Diabetic Neuropathy

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Diabetic Neuropathy

Topic Overview

What is diabetic neuropathy?

Neuropathy means nerve disease or damage. Diabetic neuropathy is nerve damage caused by diabetes. People with diabetes often have high blood sugar levels. Over time, high blood sugar levels can damage nerves throughout your body.

There are three kinds of diabetic neuropathy.

  1. Peripheral neuropathy is damage to peripheral nerves. These are the nerves that sense pain, touch, hot, and cold. They also affect movement and muscle strength. The nerves in the feet and lower legs are most often affected. This type of nerve damage can lead to serious foot problems. The damage usually gets worse slowly, over months or years.
  2. Autonomic neuropathy is damage to autonomic nerves. These nerves control things like your heartbeat, blood pressure, sweating, digestion, urination, and sexual function.
  3. Focal neuropathy affects just one nerve, usually in the wrist, thigh, or foot. It may also affect the nerves of your back and chest and those that control your eye muscles. This type of nerve damage usually happens suddenly.

What causes diabetic neuropathy?

Over time, high blood sugar levels from diabetes can damage nerves throughout your body. The higher your blood sugar levels, the more likely you are to have nerve damage. So controlling your blood sugar throughout your life is very important.

The older you get, and the longer you have diabetes, the more likely you are to have nerve damage. People with diabetes who drink too much alcohol are also more likely to have nerve damage.

About half of all people who have diabetes end up getting diabetic neuropathy.2

What are the symptoms?

Your symptoms will depend on which nerves are injured. You may not be able to feel pain, especially in your feet. This can lead to serious infections, because sores or other problems may not get treated.

When other parts of your body are affected, symptoms may include:

  • Problems with digestion, such as bloating, belching, constipation, nausea and vomiting, diarrhea, and belly pain.
  • Problems with body temperature, such as heavy sweating at night or when you eat certain foods. Some people may have reduced sweating, especially in their feet and legs.
  • Problems with urination, such as finding it hard to tell when your bladder is full or finding it hard to empty your bladder completely.
  • Sexual problems, such as erection problems in men and vaginal dryness in women.
  • Heart and blood vessel problems, leading to poor circulation or low blood pressure. This may cause dizziness, weakness, or fainting when you stand or sit up from a reclining position.
  • Trouble sensing when your blood sugar is low.

How is diabetic neuropathy diagnosed?

Your doctor will check how well you feel light touch and temperature and will test your strength and your reflexes. Tests such as electromyogram and nerve conduction studies may be done to confirm the diagnosis. You may need other tests to see which type of neuropathy you have and to help guide your treatment.

Doctors can't test for all types of nerve damage. So it’s important to tell your doctor about any pain or weakness you feel. Also mention heavy sweating or dizziness and any changes in digestion, urination, and sexual function.

How is it treated?

Treatment involves keeping blood sugar levels in a target range. This will not cure the nerve damage, but it can help keep the damage from getting worse.

The type of treatment depends on your symptoms:

  • Pain may be treated with medicines.
  • Digestive system problems or blood vessel problems may be treated with medicines.
  • Blood pressure problems may be treated with medicines and by wearing support stockings (also called compression stockings).
  • Sexual problems may be helped with medicines or devices to improve erections or with lubricating creams that help vaginal dryness.
  • A splint or brace may be used for a pinched nerve.

It is common in diabetes to lose some feeling in your feet. You could have a sore or other foot problem without noticing it. Check your feet every day. An untreated problem on your foot can lead to a serious infection or even amputation.

Be clear with your doctor about what is helping you feel better and what is not. You and your doctor can work together to find the treatment that helps you the most.

Can diabetic neuropathy be prevented?

Keeping your blood sugar levels in a target range may help prevent neuropathy from ever developing. The best way to do this is by getting to and staying at a healthy weight by exercising and eating healthy foods.

Frequently Asked Questions

Learning about diabetic neuropathy:

Being diagnosed:

Getting treatment:

Living with diabetic neuropathy:

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  Diabetes: Taking care of your feet

Symptoms

Diabetic neuropathy—especially peripheral neuropathy—initially may not cause any noticeable symptoms. If you have diabetes, it is important to have regular medical checkups to check for signs of neuropathy and treat problems before they become serious.

Symptoms of diabetic neuropathy may vary depending on the type of neuropathy you have.

Symptoms of peripheral neuropathy

Peripheral neuropathy tends to develop slowly over months or years. In general, symptoms may include:

  • Tingling, numbness, tightness, or burning, shooting, or stabbing pain in the feet, hands, or other parts of the body. Bone and joint deformities can develop, especially of the feet (such as Charcot foot). See a picture of Charcot foot.
  • Reduced feeling or numbness, most often in the feet. Check your feet every day for skin problems (chapped, broken skin or excessive dryness) or minor injuries (blisters, calluses, or ingrown toenails). People who have had diabetes 10 or more years, who have poor blood sugar control, or who have blood vessel, kidney, or eye complications are at increased risk for foot and leg sores and possible amputation.
  • Greatly reduced or greatly increased sensitivity to light touch or temperature.
  • Weakness and loss of balance and coordination.

Symptoms of autonomic neuropathy

Autonomic neuropathy may affect digestion, the body's ability to regulate temperature, urination, sexual function, and heart and blood vessel function, including blood pressure. Symptoms may get worse during pregnancy. In general, symptoms may include:

  • Frequent bloating, belching, constipation, heartburn, nausea and vomiting, diarrhea, and abdominal pain. These symptoms may indicate gastroparesis, a condition that causes the stomach to empty much slower than normal.
  • Profuse sweating of the torso, face, or neck at night or while eating certain foods, such as spicy foods and cheese. Alternatively, some people may have reduced sweating, especially in their feet and legs.
  • Difficulty sensing when the bladder is full or difficulty emptying the bladder completely.
  • Sexual problems, such as erection problems in men and vaginal dryness in women.
  • Dizziness, weakness, or fainting when you stand or sit up from a reclining position (orthostatic hypotension).
  • Difficulty knowing when your blood sugar is low (hypoglycemia unawareness).

Symptoms of focal neuropathy

Symptoms of focal neuropathy usually appear suddenly. They may include:

  • Pain, weakness, and motor problems in a single area of the body, such as a wrist, thigh, or foot. In cases of a compressed or pinched nerve, soreness and pain may develop more gradually over several weeks or months.
  • Pain in and around one of your eyes, difficulty moving the eyes, and double vision. Focal neuropathy may sometimes affect the nerves that control your eye muscles.

Symptoms of focal neuropathy usually get better over time. But focal neuropathy may be permanent.

Examinations and Tests

A diagnosis of diabetic neuropathy is based largely on your symptoms, medical history, and neurologic examination. During a neurologic examination, your doctor will check how well you feel light touch, temperature, pain, and movement. Your doctor will also check your strength and reflexes. Electromyogram (EMG) and nerve conduction studies may be done to confirm a diagnosis. These tests measure how well and how quickly the nerves and muscles conduct electrical impulses. When nerve damage is present, the speed of nerve function slows.

Problems associated with autonomic neuropathy—which affects the nerves that control internal functions—can be difficult to diagnose. When new symptoms develop, further testing may be needed to diagnose the problem, identify the cause, and guide treatment. For example, a study that measures how fast your stomach empties may be done if symptoms like bloating, indigestion, or vomiting suggest gastroparesis, a condition that causes the stomach to take too long to empty.

Nerve problems in people with diabetes may be caused by other conditions, such as kidney disease, alcohol dependence, or a vitamin B12 deficiency. A variety of laboratory tests (such as a complete blood count) may be used to screen for conditions other than diabetes that could be causing symptoms. Your symptoms and medical history will determine which tests are needed.

Early Detection

For some diseases, doctors can use screening tests to look for problems before you have any symptoms. But doctors cannot test for all types of autonomic or focal neuropathy. So it is important to report to your doctor any pain, weakness, or motor problems you have. Also mention any changes in digestion, urination, sexual function, sweating, or dizziness. Your doctor will also look for signs of autonomic neuropathy during your physical examinations.

Screening for peripheral neuropathy can help prevent foot ulcers and amputation. The Canadian Diabetes Association (CDA) recommends that people who have diabetes see a doctor to examine their feet at least once a year.5 This examination can detect a loss of sensation in your feet, which can lead to more serious foot problems.

Treatment Overview

Good control of diabetes over time is the key to treating diabetic neuropathy. There is no cure for neuropathy, but keeping your blood sugar within a target range can reduce symptoms and prevent them from getting worse.

To help control your diabetes, eat food that is good for you and exercise. Controlling diabetes means maintaining blood sugar levels (A1c) within the target range. This will do more than anything else to help prevent diabetic neuropathy from getting worse.

For more information on good diabetes control, see the topics Type 1 Diabetes: Living With the Disease or Type 2 Diabetes: Living With the Disease.

Initial treatment

Treatment for diabetic neuropathy depends on your symptoms and the type of neuropathy that you have. In general, treatment focuses on reducing current symptoms and preventing the condition from getting worse by keeping your blood sugar level (A1c) within a narrow target range. You can keep your blood sugar levels within the target range by taking your insulin or oral diabetes medicine as prescribed, checking your blood sugar levels, following your diet for diabetes, exercising, and seeing your doctor regularly. For more information, see the topics Type 1 Diabetes: Living With the Disease or Type 2 Diabetes: Living With the Disease.

Also, it is important to properly care for your feet when you have diabetic neuropathy. Diabetic neuropathy may cause a loss of feeling in your feet. It is possible for a sore or other foot problem to go unnoticed. Without proper foot care, an untreated foot sore can lead to a serious infection or possibly amputation. For more information, see:

Click here to view an Actionset. Diabetes: Taking Care of Your Feet.

It is also wise to maintain healthy habits such as seeing your doctor regularly, controlling your blood pressure, eating a balanced diet, exercising regularly, not smoking, and limiting or avoiding alcohol. Additional treatment depends on the specific type of diabetic neuropathy that you have along with your current symptoms.

Many people with peripheral neuropathy have mild to severe pain in specific parts of their bodies. Talk with your doctor about treatment that can reduce your pain and improve your physical functioning, mood, and mental well-being. These treatments may include:

  • Medicines such as pain relievers or creams to relieve pain. Prescription medicines often used to reduce pain from diabetic neuropathy may include medicines that are more commonly used to treat depression, such as tricyclic antidepressants and the antidepressant duloxetine hydrochloride, and medicines that control seizures, such as pregabalin and gabapentin. These medicines may be tried to reduce your pain even though you do not have depression or seizures.
  • Complementary therapies such as acupuncture. Acupuncture has not been well studied as a treatment for diabetic neuropathy. But some studies show that it may help with pain.4
  • Physiotherapy such as exercises, stretching, and massage. If you are told to use heat or ice, be careful. Neuropathy can make it hard for you to feel changes in temperature.
  • Transcutaneous electrical nerve stimulation (TENS), which is a type of therapy that reduces pain by applying brief pulses of electricity to nerve endings in the skin.1

Autonomic neuropathy—which affects nerves that regulate internal functions—can affect digestion, urination, sweating, sexual function, blood pressure, and other involuntary body functions. Some symptoms of autonomic neuropathy can be hard to manage, but others respond well to treatment:

  • Mild constipation. Eating small, frequent meals that are high in fibre and low in fat may help.
  • Frequent diarrhea. Eating foods that are high in fibre may help. You may need medicines that slow the rate at which digested food and waste travel through the intestines, or you may need antibiotics such as tetracycline, amoxicillin, or metronidazole.
  • Mild gastroparesis. This is a condition that causes the stomach to empty very slowly. It may get better if you eat small, frequent meals that are low in fibre and fat. Medicines that help the stomach empty more quickly may also be needed. Controlling blood sugar levels may reduce symptoms of gastroparesis.
  • Abnormal sweating. If you sweat a lot, try to avoid intense heat and humidity. If you sweat severely while eating certain foods, anticholinergic medicines may help. But these medicines have side effects that may sometimes be more troublesome than the abnormal sweating. Botulinum toxin (Botox) injections may also help.3 If you don't sweat enough, you can use moisturizers to help with dry or cracked skin. Drinking more water can prevent overheating. Try to avoid places that are very hot or very cold.
  • Lack of awareness of low blood sugar level. This is also called hypoglycemia unawareness. You can adjust your insulin and allow your blood sugar levels to be a little bit higher than the target range. Usually it is recommended that you keep your A1c in a target range.
  • Urinary problems. Urinary problems can be treated with antibiotics for urinary tract infections and medicines to improve bladder control.
  • Sexual problems. Your doctor may suggest using medicines or devices to improve erections. Or you may need non-prescription lubricants and estrogen creams for vaginal dryness. For more information, see sexual problems.
  • Blood pressure problems. Blood pressure problems can be treated with medicines and by wearing support stockings (also called compression stockings).

Ongoing treatment

Ongoing treatment for diabetic neuropathy includes making sure your blood sugar levels stay tightly controlled within a narrow target range. You also need to practice wise health habits such as seeing your doctor regularly, controlling your blood pressure, getting regular exercise, limiting or avoiding alcohol, and not smoking. Also, take good care of your feet so that foot sores and other foot problems do not develop. For more information, see:

Click here to view an Actionset. Diabetes: Taking Care of Your Feet.

Other treatment is tailored to your specific symptoms and the type of diabetic neuropathy that you have.

Many people who have peripheral neuropathy—which affects nerves that supply sensation and touch—have mild to severe pain in specific parts of their bodies. Treatment can reduce pain and improve physical functioning, mood, and mental well-being and may include:

  • Medicines such as non-prescription pain relievers or creams to relieve pain. The most common medicines used to treat symptoms of diabetic neuropathy include anticonvulsant drugs such as pregabalin and gabapentin, tricyclic antidepressants, and the antidepressant duloxetine hydrochloride.
  • Complementary therapies such as acupuncture. Acupuncture has not been well studied as a treatment for diabetic neuropathy. But some studies show that it may help with pain.
  • Physiotherapy such as exercises, stretching, and massage. If you are told to use heat or ice, be careful. Neuropathy makes it hard for you to feel changes in temperature.
  • Transcutaneous electrical nerve stimulation (TENS), which is a type of therapy that reduces pain by applying brief pulses of electricity to nerve endings in the skin.

Autonomic neuropathy—which affects nerves that regulate internal functions—can cause problems with digestion, urination, sweating, sexual function, blood pressure, and other involuntary body functions. Some symptoms of autonomic neuropathy can be hard to manage, but others respond well to treatment:

  • Mild constipation. Eating small, frequent meals that are high in fibre and low in fat may help.
  • Frequent diarrhea. Eating foods that are high in fibre may help. You may need medicines that slow the rate at which digested food and waste travel through the intestines, or you may need antibiotics such as tetracycline, amoxicillin, or metronidazole.
  • Mild gastroparesis. This is a condition that causes the stomach to empty very slowly. It may get better if you eat small, frequent meals that are low in fibre and fat. Medicines that help the stomach empty more quickly may also be needed. Controlling blood sugar levels may reduce symptoms of gastroparesis.6
  • Abnormal sweating. If you sweat a lot, try to avoid intense heat and humidity. If you sweat severely while eating certain foods, anticholinergic medicines may help. But these medicines have side effects that may sometimes be more troublesome than the abnormal sweating. Botulinum toxin (Botox) injections may also help.3 If you don't sweat enough, you can use moisturizers to help with dry or cracked skin. Drinking more water can prevent overheating. Try to avoid places that are very hot or very cold.
  • Lack of awareness of low blood sugar level. This is also called hypoglycemia unawareness. You can adjust your insulin and allow your blood sugar levels to be a little bit higher than the target range. Usually it is recommended that you keep your A1c in a target range.
  • Urinary problems. Urinary problems can be treated with antibiotics for urinary tract infections and medicines to improve bladder control.
  • Sexual problems. Your doctor may suggest using medicines or devices to improve erections. Or you may need non-prescription lubricants and estrogen creams for vaginal dryness. For more information, see sexual problems.
  • Blood pressure problems. Blood pressure problems can be treated with medicines and by wearing support stockings (also called compression stockings).

Treatment if the condition gets worse

If diabetic neuropathy gets worse, you may have serious problems such as severe gastroparesis, bladder infections, or foot problems. In addition to striving for tightly controlled, target range A1c levels and taking good care of your feet, you may need further treatment if diabetic neuropathy progresses.

Diabetic neuropathy is a major risk factor for foot infections or foot ulcers leading to amputation.7 It is possible to have permanent disfigurement in one or both of your feet (such as Charcot foot) from diabetic neuropathy. Surgery is sometimes needed to correct deformed joints that can result from Charcot foot. See a picture of Charcot foot.

Severe gastroparesis may require other treatment, such as medicines that empty the stomach more quickly or a feeding tube that is inserted into the stomach.6

Severe bladder infections or other bladder problems, such as loss of control, may require further diagnostic testing and treatments such as medicines or surgery to improve bladder function.

Also, it is common to experience symptoms of depression with any chronic disease, such as diabetes or diabetic neuropathy. Seeking help for depression may improve your overall well-being and aid in the treatment of your condition.

What To Think About

No matter what you or your doctor try, you may not be pain-free. Be clear with your doctor about what is helping and what is not. You and your doctor can work together to find the right combination of medicine and other treatments to help you the most.

Home Treatment

In addition to having regular medical checkups, the best way to avoid the progression of diabetic neuropathy is to control your blood sugar, take good care of your feet, and practice wise health habits.

Control your blood sugar level

The single most important step you can take to prevent the development and progression of diabetic neuropathy is to keep your blood sugar level (A1c) consistently within a tightly controlled and narrow target range.

Keeping your blood sugar level within the target range also helps decrease your chances of getting other complications from diabetes, such as eye disease and kidney problems. For more information, see the topic Type 1 Diabetes: Living With the Disease or Type 2 Diabetes: Living With the Disease.

Take care of your feet

Diabetic neuropathy affects the feet more often than any other part of the body. Diabetes interferes with your body's ability to fight infection, so that even a minor foot injury such as a blister, a scratch, or athlete's foot can lead to serious infections or amputation. But serious foot problems are the most preventable complications of diabetes.

Because the nerve damage caused by diabetic neuropathy may make you less likely to notice minor problems with your feet, it is wise to inspect your feet every day. Protect them from injury by wearing properly fitted shoes and socks at all times. Woolen socks are the softest and can help prevent minor injuries. If vision problems from diabetic retinopathy or another eye disease make it hard for you to examine your feet, have someone help you.

For more information, see:

Click here to view an Actionset. Diabetes: Taking Care of Your Feet.

If you have severe numbness, a history of skin sores, or bone and joint deformities (such as Charcot foot), you may benefit from custom-fitted shoes. Some provincial and private health insurance plans will pay for these shoes if they are needed.

Practice wise health habits

Many doctors believe that you can further reduce your risk of getting severe neuropathy if you:

  • See your doctor regularly. Your doctor will be able to note any changes in your health more easily when you plan regular visits. It will be easier for you and your doctor to find problems early and to take care of them right away.
  • Exercise regularly and stay at a healthy weight. Exercise and weight control can help your body use insulin better. This helps keep your blood sugar level within a tightly controlled and narrow target range, which may help prevent the development and progression of nerve damage. Talk to your doctor and have a thorough examination of your feet before starting an exercise program. Foot problems, blood pressure problems, or certain other problems linked to neuropathy may raise unique concerns about exercising safely, such as whether you should avoid repetitive, weight-bearing exercises.
  • Limit your alcohol intake. Having four or more drinks a week may make neuropathy and its symptoms worse.
  • Eat a balanced diet. Consider taking a daily multivitamin to ensure that you are meeting your nutritional needs. A balanced diet can also help you maintain a healthy weight. If you have gastroparesis, eat several small meals a day instead of three regular meals.

Other Places To Get Help

Organizations

Canadian Diabetes Association
National Life Building
1400-522 University Avenue
Toronto, ON  M5G 2R5
Phone: (416) 363-0177
1-800-BANTING (1-800-226-8464)
Fax: (416) 408-7117
Email: info@diabetes.ca
Web Address: http://www.diabetes.ca
 

The Canadian Diabetes Association (CDA) is devoted to meeting the needs of people with diabetes in Canada. This organization provides general information about diabetes and its care. It organizes summer camps for young people with diabetes and conducts educational seminars to help people manage their diabetes. The CDA also sells a range of products, including cookbooks, in its stores.


Canadian Neuropathy Association
P.O. Box 64
Pefferlaw, ON  L0E 1N0
Phone: 1-800-669-4918
Web Address: www.canadianneuropathyassociation.org
 

The Canadian Neuropathy Association promotes the understanding of neuropathy by providing information, resources, a newsletter, and other services to the public.


National Aboriginal Diabetes Association (NADA)
B1-90 Garry Street
Winnipeg, MB  R3C 4J4
Phone: (204) 927-1220
1-877-232-6232 toll-free
Fax: (204) 927-1222
Email: diabetes@nada.ca
Web Address: www.nada.ca
 

The mission of the National Aboriginal Diabetes Association (NADA) is to address diabetes among Aboriginal peoples as a priority health issue. It supports individuals, families, and communities to access resources for diabetes prevention, education, and research in culturally respectful ways; partners with organizations committed to the prevention and management of diabetes; and promotes community wellness as a strategy to prevent diabetes.


References

Citations

  1. Dubinsky RM, et al. (2010). Assessment: Efficacy of transcutaneous electric nerve stimulation in the treatment of pain in neurologic disorders (an evidence-based review): Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology, 74(1): 173–176.
  2. Ropper AH, Samuels MA (2009). Diseases of the peripheral nerves. In Adams and Victor's Principles of Neurology, 9th ed., pp. 1277–1319. New York: McGraw-Hill.
  3. Brownlee M, et al. (2008). Complications of diabetes mellitus. In PR Larsen et al., eds., Williams Textbook of Endocrinology, 11th ed., pp. 1417–1498. Philadelphia: Saunders Elsevier.
  4. Boulton AJM, et al. (2004). Diabetic somatic neuropathies. Diabetes Care, 27(6): 1458–1486.
  5. Canadian Diabetes Association (2008). Clinical practice guidelines for the prevention and management of diabetes in Canada. Available online: http://www.diabetes.ca/for-professionals/resources/2008-cpg.
  6. Vinik AI, et al. (2003). Diabetic autonomic neuropathy. In D Porte Jr et al., eds. Ellenberg and Rifkin's Diabetes Mellitus, 6th ed., chap. 46, pp. 789–804. New York: McGraw-Hill.
  7. Jeffcoate WJ, Harding KG (2003). Diabetic foot ulcers. The Lancet, 361: 1545–1551.

Other Works Consulted

  • American Diabetes Association (2004). Physical activity/exercise and diabetes. Clinical Practice Recommendations 2004. Diabetes Care, 27(Suppl 1): S58–S62.
  • American Diabetes Association (2005). Diabetic neuropathies. Position statement. Diabetes Care, 28(4): 956–962.
  • Brannagan TH (2010). Acquired neuropathies. In LP Rowland, TA Pedley, eds., Merritt's Neurology, 12th ed., chap. 134, pp. 832–833. Philadelphia: Lippincott Williams and Wilkins.
  • Brownlee M, et al. (2008). Complications of diabetes mellitus. In PR Larsen et al., eds., Williams Textbook of Endocrinology, 11th ed., pp. 1417–1498. Philadelphia: Saunders Elsevier.
  • Frykberg RG, et al. (2006). Diabetic foot disorders: A clinical practice guideline. Journal of Foot and Ankle Surgery, 45(Suppl 5): S1–S66. Also available online: http://www.acfas.org/pubresearch/cpg/diabetic-cpg.htm.
  • Ganchi PA, Eriksson E (2005). Diabetes mellitus and wound healing. In CR Kahn et al., eds., Joslin's Diabetes Mellitus, 14th ed., pp. 1133–1144. Boston: Joslin Diabetes Center.
  • Hunt D (2009). Diabetes: Foot ulcers and amputations, search date November 2007. Online version of BMJ Clinical Evidence: http://www.clinicalevidence.com.
  • Masharani U, German MS (2007). Diabetic ketoacidosis section of Pancreatic hormones and diabetes mellitus. In DG Gardner et al., eds., Greenspan's Basic and Clinical Endocrinology, 8th ed., pp. 716–746. New York: McGraw-Hill.
  • Molitch ME, Genuth S (2006). Complications of diabetes mellitus. In DC Dale, DD Federman, eds., ACP Medicine, section 9, chap. 3. New York: WebMD.
  • Tentikiyrus N, et al. (2008). Evaluation of the self-administered indicator plaster neuropad for the diagnosis of neuropathy in diabetes. Diabetes Care, 31(2): 236–237.
  • Wong M, et al. (2007). Effects of treatments for symptoms of painful diabetic neuropathy: Systematic review. BMJ. Published online June 11, 2007 (doi:10.1136/bmj.39213.565972.AE).

Credits

By Healthwise Staff
Primary Medical Reviewer Anne C. Poinier, MD - Internal Medicine
Primary Medical Reviewer Brian D. O'Brien, MD - Internal Medicine
Specialist Medical Reviewer Barrie J. Hurwitz, MD, MD - Neurology
Last Revised July 14, 2010

This information does not replace the advice of a doctor. Healthwise, Incorporated disclaims any warranty or liability for your use of this information.