genesis and mgt of paifull neuropathy

1. Diabetic Painful Neuropathy
DR.ASHOK KUMAR DAS

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. • 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. • 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. • 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. • 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. • 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. • 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. 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. • 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. • PROXIMAL MOTOR
NEUROPATHIES CAN BE DIVIDED
INTO TWO GROUPS
• 1.SYMMETRICAL PROXIMAL
MOTOR NEUROPATHY
• 2.ASYMMETRICAL PROXIMAL
MOTOR NEUROPATHY - DIABETIC
MYOTROPHY

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. PREDOMINANTLY MOTOR:
• MONONEURITIS OR MONONEURITIS
• MULTIPLEX WHICH MAY INCLUDE -
• a) OCULAR NEUROPATHY
• b) FEMORAL NEUROPATHY
• c) SCIATIC NEUIROPATHY
• d) MEDIAN NEUROPATHY

14. DIABETIC MONO NEUROPATHIES
• a)ISOLATED AND MULTIPLE
MONONEUROPATHIES
• b)CRANIAL MONONEUROPATHIES
• c)PROXIMAL MOTOR
NEUROPATHIES
• d)TRUNCAL POLYNEUROPATHY

15. • DISTAL POLYNEUROPATHIES
• a)ACUTE SENSORY NEUROPATHY
• b)CHRONIC SENSORY MOTOR
• NEUROPATHIES
• c)PROXIMAL MOTOR
NEUROPATHIES
• d)TRUNCAL POLYNEUROPATHY

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. • PARAESTHESIA MAY MANIFEST AS A
SENSATION OF
COLDNESS,NUMBNESS,TINGLING OR
BURNING
• ON EXAM - DYSESTHESIA AND CALF
TENDERNESS

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. DIABETIC NEUROPATHIC CACHEXIA:
• OUTSTANDING SYMPTOMS - WEIGHT
LOSS AND SEVERE PAIN
• EMOTIONAL DISTURBANCE
• ANOREXIA
• IMPOTENCE
• MILD DIABETES
• SIMULTANEOUS ONSET OF DIABETES
AND NEUROPATHY

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. 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. 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. • 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. • 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. • 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. 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. 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. • 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. • 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. • INVOLVEMENT OF LATERAL
CUTANEOUS NERVE MAY PRSENT
WITH SENSORY DISTURBANCE IN
THIGH
• USUALLY
ASYMMETRICALWITHOUT MOTOR
DEFICIT
• RECOVER SPONTANEOUSLY

31. • WITH THE EXCEPTION OF
PUPILLARY SPARING,DISRUPTION
OF OCULOMOTOR NERVE
FUNCTION
• RECOVERY USUALLY OCCURS
WITHIN 6-12 WEEKS

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. SEVERITY OF PAIN
• GRADE I
• GRADE II
• GRADE III
• GRADE IV

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. • 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. • 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. • 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. • COMMONEST FINDING WERE LOSS
OF ANKLE JERK IN 76.6% CASES
• IMPAIRED VIBRATION SENSE IN
43.3%
• DIMINISHED POWER IN 23.3 %

39. • PURE DISTAL SYMMETRICAL
SENSORIMOTOR
NEUROPATHIES CONSISTED
80% OF CASES
• PROXIMAL SYMMETRICAL
MOTOR NEUROPATHIES
CONSISTED 13.3% CASES

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. • PAINFUL DIABETIC
NEUROPATHY AND
AUTONOMIC NEUROPATHY
BOTH BEING PREDOMINANTLY
A SMALL FIBRE INVOLVEMENT
• AUTONOMIC DENERVATION AS
EXPECTED WAS OBSERVED IN
86.6% CASES

42. • COMPARATIVE EVALUATION OF 6
MODALITIES OF MANAGEMENT OF
PAINFUL DIABETIC NEUROPATHY
• VIZ:
NORMALSALINE,CARBAMAZEPINE,
• AMITRIPHYLINE-FLUPHENAZINE
• PHENYTOIN ,LIGNOCAINE AND
MULTIPLE SUBCUTANEOUS
INJECTION

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. AMITRIPTYLINE-FLUPHENAZINE
COMBINATION AND MULTIPLE
SUBCUTANEOUS INSULIN
INJECTION
MOTOR NERVE CONDUCTION
VELOCITY DID NOT CHANGE
SIGNIFICANTLY WITH THERAPY

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. • PROXIMAL SYMMETRICAL MOTOR
NEUROPATHY
• PAINFUL PAINLESS LEG
SYNDROME
• DIABETIC AMYOTROPHY
• EXTERNAL OPTHALMOPLEGIA IN
VARIOUS COMBINATIONS

47. • CONDITION IS ASSOCIATED
WITH
• -AUTONOMIC DENERVATION
• ARTERIOVENOUS SHUNTING
• INCREASED BLOOD FLOW
• ENHANCED ANKLE BRACHIAL
RATIO

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