones, hammertoes and hooked toes. The skin color is bright pink or red, and symmetrical areas of hyperpigmentation are often observed on the lower leg and dorsum of the foot (the so-called “spotted shin”). The nail plates can atrophy or, on the contrary, thicken and deform, which predetermines the development of onychomycosis. Ultimately, osteoarthropathy or Charcot's foot is formed (an increase in the transverse size of the foot, transverse and longitudinal flat feet, increased deformation of the ankle joint); changes in the configuration of the foot can be unilateral or bilateral, and the appearance of neuropathic edema is also possible. An important differential diagnostic feature is the preservation of pulsation in the arteries of the foot.

Prolonged pressure in areas of bone deformation leads to inflammatory autolysis of the underlying tissues and the formation of neuropathic ulcers, most often on the plantar surface of the foot and in the interdigital spaces. These ulcers may be painless for a certain period of time due to decreased sensitivity, and often only infection and the inflammatory process attract attention to the ulcerative defect. That's why early detection of signs of diabetic polyneuropathy is extremely important to reduce the risk of ulceration and subsequent possible amputation of the limb.

Unfortunately, there is no “gold standard” for identifying neuropathic disorders in diabetes mellitus. In 1998, San Antonio proposed consensus of standardized methods for diagnosing diabetic polyneuropathy, which recommends the following activities:

Identification of clinical symptoms.
Clinical examination: morphological and biochemical analysis.
Electrodiagnostic study: determination of the speed of impulse transmission along the nerve.
Quantitative sensory tests.
Autonomous functional tests.

Often used to detect diabetic neuropathy symptom scale - NSS(Neuropathy Symptom Score) and scale of characteristics - VAT(Neuropathy Dysability Score). For clinical practice, this system was adapted by M. Young et al.

NSS assessment:

burning, numbness (numbness) or crawling sensation = 2
fatigue, cramping or soreness = 1
spreading:
feet = 1
calf muscles = 1
other = 0
gain:
at night = 2
day or night = 1
daytime = 0
awakening from sleep = 1
reduction:
when walking = 2
standing = 1
sitting or lying down = 0

Sum of points is the scale value:
3-4 - minor symptoms,
5-6 - moderate symptoms,
7-9 - severe symptoms.

VAT assessment:

knee reflex
vibration sensitivity
pain sensitivity
temperature sensitivity
reflexes:
normal = 0
amplify = 1
none = 2 on each side
touch (tactile) sensitivity:
present = 0
reduced or absent = 1 on each side

Sum of points:
3-5 - minor signs
6-8 - moderate symptoms
9-10 - severe symptoms

The minimum criteria for diagnosing diabetic neuropathy according to the NSS and VAT are:

moderate signs with or without symptoms (VAT = 6-8 + NSS ≥ 0)
minor signs with moderate symptoms (VAT = 3-5 + NSS = 5-6)

To determine the severity of clinical manifestations it is necessary neurological examination of sensorimotor disorders. It includes the study of all types of sensitivity and reflexes.

Tactile sensitivity assessed using 10 g monofilament (5.07 Semmes-Weinstein). The areas to be examined are the plantar surface of the distal phalanx of the big toe, the plantar surface of the distal head and the fifth metatarsal bone. There must be at least 2 touches at one point. The vibration sensitivity threshold is determined using a neurological tuning fork or biothesiometer. The examination is carried out at standard points: the base of the big toe and the inner ankle. Vibration sensitivity is not reduced if the patient stops feeling vibration when the tuning fork scale value corresponds to 7 UE and above. A decrease in the vibration sensitivity threshold is assessed by many researchers as the most unfavorable prognostic sign. Temperature sensitivity is determined by alternating touches of a warm and cold object to adjacent areas of the big toe, dorsum of the foot, inner ankle, shin and knee. Pain sensitivity is studied using a blunt needle or special devices (Neuropen, Pin-wheel). To analyze the state of the motor part of the nervous system, the Achilles and knee reflexes are determined using a neurological hammer. To identify autonomic neuropathy, the most accessible method in routine practice is orthostatic test.

Based on clinical manifestations, the following are distinguished: stages of distal diabetic neuropathy(International Guidelines for the Outpatient Management of Diabetic Neuropathy, 1995):

0 - no neuropathy, no symptoms or signs
1 - asymptomatic neuropathy
1 A - NSS = 0, normal knee reflex
1 B - NSS = 0, reduced knee reflex
2 - symptomatic neuropathy
2 A - NSS ≥ 1, normal knee reflex
2 B - NSS ≥ 1, decreased knee reflex
3 - severe neuropathy.

This pathology develops in the majority of patients who suffer from diabetes mellitus. With age, the likelihood of polyneuropathy increases in diabetics. This disease occurs only if there is an elevated level of glucose in the blood for a long time.

At the first symptoms of diabetes, you should immediately contact specialist seek qualified help to avoid a number of complications.

Also, don’t ignore the alarming symptoms. polyneuropathy, which can also provoke certain complications in the body. If the patient receives adequate treatment, the prognosis is quite favorable.

Diabetic polyneuropathy of the lower extremities - what is it?

Polyneuropathy of the lower extremities is a pathology that causes damage to the peripheral nodes of these areas of the body. In diabetes mellitus, neuropathy acts as a complication of this disease and develops in types 1 and 2.

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In this situation there is defeat nerve fibers of different sizes, which are responsible for conducting impulses of the somatic and autonomic nervous system.

Sensorimotor neuropathy

Sensorimotor neuropathy is a reduced ability to move, which is accompanied by an unpleasant feeling due to damage to nerve tissue. This pathology can negatively affect the nerves and human movement.

Sensorimotor neuropathy– a systemic process that can damage nerve cells, nerve fibers and nerve coverings.

If a patient experiences damage to the covering of nerve cells, then slowdown nerve signals. If the patient experiences damage to fibers or whole cells, this may cause loss nerve performance.

Diabetic autonomic neuropathy

Autonomic diabetic neuropathy– damage to the autonomic part of the nervous system, which controls and coordinates the performance of internal organs. At the same time, the patient may experience disorders of organs and systems.

In most cases, due to damage to the nerves that control the digestive system, the patient may experience the following unpleasant symptoms:

Nausea.
Heartburn.
Heaviness in the stomach.
Bloating.
Gastrointestinal disorder.
Constipation.

If there is a disturbance in the nerves that control the small intestine. Then the patient will begin to suffer from nocturnal diarrhea.

If there is damage to the nerves that are responsible for the genitourinary system, then it may develop bladder paresis which leads to infection of the genitourinary tract. Emission of urine becomes frequent, sometimes involuntary. Men may also experience erectile dysfunction, and in women – vaginal dryness.

If there is damage to the cardiovascular system due to this pathology, then the patient experiences the following symptoms:

dizziness;
loss of consciousness;
tachycardia;
angina without pain and so on.

Skin with autonomic neuropathy becomes dry, there is abundant discharge sweat or its complete absence.

Distal diabetic polyneuropathy– a disease that is characterized by the death of nerve fibers and entails loss of sensitivity and the development of foot ulcers.

This pathology is considered the most common in diabetes, which can reduce the patient’s performance and to what extent it threatens life. Distal polyneuropathy affects the lower extremities, sometimes the upper ones.

The most common symptoms of this type of polyneuropathy include pain. Basically these are nagging and dull pain sensations. There are times when pain worsens at night and causes some discomfort.

Pain syndrome worsens at rest. The patient may notice heaviness in the legs, tingling, chilliness and burning. The pain can move to the upper legs - thighs. If the patient is not treated promptly, serious complications may occur.

The initial symptoms of this type of pathology include tingling and pain in the toes. Gradually, as the disease begins to develop, this symptom may also be observed in the hands. Distal neuropathy damages fine nerve fibers.

Why does it develop in diabetic patients?

Polyneuropathy advantage develops in patients who suffer from diabetes. This is explained by the fact that glucose in the patient’s blood is at an elevated level for a long time.

The human body tries to get rid of excess, but at the same time formation occurs two side pathways for carbohydrate excretion. As a result of one path, the structure of neurons changes, and the speed of impulse conduction decreases.

Also in the patient’s blood there is promotion the level of hemoglobin, which poorly absorbs oxygen and, as a result, poorly releases it to tissues.

Symptoms

Early symptoms of diabetic leg neuropathy include:

"Goosebumps" on the skin.
Numbness limbs.
Painful sensations near the feet and legs.
Gain pain at night, and the patient may notice a burning sensation in the foot.
Temperature and pain sensitivity in the legs and feet gradually decreases.

Late symptoms of diabetic polyneuropathy include:

Observed even at rest.
arise when overworked.
arise at night, which leads to insomnia.
intensify in a stressful situation.
Are decreasing when walking.
Change your character if you change the position of the limbs.

If this pathology develops over a long period of time, then:

Atrophy muscles of the lower extremities.
Weakening muscles of the fingers and feet.
Skin limbs become pink, sometimes red. Dark areas can vary in size.
Change thickness of the nail plate in different directions.
Development osteoartopathy of the foot.

Diagnostics

If the patient begins to develop first signs disease, you should seek additional advice from endocrinologist, surgeon and neurologist. These specialists, taking into account the complaints and external manifestations of the disease, prescribe additional studies.

Mandatory:

examination of limbs;
attention is paid to the pulsation of the arteries of the lower extremities;
measuring blood pressure levels in the upper and lower extremities;
ECG and ultrasound of the heart;
Determination of cholesterol and lipoprotein levels.

Laboratory methods for diagnosing diabetic polyneuropathy include:

Determination of blood sugar levels.
Determination of insulin concentration in the blood.
Determination of C-peptide.
Determination of glycated hemoglobin level.

When a patient comes to see a neurologist, the doctor conducts the following examination:

Evaluates tendon reflexes.
Determines tactile and vibration sensitivity.
Determines the level of temperature sensitivity impairment.
Assess proprioceptive sensitivity.

Instrumental research methods include:

Evoked potential method.

Based on the results of comprehensive research, experts put accurate diagnosis and effective treatment is prescribed.

Treatment

Diabetic therapy polyneuropathy complex treatment is carried out - medicinal and non-medicinal treatment.

Drug treatment

Drug treatment is considered the most effective, without which it is impossible to maintain normal blood glucose levels. After all, it is precisely because of the increased rate that a complication occurs in the form of neuropathy.

If the patient has type 1 disease, insulin is prescribed.
If the patient has type 2 diseases, then drugs are prescribed that lower sugar.

If you do not control the glycated hemoglob, the pathology will progress and the medication will no longer help.

After the patient’s sugar level has been normalized, he is simultaneously prescribed medications that help stabilize his condition.

Non-drug treatment

Non-drug therapy for neuropathy includes:

Warming up the lower extremities with the help of massage. Be sure to wear warm socks after the procedure. It is also necessary to remember that using heating pads and taking hot baths is strictly prohibited.
Using orthopedic insoles, which relieve stress from the feet.
If the patient has an open wound, then it is treated with an antiseptic. Then it is recommended to bandage with moisture-absorbent material.
Carrying out a therapeutic physical training complex. It is recommended to do exercises for at least 15 minutes a day.

If the patient does the exercises according to the doctor's recommendations, he can avoid lower limb amputation. It is necessary to check with a specialist regarding the treatment of physical education, who will be able to choose the right set of health-improving exercises.

Drugs

After the patient’s blood glucose level is normalized, the following drugs are prescribed in parallel:

Based on thioctic acid: “Berlition”, “Dialipon”, “Tioctacid”. These drugs form the basis of the treatment of diabetic polyneuropathy.
"Pentoxifylline" helps reduce platelet sediment on vascular walls, improves microcirculation.
"Vazaprostan" helps dilate blood vessels, reduces the level of platelet sediment on the vascular walls.

If the patient has not healing wounds, then he is prescribed antibiotics, and the wounds are treated with antiseptics.

Diabetic polyneuropathy– a serious disease that can cause irreversible complications. Recommended for patients who have diabetes.

When the first symptoms of the disease appear, immediately seek qualified help. If timely treatment is carried out and the patient performs health-improving exercises, amputation of limbs can be ruled out.

It is also necessary to remember that self-treatment in such a situation will not effective, and can only make the situation even worse. Only a specialist can make a correct diagnosis and prescribe effective treatment based on a comprehensive study.

Treatment of pathology will depend on the intensity and type. Also, to avoid complications of diabetes mellitus, you need to undergo regular examinations and take all tests to monitor vital signs.

15.09.2016