Diabetic neuropathy or nerve damage is a typical, chronic secondary disease of diabetes mellitus, in which the nerve pathways of the peripheral nervous system are mostly damaged and gradually die. The most common form is diabetic polyneuropathy (peripheral sensorimotor polyneuropathy), initially recognizable by sensations on the feet. A feared complication that can go hand in hand with this nerve damage is the diabetic foot. As the therapeutic options are limited and complete healing cannot be expected, early detection is the most important way to slow the course of the disease and to prevent further possible consequential damage.
People suffering from diabetes should be particularly careful when it comes to their health, because diabetes is an increased risk of a number of complications. Early warning signs should be taken seriously and those affected should seek medical advice immediately. Then you will first find a brief overview with the most important information about neuropathy, before a detailed description of the symptoms follows.
Early warning signals are sensory disturbances and pain, especially in the feet and legs:
This serious complication often shows increased cornea formation and skin cracks on the sole of the foot. Due to sensory disturbances, painful injuries to the feet go unnoticed and, due to poor circulation, wounds that heal poorly and become inflamed. Deep layers of tissue are affected and the result is death. In the worst case, an amputation can occur.
The collective term of diabetic neuropathy encompasses various types of nerve damage, which usually affect the peripheral nervous system (nerves outside the brain and spinal cord) and are caused by diabetes. A basic distinction is made as to whether only a single nerve is affected (diabetic mononeuropathy) or whether damage to many peripheral nerves occurs at the same time. The latter also characterizes the most common manifestation: sensorimotor diabetic polyneuropathy. Among the diverse symptoms, there are particularly frequent sensations and pain on the feet and legs. This characteristic typically results in a diabetic foot in the further course.
Nerves of the so-called autonomic (vegetative) nervous system are less often affected, in this case one speaks of an autonomous diabetic neuropathy.
These diseases, known as the late effects of diabetes mellitus, occur relatively frequently. For example, around ten to twenty percent of people with type 2 diabetes are diagnosed with neuropathy very early on. The secondary diseases also occur in type 1 diabetes. The incidence increases with the duration of diabetes and reaches almost half of those affected after about 25 years.
A variety of symptoms can be associated with diabetic neuropathy, depending on which nerve pathways are affected. In the most common form, sensorimotor polyneuropathy, early signs are sensations, sensory disturbances and pain mostly on the feet and legs or less often on the hands and arms:
- Skin tingling ("ant walking") and feelings of furry,
- Sensitivity disorders for pressure and temperature,
- severe, burning pain (often at night).
Connections to Burning Feet Syndrome (Burning Feet) and Restless Legs Syndrome (Restless Legs) are also established. In addition, diabetic foot syndrome is a serious complication that often results from polyneuropathy. The first, often unnoticed signs are increased cornea formation and skin cracks on the sole of the foot. The reason for this is incorrect stress caused by sensory disorders on the foot. A reduced sensation of pain often means that injuries to the feet go unnoticed. Mostly favored by existing circulatory disorders, poorly healing and inflamed wounds intervene in deep layers of tissue and can cause death. In the worst case, there is even a risk of amputation.
In the advanced stage of polyneuropathy, there may also be boring, cramp-like or permanent pain in the legs and arms. Just like feelings of numbness or hypersensitivity. For example, even touching the legs with the duvet and mattress can cause severe pain when sleeping. In the further course, motor failures can even develop into symptoms of paralysis.
If the autonomic nervous system, which controls the autonomous functions of the body, is also affected, cardiac arrhythmias, circulatory disorders, dizziness, nausea, vomiting, incontinence, diarrhea or constipation can be associated with the disease. Abnormal sweating and sexual dysfunction are also possible.
The factors that cause diabetic neuropathy have not yet been clearly researched and proven. According to experts, however, there is a connection between blood glucose levels that are not optimally adjusted (increased blood glucose levels) and nerve damage. The central risk factor seems to be a high blood sugar level over a long period of time (hyperglycaemia).
The increased blood sugar level can lead to the formation and deposition of degradation products that impair the functions and metabolic processes of nerve cells. This can also result in the deposition of sugar molecules (“saccharification”) on the body's own fats and proteins (proteins), which are important building blocks for the nerves. Clogged blood vessels and thickened vessel walls occur. As a result, the blood can no longer flow so easily through the narrow capillaries, which hinders the supply to the nerves. A resulting lack of oxygen and nutrients additionally damages the nerves. The progression of these symptoms gradually leads to the death of the nerve tissue.
Prevention and early detection are particularly important because of the limited therapeutic options for a pronounced clinical picture of polyneuropathy. People diagnosed with diabetes should have their nerves examined regularly, regardless of whether neuropathic pain or other symptoms already exist or not. This is also called neuropathy screening to prevent complications or to identify them early. People with type 2 diabetes are advised to have screening done at the time of diagnosis. People with type 1 diabetes should do this after five years at the latest. If no neuropathy is found, screening should be carried out once a year.
To determine a sensorimotor diabetic polyneuropathy, a patient survey (medical history) will first take place during a general or specialist examination in order to record possible symptoms, the medical history and the existing diabetes disease as precisely as possible. For further diagnosis, both legs and feet are examined and compared, and shoes and stockings are considered in relation to possible foot misalignments. The motor skills and possible restrictions are checked.
Furthermore, neurological examinations will take place, often using very simple methods to test the following sensations and reflexes:
- Pain sensation,
- Feeling of pressure and touch,
- Temperature sensation,
- Feeling of vibration,
- Muscular reflexes.
All results together should provide information about the possible existence of polyneuropathy and also about the current severity of existing nerve damage. If the diagnosis is not clear and there is a need for further clarification, other special procedures can be used. In most of these cases, an exact neurological examination of the nerves takes place. This usually focuses on pain diagnosis and nerve conduction speed. In addition, a comprehensive blood test can provide further information and, in rare cases, a skin biopsy (tissue extraction).
Diagnosing autonomic diabetic neuropathy is often more difficult. Various examinations may then be necessary to provide information about the patient's medical history and possible complaints. These will focus on possible dysfunctions of the cardiovascular system, the gastrointestinal tract and the urinary and genital tracts, since consequential damage is often seen in these areas.
An electrocardiogram (EKG) can be used to visualize irregularities in the heart rate. Blood pressure measurements several times in a row while lying or standing, or even over 24 hours, should determine whether there is a sharp drop in blood pressure and dizziness when standing up in connection with neuropathy (neurogenic orthostatic hypotension).
Autonomic neuropathy, which affects the gastrointestinal tract, is difficult to determine because gastrointestinal complaints can also have many other causes. It is therefore important to rule out other possible causes. Here, ultrasound or examinations with an endoscope and various functional tests are often used. If other causes are excluded, further clues can help diagnose diabetic nerve damage, such as a prolonged diabetes disease with poor blood sugar control and metabolic fluctuations.
It may be necessary to measure urine flow during urination and possible residual urine. In men, the prostate is also scanned. In the case of erectile dysfunction, the testosterone level and other laboratory values and test procedures are used.
So far there is no way to completely cure diabetic neuropathy. Treatment is therefore primarily about slowing the progress of the disease, relieving the pain and treating possible consequential damage. A variety of treatment options are available for this.
The most important therapeutic measure is a permanently constant and optimal setting of the blood sugar level. The optimal blood sugar level depends on many factors and must be determined individually for each patient. In addition, blood fat and blood pressure values should also be set well.
Affected people are advised not only to check their own blood sugar level regularly, but also to pay attention to their weight and a healthy lifestyle, with a balanced diet and sporting activity. In general, alcohol and smoking should also be avoided, as this can cause additional nerve damage.
Pain therapy aims to reduce pain perception. This can be achieved through pharmaceuticals such as antiepileptics (anticonvulsants) and antidepressants. For very severe pain, also using opioids. In any case, these drugs are prescription-only. It should be decided with the help of a pain analysis, taking into account individual factors, whether an intake makes sense. In addition, the therapy requires medical monitoring in the further course. Side effects are possible with all the means mentioned. In the case of opioids, a warning should be given in particular about a development of tolerance and subsequent dose increases or dependency. Commercial analgesics (e.g. ibuprofen, diclophenac or acetylsalicylic acid) should not be used for neuropathic pain. Paracetamol is rarely used for a limited time to attempt therapy.
Specific therapeutic measures for autonomic neuropathy depend on the type of nerve damage and the associated symptoms. It is advisable to seek specialist medical advice based on the symptoms.
In addition to the aforementioned attention to a healthy diet and lifestyle, which is indispensable for every naturopathic treatment, regular medical pedicure plays an important role. This can particularly prevent the development of a diabetic foot. The feet should also be extensively examined for injuries, bathed and applied cream every day. Adequate footwear is also a preventive measure.
Furthermore, various measures from the field of naturopathy can promise success, especially for pain relief. Naturopathic treatments can be used to support conventional medical therapy or even offer alternative treatment options.
Various physical treatments can be used for pain therapy for polyneuropathy, such as physiotherapy, cold and heat treatments, alternating and exercise baths or electrical treatments for paralyzed muscles. In addition to pain relief, these therapies also aim to improve blood circulation, strengthen weakened muscles and increase and maintain mobility.
A special alternative treatment method is offered by electrotherapeutic procedures such as transcutaneous electrical nerve stimulation (TENS) or high-frequency therapy, in which pain is combated with electricity. Electrodes are glued to the patient's painful skin region and the current impulses from an electrical stimulation device are transmitted to the body or nerves. Due to the stimulus generated, the electrical signals are conducted via the nerve pathways into the spinal cord, where the actual effect of the TENS takes place. When using high frequencies (over 80 Hertz), signal transmission to the brain and thus pain perception is inhibited or interrupted. In turn, low frequencies are supposed to release chemical substances in the brain and thus lead to reduced pain perception. Alternating electric fields in the frequency range of approximately 4 to 30 kilohertz are used for high-frequency therapy. This is said to penetrate the energy deeper into the tissue, influence the cell metabolism and thus lead to a healing effect and pain relief. However, the effectiveness of these methods has not been proven with certainty.
Traditional Chinese medicine (TCM)
In Chinese medicine, a so-called “tan” is the central cause of polyneuropathy. This means substances that can no longer be excreted and thus cause inflammation. The medicinal therapy, which is individually adapted for each patient, should be able to dissolve and excrete these substances. In addition, acupuncture is said to have a supporting effect.
Other alternative active ingredients and methods
In addition to medicinal pain therapy, various alternative active ingredients from naturopathy offer other options for alleviating symptoms. If the skin is intact, a chili preparation can be used externally to combat pain (capsicum plaster or cream, capsaicin ointment). Alpha-lipoic acid protects against damage to the nerve fibers through its antioxidant properties. Evening primrose oil, hemp oil and pomegranate seed oil are also suitable for treatment, since the gamma-linolenic acid contained can improve nerve functions. Unfortunately, these agents can have unpleasant side effects, especially in the digestive system. There is no general therapy recommendation for the active substances mentioned.
Further measures from naturopathy, which experience has shown to be particularly helpful when symptoms begin, are dark field microscopy, milieu therapy and (classic) homeopathy. Oxygen therapy can also improve the blood circulation in the tissue and thus minimize consequential damage. The psyche also plays a crucial role in coping with pain. Psychotherapy or pain management training can also help those affected to alleviate the symptoms. (jvs, cs)
Author and source information
This text corresponds to the specifications of the medical literature, medical guidelines and current studies and has been checked by medical doctors.
Dr. rer. nat. Corinna Schultheis
- German Society for Muscle Diseases (DGM): Polyneuropathy (accessed: 10.07.2019), dgm.org
- Helmholtz Zentrum München - German Research Center for Health and the Environment (GmbH): Diabetes and Nerves (accessed: July 10, 2019), diabetesinformationsdienst-muenchen.de
- Ziegler, Dan / Keller, Jutta / Maier, Christoph / et al .: Diabetic Neuropathy, Diabetology and Metabolism, 2017, thieme-connect.com
- Stracke, Hilmar: Diabetic neuropathy - contain nerve damage early, the general practitioner 15/2018, aerztekammer-bw.de
- German Pain League e.V .: Information brochure for diabetic polyneuropathy (accessed: 10.07.2019), painliga.de
- Mayo Clinic: Diabetic neuropathy (accessed: 10.07.2019), mayoclinic.org
- National Institute of Diabetes and Digestive and Kidney Diseases: Diabetic Neuropathy (accessed: 10.07.2019), iddk.nih.gov
- National Health Service UK: Overview - Peripheral neuropathy (accessed: 10.07.2019), nhs.uk
- BÄK's NVL program, KBV, AWMF: National Guideline for Care Neuropathy in Adult Diabetes, as of July 2016, detailed view of guidelines
ICD codes for this disease: G63, G99ICD codes are internationally valid encodings for medical diagnoses. You can find yourself e.g. in doctor's letters or on disability certificates.