Healthy Living With Dr. Nanchak Nimzing
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Diabetes is a chronic metabolic disorder that occurs when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. It is characterized by hyperglycemia causing excessive thirst and the production of large volumes of urine. Diabetes has long-term effects, and when left uncontrolled, it has disastrous consequences on the nerves, the eyes (diabetic retinopathy), the kidneys (renal damage), the heart (diabetic heart disease), the skin (diabetic dermopathy) and the feet.
DIABETIC NEUROPATHIES (Nerve Damage):
Diabetic neuropathies are a family of nerve disorders that are caused by diabetes mellitus either Type 1 or Type 2. People with diabetes can, over time, develop damage to nerves throughout the whole body. These neuropathies (or disorders of the nervous system) lead to numbness and occasionally pain and weakness in the hands, arms, feet and legs. Problems may also be experienced in every organ system of the body including the digestive tract, the heart, and the sex organs. It is possible for people with diabetes to develop nerve problems at any time, but generally speaking the longer a person has diabetes, the greater is the risk of developing a diabetic neuropathy. It is to be noted that estimates indicate that some 50% of those diagnosed with diabetes present with some form of neuropathy. Note also that not all who have neuropathy exhibit any symptoms. The highest rates of neuropathy are found amongst diabetics who have had the disease for at least 25 years.
Once again we mention the importance of control of blood glucose (BG) levels as part of the diabetic management program. Diabetic neuropathy appears to be most common in diabetics who have problems controlling their blood glucose levels. Those with high levels of blood fat and blood pressure, those who are overweight, and those over the age of 40 are at risk.
Diabetic neuropathies can be classified as peripheral, autonomic, proximal, and focal. Each affects different parts of the body in different ways
1. Peripheral neuropathy causes either pain or loss of feeling in the toes, feet, legs, hands, and arms. This is the most common type of diabetic neuropathy and is also known as “distal symmetric neuropathy”.
This type of neuropathy causes damage to the nerve in the arms and legs. The feet and legs are likely to be affected before the hands and arms. Many people with diabetes have signs of neuropathy upon examination but have no symptoms at all. However, symptoms of peripheral neuropathy may include:
• Numbness or insensitivity to pain or temperature
• A tingling, burning, or prickling sensation
• Sharp pain or cramps
• Extreme sensitivity to touch, even a light touch
• Loss of balance and coordination
• Muscle weakness
These symptoms are often found to be worse during the night.
Peripheral neuropathy may also cause muscle weakness and loss of reflexes, especially at the ankle joint. This leads to changes in gait (walking)
2. Autonomic neuropathy causes changes in digestion, bowel and bladder function, sexual response, vision, and perspiration. It can also affect the nerves that serve the heart and control blood pressure and control blood glucose levels. Autonomic neuropathy can also cause hypoglycemia (low blood sugar) unawareness. This is a condition in which people no longer experience the warning signs of hypoglycemia. The usual symptoms such as shakiness occur as blood glucose level drops below 70 mg/dL. In people exhibiting autonomic neuropathy, these symptoms may not occur at all. This makes hypoglycemia very difficult to recognize.
The heart and its attendant circulatory system are part of the cardiovascular system, which controls the circulation of the blood. Damage to the nerves in this system causes interference with the body’s ability to adjust blood pressure and heart rate. The consequence of this is that blood pressure may drop sharply after sitting or standing. This will cause a person to feel light-headed or, possibly, even to faint. If there is damage to the nerves that control the heart rate it can mean that the rate stays high instead of rising and falling in response to normal body function demands and/or exercise.
When there is nerve damage to the digestive system this most commonly causes constipation. Nerve damage can also cause the stomach to empty too slowly, a condition referred to as gastroparesis. A case of severe gastroparesis can lead to persistent nausea and vomiting, bloating, and loss of appetite. Gastroparesis can make blood glucose levels fluctuate widely as well, due to abnormal food digestion. A person experiencing these symptoms is in need of immediate medical advice and treatment.
If there is nerve damage to the esophagus then swallowing may become difficult. If there is nerve damage to the bowels then constipation alternating with frequent, uncontrolled diarrhea can occur. This may happen particularly during the night. When there are problems with the digestive system it usually means that the body is not getting the food it requires and consequently this may lead to weight loss.
The organs most often affected by autonomic neuropathy are those that control urination and sexual functioning. Nerve damage can prevent the bladder from emptying completely. This allows bacteria to grow in the bladder and kidneys and thus causes infections of the urinary tract. In the case of damage to the nerves of the bladder urinary incontinence may be result. This is because a person may not be able neither to sense when the bladder is full, nor control the muscles that releases urine.
Sexual activities are also disrupted by autonomic neuropathy. The sexual response in men and women can gradually decrease, although the sex drive is unchanged. A man may be unable to have erections or may reach sexual climax without ejaculating normally. A woman may have difficulty with lubrication, arousal, or orgasm.
Autonomic neuropathy also affect the nerves that control sweating. If the sweat glands do not function properly then the body is unable to regulate its temperature properly. Nerve damage can also be the cause of profuse sweating at night or while eating meals.
We discussed the eyes in the earlier lesson. However it is to be noted that autonomic neuropathy can affect the pupils. This makes them less responsive to changes in light. As a result, a person may not be able to see as well as an unaffected person when the light is turned on, or they may have seeing difficulties when driving at night.
3. Proximal neuropathy causes pain in the thighs, hips, or buttocks and leads to weakness in the legs. Proximal neuropathy is sometimes called lumbosacral plexus neuropathy, femoral neuropathy, or diabetic amyotrophy. It is usually initially experienced with pain in either the thighs, hips, buttocks, or legs, usually on one side of the body. This type of neuropathy is more common in those with Type 2 diabetes than in those with Type 1 diabetes. It is also experienced in older people. It causes weakness in the legs, and manifests itself as an inability to go from a sitting to a standing position without help. In this case treatment for weakness or pain is usually needed. The length of the recovery period will vary depending upon the severity and type of damage to the nerves.
4. Focal neuropathy results in the sudden weakness of one nerve, or a group of nerves, causing muscle weakness or pain. Any nerve in the body may be affected. However a general list may be taken as eyes, facial muscles, ears, pelvis and lower back, thighs, and abdomen.
Occasionally, diabetic neuropathy appears suddenly and affects specific nerves, most often in the head, torso, or leg.
Focal neuropathy has been found to cause:
a) Inability to focus the eye
b) Double vision
c) Aching behind one eye
d) Paralysis on one side of the face (known as Bell’s palsy)
e) Severe pain in the lower back or pelvis
f) Pain in the front of a thigh
g) Pain in the chest, stomach, or flank
h) Pain on the outside of the shin or inside the foot
i) Chest or abdominal pain that is sometimes mistaken for heart attack
j) Disease, heart attack, or appendicitis
Focal neuropathy is very painful and very unpredictable. It occurs most often in older people. However, it tends to improve by itself over weeks or months and does not cause long-term damage. You should not that all of the above do not just affect diabetics. It is therefore difficult to pin down these symptoms to diabetes in an undiagnosed situation but the presence of some of these symptoms in conjunction with other symptoms such as we have discussed earlier would lead you to consider that a person was diabetic and proceed accordingly.
Another interesting symptom is that people with diabetes also tend to develop nerve compressions, often called entrapment syndromes. The most common of these are carpal tunnel syndrome and ulnar neuropathies. These cause numbness and tingling of the hand, or numbness of the little finger, and sometimes local muscle weakness or pain.
Carpal tunnel syndrome: This is due to pressure on the median nerve as it passes through a narrow space in the wrist. It is a common problem in diabetics and non-diabetics alike. However there is no doubt that diabetics have carpal tunnel syndrome more often than non-diabetics. The symptoms are numbness and a tingling in the fingers. Like other symptoms this tends to happen much more so during the night than during the daytime. Persons who suffer from this will often wake because of the symptoms and shake or rub their hands for relief. If the symptoms are permitted to go untreated then a general clumsiness of the hands will develop.
Ulnar neuropathies: The ulnar nerve is the big nerve that crosses the inner aspect of your elbow and is what’s called the “funny bone”. When you hit your funny bone you feel an electric shock in your elbow that often sends tingles down into the little finger.Diabetics may have damage to this nerve at the elbow and it produces numbness in the little finger and clumsiness in the hand.
To conclude this section we note that both insulin-dependent (Type 1) and non-insulin-dependentdiabetics (Type 2) may develop neuropathy. By and large, like most complications of diabetes, it is the patients with severe diabetes and uncontrolled blood sugars and those with diabetes of long duration, who tend to get more complications than others. However there is a tremendous variability and sometimes patients may even develop a neuropathy before their diabetes has actually been discovered. Other patients will go many, many years with diabetes and not develop neuropathy.
Let us now look at how neuropathy is diagnosed. Diagnosis is made on the basis of presented symptoms and a physical exam. During the exam, the checks will be made on blood pressure and heart rate, muscle strength, reflexes, and sensitivity to position, vibration, temperature, or to a light touch.
Other test may be carried out in order to help determine the type and extent of nerve damage. Let us examine some of these:
Comprehensive foot examination: this assesses skin, circulation, and sensation. To assess protective sensation or feeling in the foot, a nylon monofilament rather like a brush bristle attached to a holder is used to touch various parts of the foot.
These are useful inspections and tests that can be successfully carried out by most therapists involved in physical manipulation of their clients. Note that this test, when found to be positive, provides one valuable clue as to the likelihood of the person to be diabetic.
Nerve conduction studies: these are used to check the transmission of electrical current through a nerve. In this type of test, an image of the nerve conducting an electrical signal is projected onto a screen. Nerve impulses that seem slower or weaker than usual indicate the possibility of damage. This test allows the condition of all the nerves in the arms and legs to be assessed. Such tests are normally carried out in a medical clinic.
Electromyography (EMG) shows how well muscles respond to electrical signals transmitted by nearby nerves. The electrical activity of the muscle is displayed on a screen. A response that is slower or weaker than that considered normal indicates the possibility of damage either to the nerve or the muscle. This test is often done at the same time as nerve conduction studies are carried out.
Quantitative sensory testing (referred to as QST.) these tests measure the response to stimuli, such as pressure, vibration, and temperature, in order to check for neuropathy. QST is increasingly used to recognize sensation loss and excessive irritability of nerve. Again these tests require the services of well equippedmedical facilities.
Simple vibration stimulus test. In this test a simple tuning fork is used.
A tuning fork with a frequency of 128 hz (128 cycles-per-second) is applied to the bony prominences of the ankle and feet (Figure 4.4) in order to test the ability to sense vibrations.
When the tuning fork is applied the subject is to indicate what is felt. An early sign of diabetic neuropathy is a lack of ability to feel vibrations (in this case from the tuning fork). This test can be carried out relatively easily by therapists involved in physical manipulation of the client.
Ultrasound testing: Ultrasound tests use sound waves to produce an image of internal organs. An ultrasound of the bladder and other parts of the urinary tract, for example, can show these organs preserve a normal structure and whether the bladder empties completely after urination. Again these tests require the services of well equipped medical facilities.
Heart rate variability check. This shows how the heart responds to deep breathing and to change in blood pressure and posture.
Nerve or skin biopsy test. An invasive test which involves removing a small sample of nerve or skin tissue for microscopic examination. This type of test is perhaps not particularly used for diagnostics but often as part of a laboratory’s ongoing research.
What type of treatment is currently in use for diabetic neuropathy?
NB: Two important items are to be considered; the first is to reduce weight and the second is to bring blood glucose levels within the normal range to prevent further nerve damage. These two items are to be “set running” at the same time. Blood glucose monitoring, meal planning, exercise, and oral drugs or insulin injections are needed to control blood glucose levels. Although symptoms may get worse when blood glucose is first brought under control, over time, maintaining lower blood glucose levels helps lessen neuropathic symptoms. Importantly, good blood glucose control may also help prevent or delay the onset of further problems.
Any additional treatments will depend upon the specific type of nerve problem and its presented symptom.
Foot care – people with neuropathy need to take special care of their feet. The nerves to the feet are the longest in the whole body and are the ones most often affected by neuropathy. Loss of sensation in the feet means that sores or injuries may go unnoticed. If this happens such sores or lesions may become ulcerated or otherwise infected.
More than half of all lower limb amputations in the United States have occurred in people with diabetes. At the time of writing such amputations are running at a staggering 86,00 per year. It is estimated that almost 50% of these amputations, which were due to neuropathy and poor circulation, could have been prevented by careful foot care.
Pain relief – to relieve pain, burning, tingling, or numbness, the subject’s doctor may suggest aspirin, acetaminophen, or non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen.
Acupuncture therapy is one of the most effective treatments of pain and other conditions caused by diabetic nerve damage free from the side effects that normally accompany drug therapy.
Diabetes treatment and management with acupuncture therapy is very effective.
Our experience at Meridian Specialist Medical Centre is that stimulation of the endocrine points by acupuncture needling using both body and auricular points, as well as an indicated homeopathic medicine (simillimum) used for homeopuncture has been found to restore the body’s own ability to control blood sugar levels.
Acupuncture is known to have effects on the hypothalamic-pituitary-adrenocortical axis. Consequently, these links make it understandable how acupuncture therapy is quite effective for managing endocrine disorders in general and diabetes in particular. The main effect is the restoration of normal pancreative function and restoring the functionality of the insulin receptors, through the homeostatic (regulatory) action of acupuncture needling.
Results seem to vary according to the age of the patient, duration of the disease, level of blood sugar control, compliance with our prescription for exercise, diet change and rest. Whenever these are followed accordingly, blood sugar levels improve while normal pancreatic function and insulin action are restored (i.e. blood sugar normalizes) gradually.
It should be noted that the patient’s hypoglycemic drugs should not be stopped in a rush thinking they have a cure when improvement just starts. Those individuals who are taking oral hypoglycemic drugs should consult with their doctor to properly and gradually reduce the dosage of the drug when they begin to experience the effects of acupuncture treatment.