Dr Aidin Rawshani

Diabetic neuropathy (nerve damage): causes, symptoms, treatments


Neuropathy (nerve damage): diabetes causes peripheral and autonomic neuropathy

What is the nervous system and nerves?

The nervous system consists of the brain, spinal cord and nerve fibers. Our brain stores memory, coordinates our movements, regulates hormones and interprets sensory impressions from the eyes and ears. The brain actually continues down the back in the form of the spinal cord. From the spinal cord, nerve fibers depart into the body. These nerve fibers connect the brain to the skin, muscles, internal organs, blood vessels and glands. This way the brain can control these structures. In the nerve fibers, signals are sent that are important for our sensitivity, the ability to control muscles, balance, regulate blood vessels, etc. Some of these things we can control ourselves (for example, control of muscles) while others cannot be controlled by will (for example, regulation of blood vessels). People with diabetes may suffer from neuropathy, which means nerve damage. When the nerves are damaged, their function becomes worse and this can cause many different inconveniences. Approximately 50% of all people with diabetes have some degree of neuropathy. The longer you have diabetes and the higher the blood sugar you have, the higher the risk of developing neuropathy.

There are two types of neuropathy, namely peripheral neuropathy and autonomic neuropathy. Peripheral neuropathy affects the skin, muscles and joints of the legs, feet, arms and hands. Autonomic neuropathy affects nerves that we can not control at will, namely nerves to our organs, glands and blood vessels.

Peripheral neuropathy: damage to nerves to the skin, muscles and joints

Damage to nerves that go to the skin, muscles and joints of the limbs is called peripheral neuropathy. This is the most common type of neuropathy. It usually affects the legs and feet first, and after some time the hands and arms are also affected. Many patients describe that the symptoms are the worst at night. Symptoms, as a rule, are similar on the right and left sides.

What symptoms does peripheral neuropathy give?

  • Feeling of sensation in the skin.
  • Feeling numbness in the legs, feet, arms, hands. Some patients may not feel touch on their hands and feet.
  • Less of sensation and numbness may cause you to experience it as wearing socks even when you don’t have it.
  • It becomes more difficult to distinguish heat and cold.
  • Hands may become unreasonably hot or cold.
  • Buzzing or creeping sensation in the skin.
  • Peripheral neuropathy can also lead to pain or hypersensitivity of the skin.
  • You may experience sharp pain or cramps in the legs, feet, arms and/or hands.
  • The pain may also be experienced as stabbing or burning. You may become hypersensitive to touch, insofar as it hurts when someone touches the skin. For example, one can get pain from the fact that a thin filter is located against the skin.

Peripheral neuropathy can also lead to weaker and more difficult to coordinate muscles:

  • Muscles become weaker.
  • It becomes more difficult to trigger reflexes.
  • The balance becomes worse, as well as coordination. Some patients can not feel their feet when walking, which makes it difficult to coordinate the movements of the body. The balance can actually be so bad that it will be difficult to stand up.

If neuropathy causes the nerves in the legs/arms to stop working, you do not feel any pain at all, even when you get hurt.

How to diagnose neuropathy?

Foot examination shall be carried out regularly

One should examine the feet of people with diabetes as often as possible (preferably every visit). It is quick to look for skin lesions, blisters, soreness, pain, inflammation or other problems.

In addition, once every year a thorough foot examination is to be carried out. If you have problems with neuropathy, the examinations should be done more often. A foot examination includes the following moments:

  • You look and feel at your feet to look for injuries, blisters, tenderness, pain.
  • The muscles of the foot and lower legs must be assessed in terms of strength and shape. Blood flow in the vessels must be assessed. Constrictions in the vessels are a strong risk factor for neuropathy.
  • Using a tool called monofilament, it is investigated if there is a loss of sensitivity in the foot. Monofilament is a rigid thread. Alternatively, you can use a brush. The video below shows how a monofilament survey is performed. You can use a tuning fork to investigate if you experience the vibration when you hold the tuning fork to your foot.

EMG survey

EMG stands for electromyography. With this study, it is possible to identify how quickly the nerves in the legs/arms send signals. If the signals are sent slowly, you have neuropathy.

How to prevent neuropathy?

There is a lot to do to prevent or postpone neuropathy. If you already have neuropathy, you can prevent deterioration and possibly reduce symptoms by the following measures. The following measures are crucial.

Good blood sugar control

All people with diabetes (regardless of type) should agree with their healthcare provider a target HbA1c and blood sugar level. This target value should be as low as possible, without risk of getting too low blood sugar (which is also dangerous). To have good blood sugar control, you need to have a blood glucose meter and use it regularly to check your sugar. Today, very many people with type 1 diabetes have received a continuous blood glucose meter (CGM) which makes it very easy to follow their blood sugar. It is important to periodically examine their long-term blood sugar (HbA1c) to clarify how the sugar has been over a long period of time. At least two HbA1c are recommended per year. Plan your meals and it will be easier to control blood sugar. Make sure that you are always physically active (exercise) at least a couple of times a week (however, please note that all physical activity is not suitable for neuropathy – talk to your caregiver to discuss appropriate exercise). If your blood sugar is well controlled, you have a good treatment plan, otherwise you and your healthcare provider will have to review the plan.

Report symptoms of neuropathy to the caregiver

It is important that the healthcare provider is told early on that you have neuropathy as this may affect your treatment plan.

Treat problems early

If you have blisters, ulcers or other things that can be treated, make sure that the treatment starts immediately. The earlier the treatment starts, the less the risk of severe complications. Ignoring an infection of the foot can lead to the fact that the latter needs to be amputated.

Be careful with the feet and foot hygiene

Examine your feet every day. Try to assess how the sensation is in the feet. If the sensation is impaired, you will most likely not feel when you have gravel in your shoes. Among people with diabetes who need to amputate, it is common for the wound on the foot to begin as a small abrasion or similar. Never trust that your touch will reveal wounds and injuries on your feet, as your sensation may be impaired. Therefore, always be sure to look at your feet and ask someone else to look at the areas you cannot see (alternatively use a mirror).

Attention should be paid to dry skin, lesions, blisters, inflamed (red) skin areas. Ingrown nails and nail infections should be treated early. If the skin is dry, you can use a moisturizing cream and there is absolutely no need to be an expensive cream. Clean your feet thoroughly after activities outside and wipe your feet thoroughly if wet.

If you have problems with neuropathy, you may need special shoes. These shoes are paid for by your caregiver.


It is conceivable that blood pressure and blood fats are also of importance for neuropathy. Therefore, careful control of blood pressure and cholesterol-lowering drugs can be of potential benefit.

How to treat symptoms of neuropathy, for example, pain?

There are several drugs that can reduce the pain and other symptoms of peripheral neuropathy. Talk to your healthcare provider today to see if these medicines are suitable for you.

Autonomic neuropathy: damage to nerves to organs, blood vessels and glands

Autonomic nerves are those that we humans can not control. These nerves go, among other things, to the heart, blood vessels, lungs, eyes, urinary organs and gastrointestinal tract. If you get neuropathy in these nerves, the regulation of these organs is impaired. If the heart’s nerves are affected, it can lead to poor condition, drop in blood pressure, higher blood pressure (especially at night), oxygen starvation of the heart, high heart rate or low heart rate. Additional examples of autonomic nerves and neuropathy are as follows:

When the bladder is full and we’re going to pee, nerves are activated that cause the bladder to contract, so we can urinate. If you get neuropathy in the nerves that go to the bladder, it can be paralyzed. The bladder can no longer contract normally and it becomes more difficult to empty the bladder. Nerves that go to the genital area are needed for men to have an erection. Neuropathy of these nerves leads to the fact that men with diabetes can not have an erection. This is called erectile dysfunction.

The gastrointestinal tract is very abundantly supplied by nerves. If these nerves are damaged, the functioning of these organs is disrupted. This leads to diarrhea, which occurs most often at night. However, it can also lead to constipation. If neuropathy affects the nerves to the stomach, it will make it harder to contract and empty itself. Then the food can be collected in the stomach until you become nauseous and vomit. This condition, when the stomach can not be emptied normally, is called gastroparesis. Most often, the stomach manages to empty itself at last, but it goes slower than normal.

Here are the most common signs/symptoms of autonomic neuropathy:

  • Low blood sugar levels do not feel as much as they did before (hypoglycaemia give less symptoms).
  • The bladder works worse, which makes it more frequent to urinary tract infections, urinary cornices or incontinence.
  • Constipation, diarrhea or both.
  • The stomach is emptied more slowly (gastroparesis), which leads to Dizziness, vomiting and decreased appetite.
  • It may become more difficult to starve the stomach becomes less moist and thus becomes more difficult to conduct sexual intercourse.
  • You can sweat more or less than normal.
  • Blood pressure cannot be regulated as well, which can lead to a fall in blood pressure when you get up and then you get up. dizziness or you faint in the worst case.
  • Regulation of body temperature gets worse.
  • The eyes get harder to adapt to the dark.
  • One may have abnormally high pulse while resting.

All symptoms of autonomic neuropathy

If you have any of the symptoms listed below, it is important that you tell your healthcare provider this

Symptoms from the gastrointestinal tract

  • Disturbances with digestion.
  • Heartburn.
  • Nausea and vomiting during ingestion of solid foods.
  • Feeling that the food does not leave the stomach.
  • You feel bloated after meals.
  • You get satiated early.
  • Diarrhea. constipation.
  • Blood sugar rises more slowly after meals.

Symptoms from the urinary system

  • Repeated infections of the bladder (urinary tract infection).
  • Difficult to control the bladder.
  • Difficult to empty.
  • It does not feel that you need to pee, even when the bladder is full.
  • You either urinate more often or less often than usual.

Symptoms from the genitals

Men experience difficulties in getting an erection. Women find it harder to experience orgasm. Women also get vaginal dryness.

Symptoms from the heart and vessels

You get dizzy when you get up quickly. You can faint if you get up fast. You have a high heart rate even at rest.

Symptoms related to the ability to feel low blood sugar (hypoglycaemia)

The body’s warning signs at low blood sugar become less felt. So you don’t feel that you have hypoglycaemia, which is dangerous.

The sweat glands

You sweat a lot, especially in the evening and during meals. You can also sweat less, even when you are very hot. The skin becomes dry and does not sweat.

The eyes

It will be more difficult for the eyes to adapt to dark and light rooms. Driving during the night becomes more difficult.

Treatment of autonomic neuropathy

If you already have neuropathy, you can get help in several ways. For example, in case of gastroparesis, you can get help from a dietician to find the right diet. There are medicines that reduce diarrhea. Erectile dysfunction can be treated with both medicines and devices.

Not all is neuropathy

Many of the above symptoms may also occur in other diseases that require different treatment. Therefore, one should never think that these symptoms are always neuropathy. For example, diarrhea, constipation and pain in the stomach can occur in tumors of the stomach. It is important that you tell your healthcare provider what symptoms you have, so that it can take a position on the appropriate investigation.

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