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23: DIABETIC NEUROPATHY

Mollie Venglar, DSc, MSPT, NCS

CONDITION/DISORDER SYNONYMS

  • Diabetic polyneuropathy

  • Metabolic polyneuropathy

ICD-9-CM CODES

  • 250.60 Diabetes mellitus with neurological manifestations type 2 or unspecified type not stated as controlled

  • 357.2 Polyneuropathy in diabetes

ICD-10-CM CODE

  • E13.40 Diabetes, diabetic (mellitus) with neuropathy

PREFERRED PRACTICE PATTERN

  • 5G: Impaired Motor Function and Sensory Integrity Associated with Acute or Chronic Polyneuropathies1

PATIENT PRESENTATION

A 59-year-old man was brought begrudgingly to outpatient physical therapy by his wife. She reports that he has been complaining that his ankle hurts. She also reports noticing that he constantly holds on to the wall, furniture, or other objects whenever he is walking. The man reports having fallen about 2 weeks ago when his toe caught the edge of the sidewalk, and his right ankle has hurt since then. On examination, the right ankle is discolored and demonstrates excessive inversion on passive testing. Grossly, manual muscle testing of the upper and lower extremities is within normal limits. The man does not have two-point discrimination in his feet, ankles, and up to mid-calf bilaterally. Proprioception is impaired in bilateral feet and ankles. Balance testing reveals loss of balance with feet together and eyes closed on a stable surface and with feet together and eyes open on a compliant surface. He is able to maintain single-leg stance on the left for 2 seconds with eyes open. His right ankle is too painful to perform single-leg stance. Past medical history includes: diabetes mellitus, morbid obesity, and coronary artery disease.

KEY FEATURES

Description

  • Damage to peripheral sensory (most common) and/or motor neurons

  • Three major types

    • Distal, primarily sensory, symmetric polyneuropathy (most common)

    • Autonomic neuropathy

    • Transient asymmetric neuropathies

  • Most likely due to demyelination, inflammation, ischemia, or infarction from as yet poorly understood metabolic abnormality

FIGURE 23-1

Diabetic foot and diabetic neuropathy. Data from Physical activity/exercise in diabetes. Diabetes Care. 2004;27(suppl 1):S58–S62.

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Essentials of Diagnosis

  • Distinct clinical syndromes include

    • Distal, symmetrical, primarily sensory polyneuropathy affecting feet and legs in a chronic, slowly progressive manner (most common)

      • Usually unnoticed by patient until fairly progressed

      • Most common complaint is persistent numbness or tingling, worse at night

    • Acute ophthalmoplegia affecting cranial nerve III (oculomotor) and less often cranial nerve VI (abducens) on one side

    • Acute mononeuropathy of limbs or trunk, including painful thoracolumbar radiculopathy

    • Acute or subacute painful, asymmetrical, predominantly motor multiple neuropathy affecting upper lumbar roots and proximal leg muscles (diabetic amyotrophy)

    • Symmetrical, proximal motor weakness and wasting, usually without pain, with variable sensory loss, pursing subacute or chronic course

    • Autonomic neuropathy involving bowel, bladder, sweating, circulatory reflexes

General Considerations

  • Sensory loss puts patient at risk ...

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