Neuropathy (ner - AH - puh - thee) is an abnormality of the nervous system. Diabetic neuropathy is nerve damage caused by diabetes. Peripheral refers to the edge of something, as opposed to it's center. In the case of the human body, and particularly in the case of diabetic neuropathy, this term is referring to the hands and the feet. Diabetic peripheral neuropathy is described as a loss of sensation that starts in the tips of the toes and gradually works its way up the legs. It is sometimes referred to as a stocking glove neuropathy because it progresses as if one was pulling a stocking up the leg.

Almost twenty-one million Americans have diabetes. About sixty to seventy percent of diabetics have some type of nerve damage and about 30% of diabetics over forty years of age have diabetic peripheral neuropathy (CDC, 2005). Five percent of diabetics will experience painful diabetic neuropathy and the incidence increases with age. Over 45% of individuals who have had diabetes for over twenty five years will experience some symptoms of painful diabetic neuropathy.

Symptoms
There are three types of nerves affected in diabetic peripheral neuropathy, sensory, motor and autonomic. Sensory nerves allow people to feel sensation, like pain, hot or cold or touch. Motor nerves control the muscles and allow movement. Autonomic nerves control bodily functions without our awareness or control. In the feet, an autonomic nervous response would be sweating. Neuropathy can affect all of these nerve group types, but sensory nerves are typically the first and most often affected.

Burning, numbness, tingling, hot and cold sensations, leg discomfort, shooting and electrical pain are all sensory neuropathy sensations. A diabetic may feel one or all of the these symptoms. Muscle weakness, loss of balance and changes in foot shape are due to motor neuropathy. These changes are typically seen in a more advanced stage of diabetic neuropathy. Dry feet and cracked skin are typical in all diabetics, but particularly those with diabetic neuropathy. These symptoms are associated with autonomic neuropathy.

The exact cause of diabetic neuropathy is not clearly understood. Many theories exist, but the general school of thought is that high blood sugar causes chemical changes in the nerves and also has the potential to damage blood vessels carrying oxygen and nutrients to the nerves, impairing nerve function. A theory gaining in popularity is that diabetics are susceptible to nerve compression. The increased susceptibility is thought to be due to swelling of the nerves from the increased sugar and it's conversion within the nerve. This increase in volume causes pressure on the nerves from the surrounding tissues and ligaments, resulting in a loss of function.

Complications
There is a long list of complications associated with diabetic neuropathy. As mentioned above, between 5% and 45% of diabetics will develop pain. Most diabetics with neuropathy will experience the exact opposite, numbness. This loss of sensation will result in painless injuries to the feet, which can go unnoticed. Small blisters, cuts and scrapes can turn into infections or lead to ulcerations when they are left untreated. An ulceration is a slow healing open sore on the foot. Over 2 million diabetics have ulcerations and one in four diabetics with an ulcer will have an amputation. These can be frightening statistics. Preventing diabetic ulcerations is of the utmost importance.

Treatments
Currently, there are no treatments to reverse diabetic neuropathy and there are no treatments that will eliminate the numbness. There are, however, many treatments which will decrease the symptoms associated with diabetic neuropathy, especially painful diabetic neuropathy.

The mainstay of medical treatment for diabetic peripheral neuropathy is to manage the symptoms with medications. For those individuals with painful diabetic neuropathy, prescription medications may be needed to manage the pain. Medications used for treatment include amitriptyline, desipramine and nortriptyline. These have been used to help decrease pain and help with sleep. Fluoxetine, paroxetine, sertralene and citalopram tend to be tolerated better, but are also tend to be less effective at relieving pain.

In September of 2004 the FDA approved duloxetine, known as Cymbalta. This was the first drug approved for specifically treating painful diabetic neuropathy. Gabapentin, also known as Neurontin, has been a successful treatment for painful diabetic neuropathy. Originally approved as an anti-seizure drug, gabapentin became a popular treatment for painful diabetic neuropathy. There was a controversy surrounding this medication when the manufacturer started marketing this medication for treatment in painful diabetic neuropathy, which is an off-label use. Many physicians still use this drug as a treatment. A newer medication has emerged called pregabalin, also known as Lyrica. Pregabalin was FDA approved to treat pain caused by nerve damage and many feel pregabalin is superior in effectiveness and has fewer side effects than Neurontin. Tegretol and Dilantin, common seizure medications, can be used in more severe cases.

Anodyne infrared therapy uses light energy to increase the circulation to the lower extremities. Diodes are fit into flexible pads which can be applied directly to the skin on multiple areas of the feet. The theory is that light energy helps to increase blood flow, which thereby restores function to injured nerves. Initially released in 1994, Anodyne was met with mixed reviews, but has gained in popularity in more recent years. Some studies have shown great results with reduction in pain and relief of overall symptoms of neuropathy. Anodyne has also been used for treatment of diabetic ulcers, with some great results.

Nerve decompression has been increasing in popularity in recent years as a treatment for diabetic peripheral neuropathy. This surgical treatment was initially not met with much enthusiasm. Earlier studies showed poor surgical results and many surgeons were hesitant to perform elective surgery on diabetics. A new surgical approach has been introduced and surgical success rates have improved dramatically. The theory that diabetics are more susceptible to nerve compression, may warrant decompression of those nerves to give relief of the symptoms associated with diabetic neuropathy.

Natural Alternatives
There are many natural alternative treatment options for diabetic neuropathy. Many diabetics have had success with their use, but studies have not given consistent results showing their effectiveness. For painful diabetic neuropathy, red pepper powder can help decrease the pain experienced at night. Capsaicin is the active ingredient in chile peppers. When applied to the feet it acts as a counter-irritant and can help decrease neuropathic pain. Capsaicin can be purchased at your local drug store. If you cannot afford capsaicin, try mixing 1 tablespoon of dry chile powder with 2 tablespoons of baby powder. Place the mixture in a sock and use the socks at night. Some diabetics experience an increase in pain with this treatment, so make sure you start with a small amount.

Alpha lipoic acid is an effective anti-oxidant that has been shown to relieve pain associated with neuropathy in some studies. To help relieve pain, the dose must be at least 600mg a day. It is advisable to start with a lower dose, as higher doses can cause nausea, stomach upset, fatigue, insomnia and can lower blood sugar. In general, ALA is a safe supplement. Gamma linolenic acid is an essential fatty acid, typically sold in the form of evening primrose oil. Most of the studies have shown modest results, but the possibilities are still encouraging. Take 360mg/day. Many indications require higher dosages, but side effects of long term use at higher doses may include inflammation, thrombosis (blood clots), or decreased immune system functioning. It is important to note that just because supplements are labeled "natural" it doesn't always make them safe. Always talk with your physician before use.

Prevention
As with all diabetic complications, prevention is the best treatment. Keeping the blood sugar levels within a normal range is the most important tool in treating and preventing peripheral neuropathy. Even with tight control, most diabetics will still develop some level of neuropathy. Considering the severity of the complications associated with neuropathy (ulcers and amputations), the importance of blood sugar control cannot be understated.

Treating painful diabetic peripheral neuropathy is very difficult and many of the above mentioned therapies should be tried and combined. All medications have side effects and surgical procedures can have complications. Don't expect any "cures" and make sure you give each therapy a chance to work. It is recommended to talk with your physician or podiatrist to discuss these treatment options.