Hope for Painful Diabetic Neuropathy
Hope and help for patients suffering from diabetic neuropathy as well as other neuropathies, what has helped my patients
If you have ever told your healthcare provider about burning, prickly sensation, feeling like bees are stinging your feet keeping you up at night only to be told, “oh that’s neuropathy, here try this gabapentin medication”, then this post is for you. We will delve into all the treatments but effective treatment does require multiple avenues of care with your healthcare providers. Currently, sadly there is no cure for diabetic neuropathy but there are ways to keep it manageable.
Introduction:
Definitions:
Diabetes is a metabolism disorder involving resulting in high levels of blood sugar due to no insulin or lack of insulin. Insulin shuttles glucose into the cell for energy. Type I diabetes is when the pancreas makes little to no insulin and commonly referred to as juvenile diabetes because it affects children teenagers and occasionally young adults. It is thought to have an autoimmune cause. Type II diabetes involves the pancreas not making enough insulin and/ or the body is resistant to insulin.
Peripheral neuropathy is a term that describes malfunction of the peripheral nerves in the extremities with symptoms ranging from numbness to extreme pain. In this blog post, we will explore the pathogenesis of diabetic neuropathy, delve into its various types, and discuss both symptom management and root cause treatment strategies.
Diabetic peripheral neuropathy or DPN is a common complication of diabetes. An alarming 60-70% of diabetics have peripheral neuropathy according to the Foundation of Peripheral Neuropathy .
Impact on Quality of Life
Undermanaged diabetic peripheral neuropathy emerges as the leading cause of non-traumatic lower limb amputations, profoundly affecting the quality of life. The consequences include:
1. **Pain:** Individuals experience persistent, off and on pain.
2. **Increased Falls:** Leading to the most common cause of injury-related death in those above 65.
3. **Impaired Sleep:** Sleep disturbances are common.
4. **Complications:** Such as ulcers and infections contribute to the $10 billion annual cost from complications.
There are many different causes of neuropathy yet similar symptoms and treatment strategies:
In my career, I have seen a multitude of patients with neuropathy, the most common cause was diabetes. However, other types of neuropathy often present with similar symptoms and the symptoms are treated with the same medications. Therefore , this post is also helpful for neuropathy of different causes. There are certain types of neuropathy that can be reversed if the cause is known such as neuropathy caused by hypothyroidism, Vitamin B 12 deficiency or pernicious anemia, and monoclonal gammopathy to name a few.
**Pathogenesis of Diabetic Neuropathy:**
Diabetic neuropathy develops as a result of prolonged exposure to high blood sugar levels, leading to damage of the nerves. Essentially high blood sugar is toxic to nerves. Over my career, I have seen peripheral neuropathy develop in pre-diabetics to the point that the entire foot is numb. So the peripheral nerves are very sensitive to fluctuations and even slightly high blood sugar.
Many different types of neuropathies are caused by toxins such as alcoholism and chemotherapy. Also, in my last 10 years of practice, I have seen a surge in what we call idiopathic neuropathy where no known cause can be found. I hypothesize that likely this is due to the massive amount of toxins in our environment, products, and foods. But it also could be from the massive increase in pre-diabetes.
25 % of patients with Pre-diabetes / impaired glucose tolerance have peripheral neuropathy. 21% of these patients have neuropathic pain, according to a 2011 study in the National Review of Endocrinology by Papanas N etal.
Pre-diabetes basically means that one is in poor metabolic health. A 2019 study shows 88% of Americans are in poor metabolic health. ( Araujo j etal. “Prevalance of optimal metabolic health in American Adults> National health and nutritional examination survey 2009-2016.” Metab syndr relat disord,2019 Feb;12(1):46-52)
Call to Action: Find out if you have pre-diabetes and get it reversed now. Your physician can help you. Get a health coach. Many people have no idea they have pre-diabetes. Ask your doctor to run a fasting insulin test. This can be increased 10 years prior to a diabetes diagnosis and is a marker for insulin resistance.
Risk factors for developing diabetic neuropathy:
· Type II diabetes mellitus with higher hba1c ( measure of average blood sugar over a period of 3 months) 6.5-7% was cut-off point
· Prolonged duration of type II diabetes mellitus
· Increased age.
· **Lifestyle Factors:** Smoking, alcohol use
· impaired renal function
· . **Metabolic Syndrome:** Increased triglycerides, hypertension, abdominal obesity, and prediabetes are associated with insulin resistance
Understanding the Pathogenesis
Diabetic neuropathy's pathogenesis involves intricate pathways once there is an overload of glucose leading to changes such as the damage to small blood vessels or microangiopathy causing decreased perfusion and nerve ischemia ( lack of blood flow), oxidative stress and inflammation, resulting in nerve dysfunction, and conduction delays.
1. **Decreased Perfusion causing microvascular changes :** Leads to nerve ischemia.
2. **Glucose Metabolism Impact:** The polyol pathway and the generation of free radicals contribute to oxidative stress. Excess glucose in the nerve tissues is broken down into sorbitol which demyelinates the nerve causing impaired nerve conduction. The myelin is fatty tissue around the nerve is important in nerve conduction. Demyelination occurring in diabetic neuropathy removes the nerve’s insulation.
The polyol pathway is also responsible for reduction in glutathione, an important anti-oxidant, nitric oxide, a potent vasodilator (opens up blood vessels), and myo-inositol ( vitamin B8 which affects hormones , mood, cognition.)
3 **Formation of AGEs:** With excess glucose, it can get be deposited onto every component of nerve tissues leading to toxicity. This is called deposition of AGE or Advanced Glycation Endproducts . This causes nerve conduction delay and pain. Excessive glycation of nerve tissues causes toxicity and microangiopathy (damage to microvessels). This causes nerve conduction delay and pain. Over time, these factors contribute to nerve fiber damage, causing a range of terrible symptoms.
4. **Oxidative Stress:** Increased glycolytic processes and free radicals lead to mitochondrial changes which can lead to programmed cell death and poor energy synthesis.
All of these pathways feed forward and perpetuate one another.
The process truly is a metabolic train wreck.
Types of Diabetic Neuropathy and Susceptible Anatomy
Definitions: Peripheral Neurons or nerves consist a cell body with a nucleus centrally and dendrites extending from the cell body, a very long axon like a wire extending to the axon terminal in the foot. The cell body resides in a place called the dorsal root ganglion next to the spinal cord and the axon / wire which is 20,000 longer than the cell body extends down the extremity. The long length of the axon makes it susceptible to damage. Some nerves have insulation made of fat around them called myelin. This helps the electrical impulse get propagated down the axon.
Diabetic neuropathy manifests in different types, affecting sensory, motor, and autonomic nerves. Sensory nerves, especially small C fibers, are more susceptible to damage mostly axonopathy (damage to the long wire), resulting in a stocking-glove distribution pattern.
Nerve Fiber Types
· 1. **A fibers (Alpha, Beta, Delta):** Large-diameter, myelinated fibers, serving various sensory and motor functions.
· 2. **B fibers:** Small-diameter, myelinated fibers primarily involved in autonomic functions such as cardiac, digestion function .
· 3. **C fibers:** Small-diameter, unmyelinated fibers responsible for sensory functions like pain, itching, detecting temperature.
Damage to the myelin or insulation results in large fiber disturbance causing paresthesia which is tingling and prickling sensation, decreased reflexes, muscle weakness (uncommon and late finding), loss of vibration sensation ( early finding).
Damage to blood vessels to the nerves ( vasa nervorum) can cause neuron cell death and cause damage to just a single nerve which is called mononeuropathy. This is usually exquisitely painful.
Damage to small unmyelinated C fibers cause the painful burning , loss of pinprick and temperature sensation .
B. Length-Dependent Neuropathy
· 1. **Axonopathy:** Involving the longest, myelinated, and unmyelinated sensory neurons.
· 2. **Stocking-Glove Distribution:** Damage starts with the longest axons, leading to this distinctive pattern.
Diagnosis and Management
Diagnosing diabetic neuropathy is mainly a clinical evaluation according to the American Diabetes Association or the ADA. Clinicians can utilize various screening tools to diagnose, monitor and track progression.
There is no gold standard to the diagnosis early or mild diabetic neuropathy. Currently, there are studies underway to develop early detection methods.
Early detection and follow up of progression is important to prevent serious problems. It is recommended that even patients with pre-diabetes be screened for neuropathy.
Once neuropathy detected even just the loss of vibratory sensation, it is recommended that one sees one’s podiatrist once or twice a year .
The ADA does not require electrodiagnostic tests such as nerve conduction velocity studies (NCV) and quantitative sensory testing (QST) in the diagnosis of diabetic neuropathy . These test results do not change etiology or management of diabetic neuropathy.
Treatment of Diabetic Peripheral Neuropathy
In the scientific literature, there is no established treatment except blood sugar control being much more effective in type 1 than type 2 diabetes. That said, I have seen many type 2 diabetics achieve significant reduction in neuropathy symptoms when reducing double digit Hemoglobin A1C, hba1c ( a marker for average blood sugar over 3 months) to single digit hba1c. I always view high blood sugar as gasoline on the fire of neuropathy and I’ve seen this play out in clinical practice.
Understanding the limited scope of treatment and managing expectations is important :
Also in the scientific literature indicates that There is only symptom management of DPN in only 30 to 50% get symptom relief. This is quite discouraging but in my practice it seems that symptom relief is around 70% unless patients are not being honest. I have found that patients get so discouraged they just stop complaining of their DPN which is very sad.
Keep in mind that pharmaceutical companies fund these scientific studies the majority of the time. In my experience, one can be creative with multiple treatments to help the patient more. However, the goal of treatment is to reduce symptoms to make them more manageable. Most of the time, symptoms cannot be completely eliminated..
There is hope, however. There are currently studies undergoing showing that stratifying the different neuropathy manifestations and then tailoring personalized treatment based on this can achieve better outcomes.
Treatment of DPN, a three-pronged approach
1. Disease modifying treatments:
Gylcemic control, exercise/physical therapy, supplements possibly laser.
2. Symptom Suppression :
Oral and topical medications, devices
3. Prevention of compounding complications involving close working relationship between a podiatrist and the patient
Disease modifying treatments:
1. Studies show glucose control is more effective in controlling DPN in type 1 diabetics vs type 2 diabetics:
“ Enhanced glycemic control effectively reduced the incidence of diabetic neuropathy in patients with type 1 diabetes mellitus, the effect was much smaller, or in some studies, absent, in patients with type 2 diabetes mellitus in one cochrane, systemic review.” Callaghan, B ,et al Enhanced glycemic control for preventing and treating diabetic neuropathy. Cochrane Database Systemic Review 6, CD007543 (2012)
However, the following study does show more hope for blood sugar control in type 2 Diabetics with neuropathy:
“ Data from two cohorts with uncontrolled type 2 diabetes mellitus and neuropathy at baseline demonstrated improvement in several measures of large fiber and small fiber neuropathy with improvement in hemoglobin a 1C. to near normal levels after two years.” Shibashi, F., et al Improvement in neuropathy outcomes with normalizing hemoglobin a 1C in patients with type 2 diabetes. Diabetes Care 42, 110-118 (2018)
In theory, reduction in blood sugar to more normal levels will reduce inflammation, oxidative stress, AGEs ,less toxicity via the polyol pathway which in turn causes less damage.
Disease modifying treatments:
2.Exercise:
Studies have shown ( see references below) that exercise increases epidermal nerve fiber density ( nerves in the skin) and decreases neuropathic pain..
Balducci, S. et al. Exercise training can modify the natural history of diabetic peripheral neuropathy. J. Diabetes Complicat. 20, 216–223 (2006).
•Kluding, P. M. et al. The effect of exercise on neuropathic symptoms, nerve function, and cutaneous innervation in people with diabetic peripheral neuropathy. J. Diabetes Complicat. 26, 424–429 (2012).
Singleton, J. R., Marcus, R. L., Lessard, M. K., Jackson, J. E. & Smith, A. G. Supervised exercise improves cutaneous reinnervation capacity in metabolic syndrome patients. Ann. Neurol. 77, 146–153 (2015)
Exercise, specifically, resistance training to build muscle will increase mitochondria which is targeted in the DPN pathogenesis so in theory this can combat this process.
Call to action : Have your doctor work with your physical therapist to establish a good exercise program.
3. Supplements and nutrients:
Research has suggested that many nutrients may be helpful in preventing or partially reversing the effects of diabetic neuropathy. These nutrients include alpha lipoic acid, acetyl-l-carnitine, Omega 3 fatty acids, B complex. Vitamins, coenzyme Q 10 magnesium zinc, phytochemicals from fruits, herbs and vegetables. This is according to the International Journal of Diabetes Research 2013,2(3): 56-60 DOI:10.5923/j. Diabetes. 20130203.04 Nutritional Approaches to Treat Diabetic Neuropathy: a Systematic Review.
· Acetyl- L- carnitine supplementation:
One large study in 2005 involving one 1,257 patients being treated for diabetic Neuropathy with 1500 or 3000 milligrams of acetyl -l-carnitine daily versus placebo for one year. Compared to placebo, the patient’s taking 3000 milligrams of acetyl -l-carnitine daily had significantly less pain in their extremities and had significantly better vibratory sensitivity in both their toes and fingers. The study shows that acetyl -l-carnitine may be helpful for nerve regeneration.
Sima AAF, et al Acetyl- l- Carnitine improves pain, nerve regeneration and vibratory perception in patients with chronic diabetic neuropathy. Diabetes care. 2005.; 28: 96- 101..
Another study reported that 1500 or 3000 milligrams of acetyl -l- carnitine taken daily, significantly reduced the risk of diabetic neuropathy in patients with new onset pain with the protective effects being greater at patients receiving 3000 milligrams.
Amato A, et al The protective effect of acety-l-carnitine on symptoms, particularly pain and diabetic neuropathy. Diabetes, 2005.; 55.: A, 506.
· Alpha -lipoic acid:
This is an antioxidant which has been shown to lower CRP ( marker in the blood for inflammation ) and therefore inflammation.
In the Sydney 2 trial, Patients taking 600 milligrams once daily of alpha lipoic acid for 1 year. Headed change from baseline of total neuropathy symptom score which decreased by 51%. Therefore, a dose of 600 milligrams once daily seems to provide the optimum risk to benefit ratio.
· Benfotiamine , vitamin B-1 a thiamine precursor:
This has been shown to increase the levels of thiamine inside the cell and reduce AGEs. Zillox, L., et al Treatment of diabetic sensory polyneuropathy. Curr. Treat. Options. Neurology. 13, 143 dash 159 (2011).
· Metanx, contains the bio-available forms of Vitamin B9: l- methyl folate, Vitamin B-12: l- methylcobalamin and Vitamin B-6: pyridoxal- 5- phosphate.
The partially broken down forms of these vitamins make them more bioavailable, which means they are absorbed into the nerve tissue much better.
A small study of 123 patients in the Journal of diabetes in 2016 of patients with absent monofilament sensation ( which means loss of protective sensation) at baseline, 38 patients or 60.3 % had intact sensation at six months. The patients with sensation improvement had an increase in epidmeral nerve fiber density so more nerves within the skin.
Another study on Metanx in type 2 diabetes with peripheral neuropathy. neuropathy.: a randomized trial in The American Journal of Medicine, 126., 141-149. By Fonseca, V.A. et al
Showed:
· 214 patients completing 24 weeks on Metanx
· Results showing clinically significant improvements in the neuropathy total symptoms score at week 16 and week 24
· quality of life improved.
4. Symptom Suppression:
The following are the American Academy of Neurology (AAN) Treatment Guidelines for physicians treating patients:
1.Assess pain on patient’s function and Effects on quality of life
-can assess pain with visual analog scale, pain interference: Brief Pain Inventory scale/ BPI Effects on quality of life: Norfolk Qof L for DPN
2. Manage patient expectations: GOAL is REDUCE PAIN BUT NOT ELIMINATE. 30% reduction in pain considered success in clinical trails.
3. Assess other factors affecting pain perception and Quality of Life. DM and nursing home patients are more likely to have mood and sleep disorders affecting Pain perception.
Depression and sleep disorders should be treated.
Tri-cyclic antridepressants (TCAs) and Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) can treat neuropathy and benefit mood and sleep.
4
4. 4.. For painful neuropathy , the following 4 classes of drugs have shown pain reduction in meta-analyses:
These classes of drugs are either antidepressants or anti-convulsants
*tricyclic anti-depressants (TCAs) :
Amitriptyline (Elavil) not recommended in patients over 60 years old. This was one of the only medications I had when first in practice to treat neuropathy. It did seem to work well for night time pain.
Nortriptyline (Pamelor)
Imipramine (Tofranil)
Side effects include dry mouth, constipation ,urinary retention increased heart rate, increased sweating, blurred vision, orthostatic hypotension.
*Serotonin norepinephrine reuptake inhibitors (SNRIs):
These medications are anti-depressants
Duloxetine (Cymbalta.) FDA approved for diabetic neuropathy in 2004. This is also used to treat fibromyalgia.
Venlofaxine ( Effexor)
* Gabapentinoids :
These medications are anti-convulsants and are most commonly used medications in diabetic peripheral neuropathy.
Gabapentin ( Neurontin) This is one of the most common medications to treat diabetic neuropathy. But is not FDA approved to treat diabetic neuropathy.
Pregabalin or Lyrica has been FDA approved to treat diabetic neuropathy since 2005 and is the preferred treatment for diabetic peripheral neuropathy by the American Academy of Neurology.
Require tritration:
Both of these medications require starting on a low dose with titration to higher doses as tolerated slowly over time.
Side effects:
Side effects are the main reason why these medications fail. Side effects include peripheral edema, dizziness, lethargy, confusion. Some of my patients stated that they feel drunk on these medications. They are to be used with caution in patients with cardiac renal or liver disease.
In my experience, though, lyrica and gabapentin has helped about 80% of my patients.
* Sodium channel blockers:
These are anti -seizure medications and are not commonly used to treat diabetic neuropathy.
Carbamazepine ( Tegretol)
Oxycarbazepine (Trileptal)
Lamotrigine (Lamictal)
There is a newer class of medication that is a dual mechanism partly SNRI partly opioid called NUCYNTA ( Tapentadol) It was FDA approved for diabetic peripheral neuropathy in 2012. I do not have experience with this medication to give my opinion on it. But I can say I have not seen any of my patients on this medication from the medication records that I review. But apparently it is very expensive and that might be the reason why I don't see it on patients’ medications list.
Further recommendations from the American Academy of neurology treatment guidelines:
· opioids are strongly discouraged for chronic non-cancer pain due to weak non-existent long term efficacy and severe long term adverse consequences.
· Use of tramadol ( another pain medication) however is less opioid -like and therefore less risky.
· Consider patient preferences such as topical and nontraditional methods Including cognitive behavioral therapy and mindfulness as well as exercise.
· Assess for adverse effects and cost of medications
· *** a series of medications may be needed to identify the treatment that most benefits the patient.
Ineffective or failure of medication after titrating to demonstrate effective dose and duration which takes approximately 4 to 16 weeks with no significant pain reduction or intolerance or side effects outweigh benefits , failure or partial improvement of one drug within a drug class does not preclude trying another drug in the same drug class or another drug class.
So, this means try to stick to the medication to see if it works for you over a period of at least 12 weeks unless it is intolerable or side-effects outweight benefits and if its not working after this then try a different medication. Take home point : Keep working with your doctor.
Symptom suppression/
Topical medications:
1. Lidoderm/ lidocaine topical patches:
A small randomized double-blind placebo-controlled study showed lidocaine patch 5% was highly effective at treating ongoing pain and allodynia of diverse neuropathy.( Thierry, Kuntzer https://www.sciencedirect.om/author/553032498800)
Another study showed 5% topical lidocaine patch show that three weeks 2/3 of patients had 30% decreased pain improvements in pain interference measures such as depression anger hostility fatigue inertia tension anxiety and total mood disturbance. (Richard L barbano MD PhD, et al archives of neurology 2004; 61(6): 914-918. Doi:10.1001/archneur.61.6.914)
In my experience, I have found lidocaine patches to be extremely helpful in night time neuropathy pain. They are sold over the counter typically for back pain however it can be used for any type of pain. I have my patients cut the patch in half put half of them on the top of the mid foot half on the bottom of the mid foot. They can be left on for 12 hours and have to be removed for 12 hours. Very little downside other than the possibility that it might not help you. It should not be used if there is an allergy to lidocaine or adhesive.
Symptom suppression/ compounded cream:
Compounded cream is produced by a compounding pharmacist who takes medications and compounds it into a topical cream. The medication is absorbed through the skin.
There are not any good scientific studies supporting the efficacy of topical compounded cream in diabetic neuropathy. It is hard to study because multiple medications are used at one time.
One study I found stated that the authors concluded topical compounded cream may be effective due to multiple complementary effects.
WHY I LOVED TREATING my DIABETIC NEUROPATHY PATIENTS with TOPICAL COMPOUNDED CREAM:
About 10 years ago compounding pharmacies exploded onto the scene when insurances started to cover compounded medications. During this time, I used compounded cream with gabapentin and various other medications for diabetic neuropathy. It seemed to help about 90 to 95% of the patients with painful diabetic neuropathy especially when gabapentin was in the compounded cream.
About three to four years into the heyday of compounding pharmacies, insurances stopped covering gabapentin in the compounded creams. It was very expensive to pay for gabapentin in compounded creams out of pocket. So after this point in time, the effectiveness of the compounded cream seemed to decrease markedly in patients with painful neuropathy.
So, this was very upsetting to me because the topical compounded cream with gabapentin had a much less chance of side effects in the patients. Also, patients that could not tolerate oral gabapentin and Lyrica were able to get symptom relief from the topical compounded cream.
Sometimes I would also used CBD oil in the compounded cream. I could not find any studies supporting the use of CBD oil and its effectiveness on diabetic neuropathy. In my experience, it did seem to help some patients but not as much as the gabapentin in the compounded cream.
Symptom suppression: Devices for diabetic peripheral neuropathy
· Spinal cord stimulator
FDA approved for diabetic peripheral neuropathy in a 2022 Medtronic device. Study shows 70% of patients experience pain relief. This requires a minor surgery by a neurosurgeon . This usually this treatment is not on the forefront of physicians’ mind when treating DPN because it is an invasive procedure. However, when medications are not working, I have found that spinal cord stimulators have helped many of my patients. Prior to the spinal cord stimulator becoming FDA approved, it was also very difficult to find a neurosurgeon who could do the procedure. It should be easier now that Medtronic has the FDA approved device.
· Low level laser
This is FDA approved for temporary relief of chronic nocioceptive ( pain) of musculoskeletal pain since 2019. “It reduces inflammation while promoting biostimulation at the cellular level in the muscular point of origin. “ writes Erchonia the manufacturer.
I could only find a small study of 20 patients for 24 weeks showing reduction in neuropathy pain, increased quality of life with deep tissue laser which is increased wavelength penetrating deeper to stimulate and regenerate nerve cells. It could be considered disease modifying but more information and studies are needed to determine if it will help diabetic peripheral neuropathy. But it is interesting and shows promise. Stay tuned!
Because of the lack of scientific validation, be careful of spending large amounts of money for laser treatment for diabetic neuropathy because insurance likely will not cover it at this time.
· Tens unit (transcutaneous electrical stimulation):
low cost and may be helpful
use adjunctively
long term efficacy unclear
3. PREVENTION of COMPLICATIONS / ACTION STEPS:
This requires a team of healthcare providers and is very important
· This involves keeping all maintenance appointments with your podiatrist, family physician and other healthcare providers.
· Daily vigilance of your feet including visual inspection and I recommend applying a moisturizing cream daily to also feel any problems of the feet as well as the moisturizing. DPN affects the sweat glands and can cause dryness of skin or the opposite excessive sweating. My favorite lotions include ceravae, bag blam, gold bond dry skin formula or diabetic formula.
Be sure to be checking between toes and on heels for cracks. Small things like this can turn disastrous and I have seen cracks between toes and heels turn into amputations.
· Seeking care as soon as a problem is detected and is vitally important and prevents loss of toe, limb,and/ or life
· Feel and inspect the inside of your shoes for any folds or holes on the inside that can cause wounds or blisters and if so throw those shoes away.
· Shake shoes out prior to wearing . All kinds of things get into the shoes including shoes, coins, jewlery, paper clips. I pulled a broken off piece of paper clip out of a lady’s foot in the office one day and she had no idea it was there.
· Don’t use a heating pad on feet . Don’t soak in hot water. Don’t put feet in ice .
· Wear socks and at least a rubber soled slipper in the hose and well fitting / appropriate toe box shoes.
Avoid tapered toebox shoes. Bronax and Altra sneakers have an anatomical toebox.
· Work with your physician, physical therapist and health coach for optimal blood sugar control ,an exercise plan, and anti-inflammatory diet that you can adhere to and sustain. Have physical therapist assess for need for any assistive devices to prevent falls.
· Be vigilant concerning local edema and bruising in feet, if there is numbness and have your doctor evaluate this asap. I have seen many patients with numb feet have unknown fractures .
· Discuss with your podiatrist if diabetic shoes are needed.
· Stop smoking . Stop drinking alcohol.
· Discuss with physician about going on the various supplements , topical treatments and oral medications. Supplements unfortunately are not covered by insurance and take at least 6-12 months to know if they are helping you. If I personally had DPN, I would take that chance and start metanx, alpha- lipoic acid and acetyl-l-carnitine. It might be better to start 1 at a time to determine which is helpful to you though.
· Stacking treatments I believe would give the best results: proper anti-inflammatory diet, exercise including resistance training, oral and topical medication. If this is not helpful enough, consider trying the tens unit or laser. Is still having significant pain, discuss with your physician about the spinal cord stimulator.
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