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Diabetic Neuropathy pathophysiology


Practice Essentials
Diabetic neuropathy is the most common complication of diabetes mellitus (DM), affecting as many as 50% of patients with type 1 and type 2 DM. Diabetic peripheral neuropathy involves the presence of symptoms or signs of peripheral nerve dysfunction in people with diabetes after other possible causes have been excluded.
Signs and symptoms

In type 1 DM, distal polyneuropathy typically becomes symptomatic after many years of chronic prolonged hyperglycemia, whereas in type 2, it may be apparent after only a few years of known poor glycemic control or even at diagnosis. Symptoms include the following:
Sensory – Negative or positive, diffuse or focal; usually insidious in onset and showing a stocking-and-glove distribution in the distal extremities
Motor – Distal, proximal, or more focal weakness, sometimes occurring along with sensory neuropathy (sensorimotor neuropathy)
Autonomic – Neuropathy that may involve the cardiovascular, gastrointestinal, and genitourinary systems and the sweat glands
Physical examination should include the following assessments:
Peripheral neuropathy testing – Gross light touch and pinprick sensation; vibratory sense; deep tendon reflexes; strength testing and muscle atrophy; dorsal pedal and posterior tibial pulses; skin assessment; Tinel testing; cranial nerve testing
Autonomic neuropathy testing – Objective evaluation of cardiovagal, adrenergic, and sudomotor function in a specialized autonomic laboratory; may be preceded by bedside screening to assess supine and upright blood pressure and heart rate, with measurement of sinus arrhythmia ratio
Two classification systems for diabetic neuropathy are the Thomas system and the symmetrical-versus-asymmetrical system. The Thomas system (modified) is as follows:
Hyperglycemic neuropathy
Generalized symmetrical polyneuropathies
Sensory neuropathy
Sensorimotor neuropathy
Autonomic neuropathy
Focal and multifocal neuropathies
Superimposed chronic inflammatory demyelinating polyneuropathy
Distal symmetrical sensorimotor polyneuropathy is commonly defined according to the following 3 key criteria:
The patient must have diabetes mellitus consistent with a widely accepted definition
Severity of polyneuropathy should be commensurate with duration and severity of diabetes
Other causes of sensorimotor polyneuropathy must be excluded
Pure autonomic diabetic neuropathy is rare.
Asymmetrical neuropathies include the following:
Median neuropathy of the wrist (carpal tunnel syndrome)
Other single or multiple limb mononeuropathies
Thoracic radiculoneuropathy
Lumbosacral radiculoplexus neuropathy
Cervical radiculoplexus neuropathy


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