Primary care physicians, physiatrists and neurologists deal almost daily with one of the most dangerous complications of diabetes mellitus: chronic neuropathies. Its unchecked progression will eventually produce crippling foot ulcers and a neurogenic arthropathy that may lead to amputations and inability to walk.
A new position statement by the American Diabetes Association written by professionals in North America and Europe updated a consensus statement from the American Diabetes Association published in 2004. As there is an increase in diabetic cases in modern societies and too few specialists to deal with them, the preventive measures take a new Public Health significance.
The clinical exam—outlined in a step-by-step algorithm— performed by primary physicians in the office is the critical step in order to diagnose it and to defer the costly referrals to specialists for electrophysiological studies. The distal symmetric polyneuropathy (DSPN) and autonomic neuropathy are the most common clinical variants seen in the primary care practices.
People in the early stages of the disease process—called pre-diabetes—can develop a neuropathy. The statement emphasizes that both small and large fiber neuropathy are present in patients with pre-diabetes and new onset of the disease. Close regulation of the blood glucose level can slow the progression of DSPN (distal symmetric polyneuropathy) to a certain degree.
The examination should include a good history and “either temperature or pinprick sensation (small fiber function) and vibration sensation using a 128-Hz tuning fork (large-fiber function) Patients should have a 10-g monofilament test to assess for feet at risk for ulceration and amputation.” Testing for DSPN should start 5 years after diagnosis of type I and patients with type II. Patients where motor involvement is greater than the sensory one, whose symptoms start abruptly or are asymmetric should be referred.
Diabetes is one of the few causes of neuropathy that has treatment options.
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