Nerve damage in diabetes

This series from the Guardian and BMJ reviews practical best practices for care of people with diabetes, including care of the feet.
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To see this story with its related links on the guardian.co.uk site, go to http://www.guardian.co.uk/lifeandstyle/besttreatments/diabetes-type-1-nerve-damage-in-diabetes

Nerve damage in diabetes
Wednesday January 7 2009
BMJ Group

Over time, high levels of glucose (sugar) in your blood can stop your nerves sending signals from your limbs (especially your legs and feet) to your brain. Other nerves, called autonomic nerves, also can become damaged. Autonomic nerves control many functions in your body, such as your heartbeat, digestion and blood pressure.

About half of people who have had diabetes for a long time will get some kind of nerve damage.[1] This nerve damage is called diabetic neuropathy. Nerves in your arms and legs

Damage to nerves in your arms and legs can lead to: Numbness Pins and needles A burning feeling (you might not be able to bear anything touching your feet) Pain Feeling cold.

You might not be able to feel your toes or your feet. Or you might have painful and burning feet. Nerves in your legs and arms also can get damaged. If this happens, you might have numb areas or get shooting pains in your arms or legs, especially at night.[2]

If you have damaged nerves, you may not notice if you get a cut or a sore on your foot. This means that small sores can turn into serious problems because you don’t know they’re there. If you also have poor blood circulation (see Heart and blood problems in diabetes), your wounds can take longer to heal.

For example, you could be walking around barefoot and step on a nail. Nerve damage in your foot means you don’t feel this, and your wound gets infected. Because there’s lots of glucose in your blood, the germs that get into your wound grow fast. So the infection gets worse.

Sometimes, a bad infection can cause gangrene. This is when the tissue around the wound dies. If the gangrene spreads, you might need to have part of your foot or leg removed. This is called an amputation. However, these days it’s not common for people with diabetes to need an amputation.

Your feet are most at risk. You may get the following problems in your feet: You can’t feel pain You can’t feel hot or cold You get foot ulcers (areas of broken skin that don’t heal) Your foot swells The shape or position of your foot changes, and you can’t use it properly.

Nerves in other parts of your body

If you’ve had diabetes for a long time, nerves in other parts of your body may get damaged.

Your heart: If the nerves in your heart are damaged, your heart may not work as well as it should. This means you’re more likely to have a heart attack. You may also find that your blood pressure changes. And you may feel dizzy if you stand up suddenly. Nerve damage to your heart can also mean you don’t get chest pain if you have a heart attack. This makes it hard to know that you’re having one.

Your digestive system: This includes your throat, stomach and intestines. Damage to nerves in these parts of your body can affect how fast your food passes through. You may get diarrhoea or constipation.

Your genital area: If the nerves in this area are damaged, you can get sexual problems. You may not feel like having sex. If you’re a man, you may not be able to get or keep an erection. If you’re a woman, you may have trouble getting aroused or having an orgasm. These problems are more likely if you have had diabetes for a long time.[1] If the nerves in your bladder are damaged, you may have problems controlling when you pass urine.

Your skin: Certain nerves control when you sweat. If these nerves are damaged, you won’t sweat as much as you should. This makes your skin drier and more fragile, especially the skin on your feet. Action points

Here are some tips for keeping your nervous system in good shape: Keep your blood glucose level and your blood pressure as close to normal as possible. Your doctor will help you do this. Don’t drink too much alcohol. Too much alcohol can cause nerve damage. Check your feet every day, especially if you can’t feel them well. If you smoke, stop.

Here are some more tips to protect your feet: Check your bare feet every day. Look for cuts, sores, bruises or spots. See your GP or diabetes nurse or doctor if you find any problems. If you have difficulty seeing the bottoms of your feet, use a mirror. Or ask someone to help. Wash your feet in warm water every day using mild soap. Don’t soak your feet, as this can dry your skin. Don’t have very hot baths. Dry your feet with a soft towel. Pay close attention to the areas between your toes. After washing your feet, cover them with a lotion (such as baby lotion) before putting your shoes and socks on. (But don’t put lotion or cream between your toes.) Your feet will be drier than normal, because diabetes makes you sweat less. File your toenails straight across, using a nail file. Make sure you don’t leave sharp edges that could cut the next toe. A podiatrist can help show you how to best care for your toenails. Don’t try to remove corns, calluses or warts yourself. See a foot doctor (a chiropodist or podiatrist) instead. If your feet have changed shape, wear trainers or shoes that are extra deep or wide. Or you can get specially moulded shoes that cushion your feet and let your toes move. Don’t wear flip-flops or plastic shoes. Avoid shoes with pointed toes or high heels. Never go barefoot. Check your shoes before you put them on. Make sure they don’t have any sharp edges or objects in them. Don’t wear stockings or socks with holes, seams or repairs that might rub against your feet. Don’t put heating pads or hot water bottles next to your feet. If your feet get cold at night, wear thick socks. Make sure a nurse or doctor checks your feet and the feeling in your feet regularly. References

Powers AC. Diabetes mellitus. In: Braunwald E, Fauci AS, Kasper DL, et al (editors). Harrison’s Principles of Internal Medicine. McGraw-Hill, New York, U.S.A.; 2001.

Diabetes UK. Guide to diabetes, Complications, Long term complications, Nerves (neuropathy). Available at http://www.diabetes.org.uk/Guide-to-diabetes (accessed on 2 June 2008). Glossary

blood pressure

Blood pressure is the amount of force that’s exerted by your blood on to your blood vessels. You can think of it like the water pressure in your home: the more pressure you have, the faster and more forcefully the water flows out of the shower. Blood pressure is measured in millimetres of mercury (written as mm Hg). When your blood pressure is taken, the measurement is given as two numbers, for example 120/80 mm Hg. The first, higher, number is called the systolic pressure, and the second, lower, number is the diastolic pressure. The systolic number is the highest pressure that occurs while your heart is pushing blood into your arteries. The diastolic number is the lowest pressure that happens when your heart is relaxing and is not pushing your blood.

infection

You get an infection when an organism, such as a bacterium, a fungus or a virus gets into a part of your body where it shouldn’t be. For example, an infection in your nose and airways causes the common cold. An infection in your skin can cause rashes such as athlete’s foot. The organisms that cause infections are so tiny that you can’t see them without a microscope.

bladder

Your bladder is the hollow organ at the top of your pelvis that stores urine. It is similar to a balloon, only with stronger walls. It fills up with urine until you go to the toilet.

acute myocardial infarction

Acute myocardial infarction is what doctors call a heart attack. A heart attack is when your heart muscle gets damaged because it isn’t getting enough blood and oxygen. This can happen if a branch of your coronary arteries becomes blocked. During a heart attack, you may have pain or heaviness over your chest, and pain, numbness or tingling in your jaw and left arm.

diarrhoea

Diarrhoea is when you have loose, watery stools and you need to go to the toilet far more often than usual. Doctors say you have diarrhoea if you need to go to the toilet more than three times a day.

© BMJ Publishing Group Limited (“BMJ Group”) 2009

Copyright Guardian Newspapers Limited 2009

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David G. Armstrong

Dedicated to amputation prevention, wound healing, diabetic foot, biotechnology and the intersection between medical devices and consumer electronics.

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