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1362405151 genesis and mgt of paifull neuropathy

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genesis and mgt of paifull neuropathy

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1362405151 genesis and mgt of paifull neuropathy

  1. 1. Diabetic Painful Neuropathy DR.ASHOK KUMAR DAS
  2. 2. • INVESTIGATIONS ON THIS PAINFUL DIABETIC NEUROPATHY SUBGROUPS OF PATIENTS ARE LACKING. • CLINICAL CHARACTERISTICS, BIOCHEMICAL ABERRATIONS AND ELECTROPHYSIOLOGICAL PROFILES OF PAINFUL DIABETIC NEUROPATHY SYNDROME HAS NOT BEEN CLEARLY EVALUATED
  3. 3. • THIS IS A DEFINITE SUBSET OF DIABETIC NEUROPATHY AND REQUIRES MORE ATTENTION OWING TO ITS PAINFUL CONDITION,DIASBILITY AND WIDE SPECTRUM OF CLINICAL SYNDROME
  4. 4. • ENTITY COMPRISES OF CLINICAL SYNDROMES LIKE ACUTE PAINFUL NEUROPATHY, CHRONIC SENSORIMOTOR NEUROPATHY, PROXIMAL PAINFUL SYMMETRICAL MOTOR NEUROPATHY, PROXIMAL PAINFUL ASYMMETRICAL MOTOR NEUROPATHY (DIABETIC AMYOTROPHY) PAINFUL DIABETIC EXTERNALOPHTHALMOPLEGIA, TREATMENT INDUCED INSULIN NEURITIS, HYPOGLYCAEMIC NEURITIS AND PAINFUL PAINLESS LEG .
  5. 5. • PAIN IS A FEATURE OF SMALL FIBRE NEUROPATHY. THE SMALL FIBRES ALSO CARRY AUTONOMIC IMPULSES. • IT SEEMS LOGICAL TO EXPECT INCREASED INCIDENCE OF AUTONOMIC DENERVATION IN PAINFUL DIABETIC NEUROPATHIES
  6. 6. • WATKINS ET AL, BOULTON ET AL HAVE POSTULATED A SYMPATHETIC FAILURE IN PAINFUL DIABETIC NEUROPATHY AND HYPOLTHESISED INCREASED BLOOD FLOW AS ONE OF THE MANY MECHANISMS OF PAINFUL DIABETIC NEUROPATHY AND THIS NEEDS CONFIRMATION
  7. 7. • RELIEF OF PAIN IS OF PARAMOUNT IMPORTANCE AND OBLIGATORY ON THE PART OF PHYSICIAN. BUT THE STATE OF THE ART OF PAIN RELIEF IN THIS SYNDROME IS FAR FROM SATISFACTORY. MANY MODALITIES OF TREATMENT HAS BEEN ADVOCATED BUT THE ARENA OF THERAPY IS FULL OF CLAIMS AND COUNTER CLAIMS.
  8. 8. • THESE MODALITIES RANGE FROM SIMPLE ANALGESIC TO MOST MODERN ALDOLASE REDUCTASE INHIBITORS • IN THE NATIONAL CONTEXT,PAIN RELIEF MUST BE OBTAINED BY SIMPLE MEASURES
  9. 9. CLINICAL TYPES OF PAINFUL DIABETIC NEUROPATHY • ALTHOUGH A RIGID CLASSIFICATION OF PAINFUL DIABETIC NEUROPATHY IS VERY DIFFICULT THEY MAY BE GROUPED UNDER FOLLOWING THREE MAJOR CATEGORIES • 1 .SYMMETRICAL DISTAL PAINFUL POLYNEUROPATHIES • 2.PROXIMAL MOTOR NEUROPATHIES • 3.FOCAL ASYMMETRICAL PAINFUL NEUROPATHIES
  10. 10. • SYMMETRICAL DISTAL PAINFUL POLINEUROPATHIES MAY BE GROUPED AS • 1.SMALL FIBRE TYPE • 2.MIXED LARGE AND SMALL FIBRE TYPE • 3.HYPOGLYCAEMIC NEUROPATHY/INSULIN NEURITIS • 4.MIXED DISTAL SENSORY-MOTOR NEUROPATHY
  11. 11. • PROXIMAL MOTOR NEUROPATHIES CAN BE DIVIDED INTO TWO GROUPS • 1.SYMMETRICAL PROXIMAL MOTOR NEUROPATHY • 2.ASYMMETRICAL PROXIMAL MOTOR NEUROPATHY - DIABETIC MYOTROPHY
  12. 12. FOCAL ASYMMETRIC NEUROPATHIES MAY BE GROUPED AS • 1. PREDMOMINANTLY SENSORY: • A) Intercostal Neuropathy • B) Truncal neuropathy • C) Thoraco-abdominal radiculopathy • D) Neuropathy due to involvement of lateral cutaneous nerve of thigh
  13. 13. PREDOMINANTLY MOTOR: • MONONEURITIS OR MONONEURITIS • MULTIPLEX WHICH MAY INCLUDE - • a) OCULAR NEUROPATHY • b) FEMORAL NEUROPATHY • c) SCIATIC NEUIROPATHY • d) MEDIAN NEUROPATHY
  14. 14. DIABETIC MONO NEUROPATHIES • a)ISOLATED AND MULTIPLE MONONEUROPATHIES • b)CRANIAL MONONEUROPATHIES • c)PROXIMAL MOTOR NEUROPATHIES • d)TRUNCAL POLYNEUROPATHY
  15. 15. • DISTAL POLYNEUROPATHIES • a)ACUTE SENSORY NEUROPATHY • b)CHRONIC SENSORY MOTOR • NEUROPATHIES • c)PROXIMAL MOTOR NEUROPATHIES • d)TRUNCAL POLYNEUROPATHY
  16. 16. SYMMETRICAL DISTAL POLYNEUROPATHIES • SMALL FIBRE TYPE: IN SMALL FIBRE TYPE NEUROPATHY PAIN AND PARAESTHESIS, MOST COMMONLY OF THE LOWER EXTREMITIES ARE THE CHARACTERISTIC SYIMPTOMS PAIN - DULL ,BURNING,ACHING, LANCINATING,CRUSHING AND CRAMP- LIKE
  17. 17. • PARAESTHESIA MAY MANIFEST AS A SENSATION OF COLDNESS,NUMBNESS,TINGLING OR BURNING • ON EXAM - DYSESTHESIA AND CALF TENDERNESS
  18. 18. • IN ADDITION - DIMINISHED PAIN AND TEMPERATURE PERCEPTION IN THE LOWER EXTREMITY WITH LESS INVOLVEMENT OF REFLEX AND POSITION AND VIBRATORY ENSATION • AUTONOMIC DYSFUNCTION MOST PREVALENT
  19. 19. DIABETIC NEUROPATHIC CACHEXIA: • OUTSTANDING SYMPTOMS - WEIGHT LOSS AND SEVERE PAIN • EMOTIONAL DISTURBANCE • ANOREXIA • IMPOTENCE • MILD DIABETES • SIMULTANEOUS ONSET OF DIABETES AND NEUROPATHY
  20. 20. PAINFUL-PAINLESS LEG • PATIENT EXPERIENCE PAIN OR PARAESTHESIAS • ON NEUROLOGICAL EXAMINATION • PAIN SENSATION ABSENT • SUCH PATIENTS ARE AT GREATEST RISK OF PAINLESS INJURY TO THE FEET
  21. 21. HYPOGLYCEMIC NEUROPATHY/INSULIN NEURITIS • HYPOGLYCAEMIA IS RARE -BUT TREATABLE • USUALLY PRESENTS SYMMETRICAL MOTOR, SENSORY OR MIXED NEUROPATHIES OF UNCERTAIN AETIOLOGY • DISTAL SYMMETRICAL SYMPTOMS • MORE COMMON IN NONDIABETIC PATIENTS SUBJECTED TO INSULIN SHOCK THERAPY
  22. 22. MIXED DISTAL SENSORY MOTOR NEUROPATHIES • USUALLY OCCUR IN MIDDLE AGED AND ELDERLY WITH TYPE II DIABETES • THERE ARE TWO ENTITIES • 1.SUBACUTE PROXIMAL NEUROPATHY OF INSIDIOUS ONSET • ISCHAEMIC MONONEUROPATHY MULTIPLEX OF ACUTE ONSET
  23. 23. • ASBARY HYPOTHESIZED PROXIMAL MOTOR DIABETIC NEUROPATHIES REPRESENT CLINICAL CONTINUAAM • ONE POLE REPRESENTED BY ASYMMETRIC WEAKNESS OF RAPID EVOLUTION ON AN ISCHAEMIC BASIS AND THE OPPOSITE POLE MARKED BY SLOWLY EVOLVING SYMMETRIC WEAKNESS DUE TO METABOLIC FACTORS
  24. 24. • IN THE ISCHAEMIC TYPE , SUDDEN AND USUALLY ASYMMETRIC WEAKNESS OF PELVIC GIRDLE MUSCLE OCCUR ASSOCIATED WITH PAIN • SEVERAL SMALL INFARCTIVE LESIONS OF PROXIMAL MAJOR NERVE TRUNK OF THE LEG AND LUMBOSACRAL PLEXUS MAY BE SEEN • RECOVERY WITHIN ONE YEAR
  25. 25. • SUBACUTE PROXIMAL DIABETIC NEUROPATHY MANIFESTS WITH PROGRESSIVE WEAKNESS OF HIP AND THIGH MUSCLES • SOMETIMES ASSOCIATED WITH ACHING OF THESE MUSCLES • OCCASIONALLY PROXIMAL EXTREMITIES ARE ALSO INVOLVED
  26. 26. FOCAL ASYMMETRICAL DIABETIC NEUROPATHY • INTERCOSTAL NEUROPATHY • MIDDLE AGED OR OLDER PATIENTS • PRESENT WITH LONGSTANDING DIABETES WITH ABRUPT ONSET OF UNILATERAL PAIN • ASSOCIATED WITH PERIPHERAL SENSORY NEUROPATHY,WEIGHT LOSS AND WORSENING OF PAIN AT NIGHT • CONDITION RECOVERS IN 3 MONTHS
  27. 27. TRUNCAL NEUROPATHY • PAIN THE TRUNK • RESULTING ABDOMINAL BULGE CAUSING MUSCLE WEAKNESS • CLINICAL FEATURES SUGGESTIVE OF MALIGNANT DISEASE • ELECTROMYOGRAPHY REVEALS CORRECT DIAGNOSIS • SPONTANEOUS AND COMPLETE RECOVERY
  28. 28. • MOST DIABETIC WITH THIS SYNDROME ARE IN 5TH OR 6TH DECADE OF LIFE • ASSOCIATED WITH WEIGHT LOSS,BEGINNING WITH THE ONSET OF PAIN • DENERVATION OF PARASPINAL MUSCLES PRESENT • LESION IS PROXIMAL,EITHER IN THE NERVE ROOTS OR THE SPINAL NERVES
  29. 29. • SPINAL CORD COMPRESSION SHOULD BE EXCLUDED BY APPROPRIATE INVESTIGATIONS • CAUSED BY ISCHAEMIC INFARCTION OF NERVE • NO PATHOLOGICA L EVALUATION OF INVOLVED INTERCOSTAL NERVE HAS BEEN REPORTED
  30. 30. • INVOLVEMENT OF LATERAL CUTANEOUS NERVE MAY PRSENT WITH SENSORY DISTURBANCE IN THIGH • USUALLY ASYMMETRICALWITHOUT MOTOR DEFICIT • RECOVER SPONTANEOUSLY
  31. 31. • WITH THE EXCEPTION OF PUPILLARY SPARING,DISRUPTION OF OCULOMOTOR NERVE FUNCTION • RECOVERY USUALLY OCCURS WITHIN 6-12 WEEKS
  32. 32. SYMPTOMS OF PAINFUL NEUROPATHY • NOCTURNAL EXACERBATION OF PAIN • BURNING • PINS AND NEEDLES • AUTONOMIC SYMPTOMS, IMPOTENCY POSTURAL HYPOTENSION,GUSTATORY SWEATING,NOCTURNAL DIARRHOEA,DIABETIC CYSTOPATHY FOOT DROP,CHARCOT’S JOINT
  33. 33. SEVERITY OF PAIN • GRADE I • GRADE II • GRADE III • GRADE IV
  34. 34. NEUROLOGICAL EXAMINATIONS • ABSENT DEEP TENDON JERKS • DIMINISHED VIBRATORY SENSATION • DIMINISHED POWER • HYPERESTHESIA • DIMINISHED TOUCH SENSATION • ABSENT TOUCH SENSATION • DIMINISHED PAIN SENSATION • ABSENT PAIN SENSATION • ABSENT POSITION SENSE
  35. 35. • MALES OUTNUMBERED • 53.3% WERE YOUNG DIABETES • BELOW 40 YRS OF AGE • SIGNIFIES DIABETIC PAIN FUL NEUROPATHY VERY IMPORTANT SIGNIFICANT DIABETIC SYNDROME IN YOUNG ADULTS
  36. 36. • ONSET OF PAIN FOLLOWED KNOWN CLINICAL DIAGNOSIS OF DIABETES IN 56.6% CASES • IN 6.6% CASES PAINFUL NEUROPATHY PRECEDED DIABETES MELLITUS SIGNIFYING A HIGH INDEX OF SUSPICISON NECESSARY TO DIAGNOSE THE CASES. • IN A THIRD OF CASES,PAINFUL NEUROPATHY WAS THE INITIAL PRESENTING SYMPTOM
  37. 37. • SYMPTOMS OF PAINFUL DIABETIC • NEUROPATHY WERE • 100% IN LOWER LIMBS • BURNING SENSATION 60% • PINS AND NEEDLES 50% • NOCTURNAL EXACERBATION OF SYMPTOMS IN 70% CASES
  38. 38. • COMMONEST FINDING WERE LOSS OF ANKLE JERK IN 76.6% CASES • IMPAIRED VIBRATION SENSE IN 43.3% • DIMINISHED POWER IN 23.3 %
  39. 39. • PURE DISTAL SYMMETRICAL SENSORIMOTOR NEUROPATHIES CONSISTED 80% OF CASES • PROXIMAL SYMMETRICAL MOTOR NEUROPATHIES CONSISTED 13.3% CASES
  40. 40. • DIABEETIC AMYOTROPHY AND EXTERNAL OPTHALMOPLEGIA WAS PRESENT IN 3.3% • 2 CASES (6.6%) FELL IN THE ‘PAINFUL PAINLESS’ LEG SYNDROME SUB GROUP
  41. 41. • PAINFUL DIABETIC NEUROPATHY AND AUTONOMIC NEUROPATHY BOTH BEING PREDOMINANTLY A SMALL FIBRE INVOLVEMENT • AUTONOMIC DENERVATION AS EXPECTED WAS OBSERVED IN 86.6% CASES
  42. 42. • COMPARATIVE EVALUATION OF 6 MODALITIES OF MANAGEMENT OF PAINFUL DIABETIC NEUROPATHY • VIZ: NORMALSALINE,CARBAMAZEPINE, • AMITRIPHYLINE-FLUPHENAZINE • PHENYTOIN ,LIGNOCAINE AND MULTIPLE SUBCUTANEOUS INJECTION
  43. 43. • VISUAL ANALOG SCORE IMPROVEMENT WAS MAXIMUM WITH NORMAL SALINE INFUSION • WARRANTS EVALUATION OF SIMPLE THERAPY • SIGNIFICANT SUBJECTIVE IMPROVEMENT OF PAIN WAS BROUGHT ABOUT BY CARBAMAZEPINE
  44. 44. AMITRIPTYLINE-FLUPHENAZINE COMBINATION AND MULTIPLE SUBCUTANEOUS INSULIN INJECTION MOTOR NERVE CONDUCTION VELOCITY DID NOT CHANGE SIGNIFICANTLY WITH THERAPY
  45. 45. CONCLUSION • PAINFUL D NEUROPATHY IS A MIXED FIBRE NEUROPATHY • FEATURES OF BOTH SMALL AND LARGE FIBRE INVOLVEMENT • COMPRISES OF CLINICAL SYNDROME OF DISTAL SENSORY MOTOR NEUROPATHY
  46. 46. • PROXIMAL SYMMETRICAL MOTOR NEUROPATHY • PAINFUL PAINLESS LEG SYNDROME • DIABETIC AMYOTROPHY • EXTERNAL OPTHALMOPLEGIA IN VARIOUS COMBINATIONS
  47. 47. • CONDITION IS ASSOCIATED WITH • -AUTONOMIC DENERVATION • ARTERIOVENOUS SHUNTING • INCREASED BLOOD FLOW • ENHANCED ANKLE BRACHIAL RATIO
  48. 48. 6 DIFFERENT MODALITIES • -NORMAL SALINE INFUSION • CARBAMAZEPINE • AMITRYPHYLINE-FLUPHENAZINE COMBINATION • MSC INJECTION FOUND TO BE EFFECTIVE IN REDUCING PAIN • WHEREAS LIGNOCAINE AND PHENYTOIN FAILED TO DO SO

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