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Diabetic polyneuropathy. Dysmetabolic (autonomous, hereditary, distal, sensorimotor, amyloid) polyneuropathy

Polyneuropathy is a group of diseases that affects a large number of nerve endings in the human body. The disease has various reasons occurrence. The factors that cause the onset of the disease first of all irritate the nerve fibers, and only then lead to disruption of their functioning. Characteristic signs illness - muscle weakness and pain in the affected area of the body.

The disease manifests itself as paralysis, impaired sensitivity to tactile touch, various disorders in the functioning of the upper and lower limbs human body. The signs of the disease and the intensity of their manifestation completely depend on the form and type of the disease. Typically, polyneuropathy causes a lot of suffering to patients, and treatment is protracted. The course of the disease is progressive and the process can become chronic. Most often, this disease occurs in the lower parts of the body.

Polyneuropathy can occur in a sluggish form, and also have fulminant development.

Etiology

The causes of polyneuropathy are varied. The main ones include:

poisoning with pure alcohol, gas, arsenic ( chemical poisoning);
chronic diseases ( , );
systemic pathologies of the body;
long-term use some groups of pharmaceuticals;
alcoholism;
impaired immunity;
hereditary factor;
metabolic disorder;

The pathology may be of the following nature:

inflammatory. In this case, intense inflammation of the nerve fibers is observed;
toxic. Develops due to ingestion of large quantity toxic substances;
allergic;
traumatic.

Nowadays, the most common type is diabetic polyneuropathy. It is worth noting that polyneuropathy is quite dangerous pathology, which requires timely and adequate treatment. If it is not there, the progression of the disease can lead to muscle atrophy and the appearance of ulcers. The most dangerous complication is paralysis of the legs or arms, and then the breathing muscles.

Varieties

According to the mechanism of damage, the disease is divided into the following types:

demyelinating polyneuropathy. The development of the disease is associated with the breakdown of a protein in the body that envelops the nerves and is responsible for the high speed of impulses carried through them;
axonal. This type is associated with a disruption in the functioning of the nerve core. This type is accompanied heavy treatment And long recovery;
neuropathic. With it, damage is observed directly to the bodies of nerve cells;
diphtheria and diabetic polyneuropathy;
polyneuropathy of the lower extremities;
alcoholic polyneuropathy.

According to the primacy of nerve damage, polyneuropathy occurs:

sensory. Manifests itself in the form of numbness or pain;
motor. Motor fibers are affected, which is accompanied by muscle weakness;
sensory-motor. Characteristic symptoms lesions – decreased sensitivity and motor activity of muscle structures;
vegetative. There is a disruption in work internal organs due to inflammation of the nerves;
mixed. Includes all the characteristics of the types described above;
polyneuropathy of the lower extremities.

Depending on the cause of development, polyneuropathy can be:

idiopathic. The occurrence is associated with operational disturbances immune system;
hereditary. Passed on from one generation to another;
dismetabolic. Progresses due to metabolic disorders;
toxic polyneuropathy develops from toxic substances entering the body;
post-infectious. Occurs when infectious processes in organism;
paraneoplastic. Development occurs in conjunction with cancer;
in diseases of the body, develops as part of the disease;
alcoholic polyneuropathy.

According to the nature of the flow:

spicy. Development time from two to four days. Treatment lasts several weeks;
subacute Develops in a few weeks, treatment takes months;
chronic. It progresses over six months or more, and has an individual treatment term for each person.

Symptoms

Regardless of what type of disease a person has, be it alcoholic or diabetic, hereditary or toxic polyneuropathy or demyelinating, the symptoms are often the same.

Wide range of factors causing disease, often primarily affect the nerve, and then lead to disruption of their function. The main symptoms of the disease are:

weakness in the muscles of the arms and legs;
violation respiratory process;
decreased reflexes and sensitivity, up to their complete absence;
prolonged sensation of “goosebumps” all over the skin;
increased sweating;
tremors or seizures;
swelling of the arms and legs;
cardiopalmus;
unsteady gait and dizziness;
constipation

Complications

In fact, there are not many complications of polyneuropathy, but they are all cardinal. Complications of the disease are as follows:

sudden cardiac death;
impairment of motor functions, complete immobilization of the patient;
violation of respiratory processes.

Diagnostics

It will not be possible to independently diagnose any of the above types of polyneuropathy based only on a person’s symptoms (many symptoms are similar to the manifestations of other diseases). If one or more signs are detected, you should consult a doctor as soon as possible. To make a diagnosis, specialists will conduct a wide range of studies, which include:

initial examination and survey;
neurological examination and testing of basic nerve reflexes;
full analysis blood;
radiography;
biopsy;
consultation of the patient with specialists such as a therapist and an endocrinologist.

Treatment

Primary treatment of polyneuropathy is aimed at eliminating the cause of its occurrence and symptoms. Prescribed depending on the type of pathology:

treatment of diabetic polyneuropathy begins with a decrease in glucose levels in the body;
at alcoholic polyneuropathy you must strictly abstain from drinking alcoholic beverages and anything that may contain alcohol;
cessation of all contacts with chemicals to prevent the occurrence toxic type diseases;
taking large amounts of fluid and antibiotics for infectious polyneuropathy;
surgical intervention with paraneoplastic type of disease.
use of painkillers for severe pain.

Among other things, you may need complete blood purification, hormone therapy or treatment with vitamins (this type of therapy, in medical circles, is considered the most effective).

A good method of treating polyneuropathy is physical therapy. It will be especially useful for chronic and hereditary forms diseases.

Prevention

Preventive measures for polyneuropathy are aimed at eliminating the causes that adversely affect nerve fibers. Prevention methods:

complete abstinence from alcoholic beverages;
if the work is related to chemicals, perform it only in protective clothing;
monitor the quality of food consumed;
do not take medications without a doctor’s prescription;
promptly treat diseases of any nature and complexity;
include vitamins in your diet;
fulfill physical exercise;
Constantly monitor blood sugar levels;
periodically go for therapeutic massages.

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Diseases with similar symptoms:

Guillain-Barré syndrome is a group of acute autoimmune diseases that are characterized by rapid progression. The period of rapid development is approximately one month. In medicine, this disorder has several names - Landry's palsy or acute idiopathic polyneuritis. The main symptoms are considered muscle weakness and the absence of reflexes that occur against the background of extensive nerve damage (as a consequence of an autoimmune process). This means that the human body accepts its own tissues as foreign, and the immune system forms antibodies against the affected nerve sheaths.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2017

Diabetic polyneuropathy (E10-E14+ WITH COMMON FOURTH DIGIT.4)

Endocrinology

general information

Short description

Approved
Joint Commission on Healthcare Quality
Ministry of Health of the Republic of Kazakhstan
dated November 28, 2017
Protocol No. 33

Diabetic neuropathy- nerve damage due to diabetes, clinically obvious or subclinical, in the absence of another possible etiology (WHO). The most studied and common form of diabetic neuropathy is distal symmetrical polyneuropathy. DSPN is the presence of symptoms of distal peripheral nerve dysfunction in patients with diabetes mellitus after excluding other causes.

INTRODUCTORY PART

ICD-10 code(s):

Date of protocol development/revision: 2017

Abbreviations used in the protocol:

GPP	Good Point Practice clinical practice)
WHO	World Health Organization
YOUR	visual analogue scale
DAN	diabetic autonomic neuropathy
DMN	diabetic mononeuropathy
DN	diabetic polyneuropathy
DPN	diabetic polyneuropathy
DSPN	diabetic sensorimotor polyneuropathy
ICD 10	international classification of diseases 10th revision
NS	nervous system
RCT	randomized clinical researches
DM I	diabetes mellitus type I
SD 2	diabetes mellitus type II
ENMG	Electroneuromyography

Protocol users: neurologists, endocrinologists, general practitioners.

Level of evidence scale:
Table 1 - Level of Evidence Scale

A	A high-quality meta-analysis, systematic review of RCTs, or large RCTs with a very low probability (++) of bias, the results of which can be generalized to an appropriate population.
IN	High-quality (++) systematic review of cohort or case-control studies, or High-quality (++) cohort or case-control studies with very low risk of bias, or RCTs with low (+) risk of bias, the results of which can be generalized to an appropriate population .
WITH	Cohort or case-control study or controlled trial without randomization with low risk of bias (+). The results of which can be generalized to the relevant population or RCTs with very low or low risk of bias (++ or +), the results of which cannot be directly generalized to the relevant population.
D	Case series or uncontrolled study or expert opinion.
GPP	Good clinical practice.

Classification

Classificationdiabetic neuropathies:

According to the 2016 American Diabetes Association classification:

Diffuse neuropathies
Diabetic sensorimotor polyneuropathy:
· predominantly small fibers;
· predominantly large fibers;
· mixed (small and large fibers) - the most common.

Autonomic neuropathy
Cardiovascular
· bradycardia;
· tachycardia at rest;
Orthostatic hypotension;
Sudden death (malignant arrhythmia).

Gastrointestinal:
· diabetic gastroparesis (gastropathy);
· diabetic enteropathy (diarrhea);
· colonic hypomotility (constipation).

Urogenital:
· diabetic cystopathy (neurogenic bladder);
· erectile disfunction;
· female sexual dysfunction.

Sudomotor dysfunction:
· distal hypohidrosis/anhidrosis;
· “gustatory” sweating (associated with food intake);
· absence of precursors of hypoglycemia;
· abnormal pupillary function.

Mononeuropathy(atypical forms):
isolated neuropathies of the cranial or peripheral nerves;
multiple mononeuropathies.

Radiculopathy/polyradiculopathy(atypical forms):
radiculoplexus neuropathy (lumbosacral polyradiculopathy, proximal motor amyotrophy);
· thoracic radiculopathy.

Diagnostics

DIAGNOSTIC METHODS, APPROACHES AND PROCEDURES

Diagnostic criteria

Complaints:
Numbness of the tips of the toes and feet;
· paresthesia;
· burning sensation in toes, soles, calves;
· pain in toes, soles, calves;
weakness in the lower extremities;
· crumpy;
· symmetrical distal localization of neurological symptoms.

Anamnesis:
presence of T1DM or T2DM;
· the appearance and gradual increase in the severity of the above complaints, correlating with the severity and duration of diabetes;
Symptoms tend to intensify at night;
· suffered long-term non-healing ulcers in the feet;
· suffered cuts, etc. traumatic injuries in the feet, not accompanied by pain

Physical examination:
General neurological examination:
· study of tactile sensitivity on the limbs using a standard microfilament (10 g) (80);
· study pain sensitivity on the extremities using a neurological needle, a disposable toothpick/gear wheel (Pin-wheel);
· study of temperature sensitivity on the extremities using a thermal tip (Tip-term), alternately touching test tubes with water different temperatures(20°C and 40°C);
· study of vibration sensitivity using a graduated tuning fork 128 Hz or a biotensiometer;
· study of muscle-joint sensation;
· study of knee and Achilles reflexes;
· study of muscle strength;
· study of statics and gait with open and closed eyes;
· study of coordination tests (finger-to-nose and heel-knee) with open and closed eyes.
All sensitivity studies are carried out symmetrically on both sides in the direction from the distal to the proximal.

The following signs are clinically significant:
· reduction/absence of pain and temperature sensitivity in the distal parts of the lower extremities;
· allodynia (a syndrome in which a person feels pain from factors that usually do not cause pain, for example, mechanical/tactile allodynia, when pain occurs from touch) in the distal parts of the lower extremities;
· hyperesthesia (increased sensitivity to irritants) in the distal parts of the lower extremities;
· reduction/absence of vibration sensitivity and muscle-articular sensation in the distal parts of the lower extremities;
· decrease/loss of Achilles and knee reflexes;
· decreased muscle strength in the distal limbs;
lack of coordination when closed eyes(sensitive ataxia).

Laboratory research: look clinical protocol T1DM and T2DM in adults.

Instrumental studies:
WITHstimulation ENMG of the lower extremities with an assessment of the conduction velocity along motor and sensory fibers, at least 2 nerves on each side (reduced in patients with diabetes to 35-40 m/sec when the norm is 50-65 m/sec, most pronounced in the distal parts of the lower extremities) (UD -B) .
Carrying out this study is the most objective for dynamic observation, assessing the effectiveness of therapy.

Duplex scanningvessels of the lower extremities(if diabetic angiopathy is suspected) will show the thickness of the arterial wall, stenosis of the lumen of the arteries of the lower extremities, the presence of atherosclerotic plaques, the degree of calcification, decreased elasticity of the arterial wall.

X-ray of the foot in 2 projections(if Charcot neuroosteoarthropathy is suspected) reveals deformation, destruction of bones and joints; in more late stages- fragmentation of joints with bone remodeling that occurs compensatory in order to restore the stability of bones and joints, while the bones are fixed in a new position.

Pproviding specialist consultation:
· consultation with an angiosurgeon - for the purpose of exclusion/diagnosis diabetic angiopathy, syndrome diabetic foot;
· consultation with an orthopedic surgeon - to exclude/diagnose Charcot neuroosteoarthropathy;
· consultation with a surgeon - if ulcerative defect feet with/without infection;
· consultation with an endocrinologist - in case of unstable glycemia, aggravating the course of DSPN;
· consultation with a cardiologist;
According to the San Antonio consensus (1988, 1992), the diagnosis of DSPN requires at least one symptom and one electrodiagnostic abnormality.

Screening for DSPN

Table 2 - Categories of patients for screening for DSPN

Diagnostic algorithm:

Figure 1. Algorithm for diagnosing DSPN

Differential diagnosis

Differential diagnosis and rationale for additional research
DSPN is an exclusion diagnosis. Availability diabetes mellitus and signs of polyneuropathy do not automatically mean the presence of diabetic polyneuropathy. A thorough differential diagnosis is required to make a definitive diagnosis.

Table 3 - Differential diagnosis of DSPN

Diagnosis	Rationale for differential diagnosis	Survey	Diagnosis exclusion criteria
Alcoholic PN		Blood chemistry. Ultrasound OBP.	Anamnestic data. The presence of alcoholic liver dystrophy, other manifestations of the nervous system: alcoholic encephalopathy, alcoholic myelopathy, alcoholic polyradiculoneuropathy
PN for autoimmune diseases	Signs of polyneuropathy that do not fit into the framework of DPNP*	Immunological blood tests.	History of autoimmune diseases. Clinical and laboratory signs of these diseases.
PN with vitamin B12 deficiency	Signs of polyneuropathy that do not fit into the framework of DPNP*	Determination of B12 level in the blood.	Low concentration of vitamin B12 in serum. Possible combination with macrocytic megaloblastic anemia.
PN for others metabolic disorders(hypothyroidism, hyperthyroidism, obesity)	Signs of polyneuropathy that do not fit into the framework of DPNP*	Blood test for hormones thyroid gland. Ultrasound of the thyroid gland	Anamnestic data. Clinical, laboratory and instrumental signs of these diseases.
Paraneoplastic syndromes	Signs of polyneuropathy that do not fit into the framework of DPNP*	In accordance with the CP of oncological diseases.	Anamnestic data. Results of instrumental studies indicating the presence of an oncological process.
Inflammatory demyelinating PN (post-vaccination, after previous acute infection)	Signs of polyneuropathy that do not fit into the framework of DPNP*	ENMG. CSF analysis. Biopsy n.suralis	Anamnestic data. Specific data on ENMG. Detection of protein in cerebrospinal fluid. Specific changes in n.suralis biopsy
Hereditary PN	Signs of polyneuropathy that do not fit into the framework of DPNP*	Research in molecular genetic laboratories. ENMG	Anamnestic data. Family history. Clinical and laboratory signs of a particular hereditary disease.
PN for exogenous intoxications (lead, arsenic, phosphorus, etc.)	Signs of polyneuropathy that do not fit into the framework of DPNP*	Blood and urine tests for the presence of toxic substances.	Anamnestic data. Clinical and laboratory signs of one or another intoxication.
PN with endogenous intoxications (chronic liver failure, chronic renal failure)	Signs of polyneuropathy that do not fit into the framework of DPNP*	Biochemical tests blood and urine. Ultrasound and/or MRI of the kidneys and kidneys	Anamnestic data. Clinical, laboratory and instrumental signs of chronic liver failure or chronic renal failure.
PN for infections (syphilis, leprosy, HIV, brucellosis, herpes, diphtheria, etc.)	Signs of polyneuropathy that do not fit into the framework of DPNP*	Blood test (ELISA, PCR, etc.) for the presence of certain infections.	Anamnestic data. Clinical and laboratory signs of a particular infection

*asymmetrical/predominantly motor/localized in the upper extremities/acutely developed polyneuropathy

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Diabetic polyneuropathy of the lower extremities occurs due to impaired muscle function in people with diabetes. The disease causes sensations of numbness, tingling, and intense itching in the legs. The appearance of such symptoms is explained by the fact that in patients with diabetes mellitus the level of glucose in the blood is unstable. Pathology can lead to the development of gangrene.

What is diabetic polyneuropathy?

Diabetic polyneuropathy is a complex of nervous system disorders that is typical for people who often violate their diet with diabetes. Pathology occurs due to increased blood glucose levels.

Polyneuropathy is diagnosed in 45-54% of patients with diabetes. The peripheral nervous system includes somatic and autonomic divisions. The first is responsible for human control over own body. The second regulates the work of internal departments autonomously. In diabetic polyneuropathy, the functions of both systems are impaired.

Against the background of lesions in the peripheral parts, changes occur in the functioning of the leg muscles. As the pathology progresses, similar processes affect the sections located above the lower extremities.

Mechanism of defeat

Diabetic polyneuropathy is considered a disease of unknown origin, but researchers have figured out how it develops.

An increase in the concentration of glucose in the blood causes an active course of oxidative processes, due to which the number of free radicals in the body increases. The latter amaze healthy cells, which leads to disruption of their functions.

At the same time, an increase in glucose concentration promotes an autoimmune response. The body begins to inhibit the growth of cells that make up the conductive nerves. Also, due to the autoimmune response, the tissue that forms these fibers is destroyed.

An increase in glucose concentration, caused by a violation of fructose metabolism, provokes an imbalance of particles that are located in the intercellular space. Because of this nerve tissue swelling, neuron conductivity decreases.

Over time, the concentration of myonositol decreases, which leads to inhibition of phosphoinositol synthesis, important element nerve cell. This provokes a sharp decrease in the rate of energy metabolism. As a result, nerve impulses stop flowing to parts of the body.

These processes are characteristic of all species. But the most dangerous form is considered to be the dysmetabolic form, in which the functions of the gastrointestinal tract organs are disrupted against the background of damage to nerve fibers.

Classification of polyneuropathy in diabetes

There are several classifications of polyneuropathy. The first takes into account the division peripheral nervous system.

When the autonomic part is damaged, the functioning of the heart and blood vessels is disrupted (often provokes death), problems with urination and work occur reproductive organs in men.

A disorder of the somatic nervous system is characterized by the formation of trophic ulcers on the legs.

The second classification takes into account the functions of the central nervous system. According to this gradation, the following forms of diabetic polyneuropathy are distinguished:

Sensory. It is characterized by decreased sensitivity of the skin of the lower extremities or increased pain in the legs.
Motor. It is characterized by the development of muscular dystrophy, which leads to loss of motor functions.
Sensorimotor. It is characterized by the simultaneous manifestation of symptoms characteristic of the above types of pathology.

Sensorimotor polyneuropathy differs in that the fibers of the peroneal nerve are affected. With this disorder, sensitivity disappears in some areas of the legs or feet. These zones do not respond to high and low temperatures. The ability to control the feet is also lost, causing the gait to change.

Possible in sensory form total loss sensitivity of the lower extremities. Disruption of nerve conduction causes tingling sensations, deformation of the feet and the appearance of ulcers on the surface of the skin. Despite the lack of sensitivity, patients experience unbearable pain in the lower extremities, which occurs unexpectedly.

The first changes in the sensory form appear first on one leg. Over time, there is a decrease in sensitivity on the other limb. And as the pathology progresses, numbness rises higher to the rest of the body.

Depending on the severity of the lesion, the following types of diabetic polyneuropathy are distinguished:

distal;
peripheral;
dismetabolic.

For diabetic distal polyneuropathy The tissues that make up the nerve fibers die. The course of the pathology provokes a complete loss of sensation in the lower extremities. Ulcers also form on the feet. The main symptom of the distal form is intense but dull pain that interferes with sleep. As the disease progresses, the following complications arise:

pain in the shoulders;
flat feet;
bone deformation;
muscle atrophy.

IN advanced cases Due to the development of these processes, the need for amputation of the feet arises.

With the peripheral type of pathology, concern intense pain and a feeling of numbness not only in the legs below the knee, but also in the hands. This form of the disorder often occurs as a complication of taking antiviral drugs such as Zalcitabine or Didanosine.

The dysmetabolic type of pathology is characterized by dysfunction of the gastrointestinal tract, liver and kidneys. With this combination, multiple lesions of the nerve plexuses occur. If the pathological process affects the sciatic and femoral neurons, the following symptoms are noted:

intense pain;
trophic ulcers;
impairment of motor activity;
loss of knee and tendon reflexes.

Often in the dismetabolic form, the conductivity of the ocular, ternary and ulnar nerves. In some cases, this type of pathology does not cause painful sensations.

Causes of diabetic polyneuropathy

Unlike other forms of polyneuropathy, diabetic polyneuropathy develops due to increased blood glucose levels. Because of this, the feet become numb in diabetes mellitus. The following factors can also provoke the disease:

Possible precipitating factors include vascular damage and heredity. The latter option is supported by research results showing that people whose relatives were previously diagnosed with diabetic polyneuritis are more likely to suffer from this pathology.

In addition, there is a certain relationship between the course of diabetic and polyneuropathy.

Symptoms

With diabetic polyneuropathy, the first symptoms appear as a sensation of “pins and needles” in the lower extremities and pain. Over time, some parts of the legs become numb. The pain is disturbing at rest and intensifies when the patient begins to move. In the future, a feeling of discomfort occurs at night. During this period, the patient feels a burning sensation in the feet.

Without appropriate treatment, diabetic polyneuropathy provokes the following symptoms:

constant pain in the lower extremities, independent of the patient’s activity;
increased intensity of pain during movement or due to stress;
insomnia;
muscle atrophy, causing weakening of the fingers and toes;
redness of the skin on the legs, the appearance of dark spots.

Due to deformation, the toenails become thicker or thinner. In extreme cases, the shape of the foot changes, leading to flat feet. Osteoarthropathy, characterized by deformity of the ankle joint, also develops.

At this stage of the disease, the pulse in the foot remains intact. When thick nerve fibers are damaged, sensitivity sharply increases: patients experience severe pain with minor touches.

Despite the above symptom, the course of diabetic polyneuropathy of the lower extremities causes numbness of the fingers. The intensity of the manifestation of pathology intensifies at night. With this disorder, the legs become swollen and chilly, and the skin begins to peel off due to drying out, or the skin remains constantly wet. Often, when nerve fibers are damaged, ulcers occur on the feet.

An advanced form of leg damage in diabetes mellitus provokes extinction of tendon reflexes and dysfunction of internal organs.

Because of this, the following phenomena may occur:

impotence;
anorgasmia (in women);
urinary incontinence;
stomach upsets;
surges in blood pressure.

In older people, the nerves of the fundus of the eye are often affected, which contributes to the development of cataracts, anisocoria and other pathologies. If neurons in the abdomen or liver are affected, patients experience sharp pain in the specified zone. At this stage of development of the disease, the mobility of the limbs sharply decreases: the legs and arms seem to become stiff. The result of the described processes is unsure gait, which signals irreversible changes.

Treatment of diabetic polyneuropathy is determined depending on the stage of development of the disease based on diagnosis and symptoms. As a last resort, when nerves are affected upper sections body, it is impossible to achieve complete recovery of the patient.

Diagnostic methods

If polyneuropathy is suspected in diabetes mellitus, electroneuromyography is prescribed. This method allows you to evaluate the conductivity of nerve fibers. Using ENMG, it is possible to identify the location and extent of tissue damage.

During the examination of a patient with diabetes mellitus, the following are assessed:

condition of the lower extremities;
tactile and temperature sensitivity;
vibration sensitivity;
patient stability in the Romeberg position.

Additionally, a blood test is prescribed to determine the level of cholesterol, sugar, insulin and lipoproteins. An ECG and ultrasound of the heart are required, pulsation in the feet and blood pressure levels in the extremities are examined.

Methods of treating the disease

For the treatment of diabetic polyneuropathy of the lower extremities, certain medications are selected that stop the development of pathology and relieve symptomatic manifestations. In advanced cases, other drugs are used to heal wounds resulting from the formation of trophic ulcers.

Diabetic polyneuropathy on initial stage development is well stopped by non-drug methods. In order to improve the nutrition of the tissues of the lower extremities and, as a result, restore the conductivity of nerve fibers, it is recommended to massage the feet daily. If the skin is dry, the epidermis should be treated with a moisturizer before the procedure.

When a feeling of numbness occurs in the lower extremities, hot baths are prohibited. The legs stop feeling the effects of high temperatures, which can result in skin burns.

After the first signs of the disease appear, it is highly not recommended to reduce motor activity. Doctors recommend walking more often, thereby developing the limbs and increasing blood flow to the affected fibers. At the same time, you should perform certain exercises every day. The exercise therapy complex is developed individually.

Drug therapy

Diabetic polyneuropathy of the lower extremities almost always provokes pain in the legs, which disappears after restoration of blood glucose levels. To relieve this symptom, anticonvulsants and antiarrhythmic drugs are used. To eliminate painful sensations, the ointments “Finalgon” and “Alizartron”, tictoic and lipoic acids (contained in the drug “Berlition”) are recommended.

Lipoic acid takes part in the metabolism of glucose and lipids, prevents the accumulation of cholesterol, normalizes cell membranes, and reduces the impact of free radicals. As a result, inflammation is eliminated and pain is suppressed.

To restore metabolism, the following are prescribed:

B vitamins;
angioprotectors and circulation correctors (“Actovegin”).

Depending on the intensity of the pain syndrome, the following are used to relieve this symptom:

analgesics (Tramadol, Targin);
antidepressants (Duloxetine, Imipramine);
opioids (Tramadol).

The dosage and type of the above medications are selected based on individual characteristics the course of the pathology in each case.

Polyneuropathy in diabetes mellitus is also treated with antibiotics. Antibacterial drugs prescribed for high risk of developing gangrene.

Drug treatment is often supplemented with physiotherapeutic measures. In case of formation of trophic ulcers, it is recommended to treat the affected areas antiseptic compounds. If the course of the pathology is accompanied by the formation of phlegmon, tissue suppuration or other complications, surgical intervention is used, including amputation of the limb.

Treatment with folk remedies

Besides drug therapy used for polyneuropathy, treatment folk remedies also gives a certain effect. To eliminate the symptoms of the disease and restore nerve conduction, it is recommended to use compresses made from blue or green clay. The latter in the amount of 100 g should be diluted in chamomile infusion to a mushy state and applied to the feet. Such compresses should be applied for two weeks. Then you need to take a break for 14 days and repeat the course.

To normalize blood sugar levels in diabetic polyneuropathy, treatment is supplemented with an infusion of dandelion root, nettle and galega leaves, and bean leaves, taken in equal proportions. From the resulting composition you need to take 1 tablespoon daily, brew it in a glass of boiling water and drink throughout the day.

Eliminate free radicals Clove powder helps, which is brewed with cardamom and ginger (¼ tsp per glass of boiling water).

Prevention and consequences of the disease

To avoid the appearance of diabetic polyneuritis, patients must follow certain clinical recommendations. The basis of prevention is lifestyle correction. Patients with diabetes mellitus should follow their doctor's nutritional instructions and promptly correct the lack of insulin by administering the appropriate medication. It is also recommended to constantly monitor your blood sugar levels.

Failure to comply with these requirements leads to the development of the following complications caused by the course of diabetic polyneuropathy:

complete loss of sensation in the lower extremities;
intense pain of various types;
ingrown nail;
cracked and dry skin of the feet;
addition of fungal diseases;
deformation of the foot and legs;
diseases of internal organs;
death of the patient.

To reduce the risk of complications, patients with diabetes should be active image life, regularly take B vitamins and lipoic acid.

If you have this disease, it is prohibited to use alcoholic drinks regardless of their strength.

Distal polyneuropathy- one of the types of polyneuropathy. This is a disease that is characterized by the process of death of nerve fibers, which, in turn, entails the loss of all sensitivity and the further development of foot ulcers. This disease is the most common complication that develops in diabetes mellitus, which significantly reduces the patient’s performance and, in general, threatens his life and health.

The main type of damage to nerve fibers in patients with diabetes is the so-called distal polyneuropathy. With this type of polyneuropathy, in most cases the lower and occasionally the upper extremities are affected.

The most common symptom of distal polyneuropathy is the symptom pain. Usually these are pulling and dull pain. Sometimes the pain reaches such a level that it prevents you from sleeping at night. The pain becomes stronger when the patient is at rest, but can also be observed during prolonged walking. Quite often, paresthesias make themselves felt, which manifest themselves in the form of numbness, a sensation of “crawling goosebumps,” tingling, chilliness, or, conversely, burning. You feel heaviness and even weakness in your legs.

The shoulders, forearms and top part legs - hips. Pain can be felt when palpating the upper part of the leg - this is one of the main symptoms when diagnosing dangerous distal polyneuropathy. In the absence of appropriate treatment, the pathology becomes increasingly serious.

The initial signs of diabetic distal neuropathy manifest themselves in the fingers of the lower extremities; as the process develops, similar symptoms of deterioration in sensitivity make themselves felt in the fingers of the upper extremities. The disease rarely begins to develop from the distal parts of the arms.

With distal polyneuropathy, thin and sometimes thick nerve fibers are usually affected. If thin fibers are affected to a greater extent, the disease is characterized by a significant decrease in temperature and pain sensitivity. In case of damage to thick fibers, tactile sensitivity is partially lost or even completely lost. Signs of diabetic distal neuropathy are observed in approximately 40% of people with diabetes, approximately half of these individuals complain of pain.

Further development of distal polyneuropathy can lead to serious disorders of the musculoskeletal system - weakness in the lower extremities and muscle atrophy. The patient's sweating process noticeably worsens, and the skin becomes drier. Typical bone deformities are acquired.

The color of the skin also changes slightly, acquiring a bright pink, even reddish tint, and symmetrical areas of pigmentation appear on the lower part of the lower leg and the back of the foot. Nails can atrophy or, conversely, may become deformed.

As a result, osteoarthropathy develops, which is characterized by flat feet, both transverse and longitudinal, increased ankle deformity, as well as an increase in the size of the foot in the transverse dimension. Such changes observed in the foot can be either unilateral or bilateral.

Prolonged pressure in the area of bone deformities ultimately inevitably leads to the development of neuropathic ulcers, usually on the outside of the foot and between the toes. Such ulcers do not cause pain for some period of time due to partially lost sensitivity, and only the development inflammatory process draws attention to this defect.

In this regard, it is especially important early diagnosis distal polyneuropathy - this reduces the risk of developing a foot ulcer and even possible amputation of the lower limb. Unfortunately, no standard has yet been established for determining neuropathic abnormalities in a patient suffering from diabetes.

To make a diagnosis of distal polyneuropathy, it is sufficient to identify the following criteria, according to the scale of symptoms and signs. These include moderate signs without symptoms or with the presence and minor signs with moderate symptoms.

To more accurately determine the severity clinical manifestations It is necessary to conduct additional neurological examination for the presence of sensorimotor disorders. This examination includes a detailed study of absolutely all types of sensitivity and determination of reflexes.

The main reason for the progressive development of distal neuropathy is, first of all, the presence of large amounts of glucose. In this regard, the most effective method treatment of the disease, which allows you to reverse the process, is constant monitoring of the level of glycemia in the blood. In addition, it is necessary to carry out symptomatic treatment, which is important in relieving pain.

Expert editor: Mochalov Pavel Alexandrovich| Doctor of Medical Sciences general practitioner

Education: Moscow Medical Institute named after. I. M. Sechenov, specialty - "General Medicine" in 1991, in 1993 " Occupational diseases", in 1996 "Therapy".

Diabetic polyneuropathy is one of the most common forms of polyneuropathy.

Its development manifests itself in 50-70% of patients with diabetes mellitus of both types for more than 5 years.

Information for doctors. To encrypt the diagnosis of diabetic polyneuropathy, you should use code G63.2* according to ICD 10. In this case, you should indicate the type of disease (sensory, motor, autonomic, or a combination thereof), and the severity of the manifestations. The first diagnosis must indicate diabetes mellitus directly (according to ICD 10 codes E10-E14+ with a common fourth character of 4).

Causes

The development of the disease is associated with a chronic hyperglycemic state, lack of insulin (absolute or relative), microcirculation disorders in peripheral nerves. Damage to nerve axons usually develops, but segmental demyelination may also occur. The combination of polyneuropathy and angiopathy of the extremities is the leading cause of trophic disorders in diabetes mellitus, in particular the cause of the development of diabetic foot.

Classification

Based on the type of manifestations and localization of symptoms, the following forms of diabetic polyneuropathies are distinguished:

Proximal symmetrical polyneuropathy (amyotrophy).
Asymmetrical proximal neuropathy of large nerves (usually femoral, sciatic or median).
Neuropathies of the cranial nerves.
Asymptomatic polyneuropathies.
Distal types of polyneuropathy.

Distal polyneuropathy is the most common type of diabetic polyneuropathy. It accounts for more than 70% of all types of this disease. The word distal indicates damage to parts of the extremities remote from the body (hands, feet). The lower extremities are more quickly affected. Depending on the nature of the lesion, the following forms are distinguished:

Sensory.
Motor.
Vegetative.
Mixed (sensorimotor, motor-sensory-vegetative, sensory-vegetative).

Symptoms

The clinical picture of the disease depends on the form of polyneuropathy, the degree of nerve damage, and blood sugar levels.

Proximal polyneuropathies are characterized, first of all, by the development of impaired muscle trophism, weight loss of the entire limb, and a decrease in its strength. Autonomic and sensory functions are affected to a lesser extent.
Diabetic cranial nerve neuropathies vary depending on the extent of the individual pair's involvement. Thus, the most common lesion is oculomotor nerve, often manifesting itself in the form of acutely developing painful ophthalmoplegia. Defeat optic nerve characterized by a pronounced decrease in vision, blurred vision, and impaired twilight vision. Less commonly affected are the trigeminal, trochlear, facial nerves. Most common cause Cervical nerve lesions are caused by acute ischemia, and timely therapy usually leads to good results.
Asymptomatic polyneuropathies are usually discovered incidentally during a routine neurological examination. They manifest themselves as a decrease in tendon reflexes, most often knee reflexes.
Distal forms of polyneuropathy usually manifest themselves quite clearly. Yes, availability sensory disorders manifests itself in the presence of a crawling sensation in the patient, a painful burning sensation, and numbness in the limb. A person may also notice a pronounced disturbance of sensitivity, may notice a feeling of “walking on a pillow”, in which he does not feel support and his gait is disturbed. At distal form diabetic polyneuropathy of the lower extremities often develop painful cramps. Gait disturbances can lead to the development of foot deformities and, subsequently, the development of diabetic foot.

Autonomic disorders can lead to the development of tachycardia, hypotensive orthostatic reactions, intestinal dysfunction and Bladder, decreased potency, impaired sweating. The risk of sudden cardiac death also increases.

Motor disturbances in the distal form of polyneuropathy are rare, especially in the isolated form. They are characterized by the development of hypotrophy of distal muscle groups and a decrease in their strength.

Diagnostics

Diagnosis of the disease is based on the clinical picture and the documented fact of the presence of diabetes mellitus for a long time. IN difficult situations it is possible to conduct an ENMG study, additional consultation endocrinologist.

The mechanism of development of diabetes complications - video material by the author

Video about diabetic polyneuropathy

Treatment

Treatment of diabetic polyneuropathy should be comprehensive and carried out jointly with an endocrinologist and therapist. The first thing you need to do is control your blood sugar levels. It is also imperative to exclude the presence of micro- and macroangiopathies and, if necessary, carry out appropriate treatment.

For cupping neurological manifestations The most widely used preparations are thioctic (alpha-lipoic) acid (berlition and its analogues). Drug therapy is carried out in adequate dosage (the initial dose should be at least 300 mg per day) and in long courses (at least 1.5 months). B vitamins are also widely used.

If painful cramps are present, muscle relaxants and anticonvulsants can be used. In case of severe pain, you can resort to symptomatic treatment NSAIDs and other analgesics.

Exercise therapy, physiotherapy, and massage play an important role in the treatment of diabetic polyneuropathy. If there are signs of foot deformation, orthopedic selection of insoles and shoes is necessary. In all cases vital role Careful care for the condition of the skin and prevention of microdamage play a role.