TUTORIAL KLINIK

Mononeuropathy one nerve Mononeuritis multiplex Radiculopathy nerve root Plexopathy brachial or lumbosacral plexus Cranial neuropathy Bells Palsy, 3rd nerve palsy Distal symmetric peripheral neuropathy (DSPN)

Small fiber versus large fiber Sensory only Motor only Sensorimotor

Numbness, or a feeling of walking on cotton wool or wearing a thick sock 2. Pains that can be dull, constant and boring in type, or more spontaneous sharp, shooting, or stabbing in nature; a sensation as if walking on pebbles 3. Tingling, pins and needles 4. Hot or cold sensations (e.g., burning feet; like walking on hot sand 5. Allodynia (pain caused by an otherwise nonpainful stimulus, such as light touch or stroking); this can be very troublesome at night when the feet and legs rub against the bedclothes 6. Cramps in the calves and foot muscles.
1.

Sensory symptoms
Gains and/or Losses

Motor symptoms
Gains (cramps) and/or Losses (distal predominant)

Autonomic symptoms

Orthostasis Impotence Anhidrosis Vascular instability in feet

Painful feet Arthritis, including gout Mortons Neuroma Tarsal tunnel syndrome Arterial insufficiency Tingling in the legs Venous stasis/peripheral edema Restless leg syndrome idiopathic Numbness/Weakness Radiculopathy CNS dysfunction (i.e. spinal cord pathology or stroke)

Diabetes and Pre-Diabetes Alcohol neuropathy Chemotherapy Platinum-based Paraproteinemia Vasculitis and Connective Tissue Diseases Heavy metals and other toxins HIV Amyloidosis Porphyria

Closely associated with sensorimotor neuropathy Signs are common if looked for (40% subjects have abnormal CVS tests) but symptoms are rare (<1%) Affects the response to hypos but not awareness If symptoms: mortality=30-50% over 10 years

Annual review Enquire annually for: Painful neuropathy Loss of sensation Erectile impotence Note duration of DM, treatment, complications & weight Ask about other manifestations of autonomic neuropathy if: Other complications are present Anaesthesia is contemplated Blood glucose control is erratic

Tricyclic antidepressants Anticonvulsants (gabapentin, lamotrigine) Vitamin E Glutamine Topical treatment

Nortriptyline Modest benefit, small study, lack of effectiveness Amitriptyline - Failed to improve sensory symptoms, but QOL improved Gabapentin, duloxetine and pregabalin - Studies failed to demonstrate benefit Lamotrigine not effective Glutamine Up-regulate nerve growth factor, decrease PN in a few previous trials Alpha-Lipoic- Acid Diabetic PN, may interfere w/ Bortezomib

Acupuncture limited data on PN No data in PN on

Physical activity/exercise TENS (transcutaneous external nerve

stimulation) Meditation/bio-feedback Pulsed infrared light therapy or anodyne therapy

Postural hypotension Fludrocortisone NSAIDs Compression stockings Elevate the head of the bed Bladder Manual SP pressure ISC ? Anticholinesterase Cyclical antibiotics if recurrent infections Sweating ?clonidine Erectile dysfunction

Gastroparesis Improve glycaemic control Prokinetic drugs

Metoclopramide, domperidone, cisapride, erythromycin (250

mg tds)

Octreotide? If severeadmit for IV fluids, IV drugs NG tube IV/jejunal feeding Diarrhoea Codeine/loperamide/diphenoxylate Clonidine or octreotide Treat bacterial overgrowth (oxytet/erythromycin) if suspected/present