Clinical Practice Guidelines
Neuropathy

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Introduction

Detectable sensorimotor polyneuropathy will develop within 10 years of the onset of diabetes in 40% to 50% of people with type 1 or type 2 diabetes (1). Furthermore, up to 50% of children with type 1 diabetes will have subclinical polyneuropathy (2). While clinical neuropathy is uncommon in people with type 1 diabetes within the first 5 years after the onset of diabetes, people with type 2 diabetes may have neuropathy at the time of diagnosis (3). Risk factors for neuropathy include elevated blood glucose levels, elevated triglycerides, high body mass index, smoking and hypertension (4). Foot ulceration, which depends on the degree of foot insensitivity (5), and amputation are important and costly sequelae of diabetic neuropathy (6). Although not all patients with neuropathy have motor or sensory symptoms, the neuropathic pain associated with symptomatic disease is frequently bothersome and often limits physical activity, quality of life and work productivity 7, 8. Additionally, patients with neuropathy utilize more health resources than those without this complication (9). Both somatic and autonomic neuropathies may occur and may require referral to a specialist experienced in managing the affected body system. Mononeuropathy, particularly carpal tunnel syndrome, is common in people with diabetes and can be difficult to diagnose (10). The underdiagnosis of neuropathy is a fundamental problem in the primary care of people with diabetes and impedes the benefits of early identification, the management necessary to achieve improved glycemic control and the prevention of neuropathy-related sequelae (11).

Section snippets

Screening for Peripheral Neuropathy

Screening for neuropathy can be performed rapidly and reliably using the 10-g Semmes-Weinstein monofilament or the 128-Hz tuning fork 12, 13, 14, 15, 16. Methods for using the monofilament or tuning fork to detect diabetic neuropathy are explained in Appendix 8 12, 13, 16. In individuals with significant early progressive symptoms of neuropathy or in whom a clinical suspicion of nondiabetic neuropathy exists, referral for additional neurological evaluation is indicated.

Management of Neuropathy

Intensive glycemic control is effective for the primary prevention and secondary intervention of neuropathy in people with type 1 diabetes 8, 17, 18. In fact, the benefits of intensive insulin treatment persist for over a decade for the primary prevention of neuropathy (19). In those with type 2 diabetes, lower blood glucose levels are associated with a reduced frequency of neuropathy 7, 20. No other disease-modifying treatments are currently available. Multiple treatments are available for the

Other Relevant Guidelines

Targets for Glycemic Control, p. S31

Foot Care, p. S145

Type 1 Diabetes in Children and Adolescents, p. S153

Type 2 Diabetes in Children and Adolescents, p. S163

Relevant Appendix

Appendix 8: Rapid Screening for Diabetic Neuropathy

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      Furthermore, depending on the affected nerves, symptoms of diabetic neuropathy can range from pain and numbness in the legs and feet, to problems with the digestive system, urinary tract, blood vessels, and heart. Although some individuals with diabetic neuropathy have mild symptoms, for other patients, it can be quite painful and disabling [4]. Nerve growth factor (NGF) has a key role in the growth, maintenance, and proliferation of neurons [5].

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      It can cause pain, imbalance, and foot deformity; in later stages it can result in infection, ulceration, and amputation. In view of a long subclinical phase there is an urgent need for a biomarker of early DSP for use in clinical practice and implementation in future trials of therapies aimed at preventing DSP onset and progression (Canadian Diabetes Association Clinical Practice Guidelines Expert Committee et al., 2013; Ziegler & Luft, 2002). From a research perspective and frequently in clinical practice, the diagnosis of DSP requires confirmation by electrodiagnostic nerve conduction studies (NCS) (England et al., 2005; Tesfaye et al., 2010).

    • Falls and Balance Impairments in Older Adults with Type 2 Diabetes: Thinking Beyond Diabetic Peripheral Neuropathy

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      Allied healthcare professionals (physical and occupational therapists) are trained in detailed evaluations of sensorimotor and cognition domains relevant to postural control, balance and safe mobility. Clinical tools that are reliable and sensitive to detect early changes related to type 2 diabetes in these functions include, but are not limited to, 10 g Semmes-Weinstein monofilament and 128 Hz tuning fork (somatosensory system) (39); Snellen and Pelli-Robson charts (visual system) (40); modified Clinical Test of Sensory Integration for Balance (vestibular system; sensory integration) (17); handheld dynamometer (lower-limb muscle strength) (41); walking performance assessments with cognitive and physical loading (42); and the Trail Making Test Part-B (43) (executive functions). Furthermore, structured exercise interventions have been found to improve balance, reaction times, muscle strength and overall functional status in older adults with type 2 diabetes (44) as well as reducing neuropathic pain and improving sensation in patients with DPN (45).

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