Diabetic Neuropathy and Clinical Practice

306 Pages·2020·2.334 MB·English

by  Sanjeev Kelkar

Diabetic Neuropathy
and Clinical Practice
Sanjeev Kelkar
123
Diabetic Neuropathy and Clinical Practice
Sanjeev Kelkar
Diabetic Neuropathy
and Clinical Practice
Sanjeev Kelkar
Independent Health Researcher
Pune, Maharashtra
India
ISBN 978-981-15-2416-5 ISBN 978-981-15-2417-2 (eBook)
https://doi.org/10.1007/978-981-15-2417-2
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Singapore
To Mr. Dhananjay Kesheo and
Mrs. Sai Dhananjay Kelkar
For their significant contribution to the
development of
The movement for better Diabetic Foot
Management in India
Through the development of fine
instrumentation,
Yeoman’s work in Diabetic Footwear
That received less recognition than it
deserved
Preface
The cornerstone of clinical practice, Communication between the doctor and the
patient, the cornerstone of clinical practice, is the greatest casualty in the last two
decades. There is a failure to understand the meaning of what the patient is saying,
explaining not just the complaints but his concerns. The art and science of history
taking, communication through fingers and eyes in examining a patient, about arriv-
ing at a primary diagnosis and extending a differential one, pertinence of investiga-
tion and rational management, and the various forms of communication are as good
as lost today.
There are many reasons for this, which have been elaborated in the two volumes
on India’s Public Health Care Delivery: Policies for Universal Health Care and
India’s Private Health Care Delivery: Critique and Remedies I have written. These
two volumes will soon be published by Palgrave Macmillan. In addition, there is a
lack or loss of critical clinical reasoning and its articulate, non-jargonistic and
empathic articulation in the business of patient care.
A more important reason for the genesis of this principally comes from the loss
of the grip on the basics of clinical medicine which lie in the nonclinical subjects
first taught, viz. anatomy, physiology, biochemistry, and pathology. The direct
effect of this loss of grip continues to affect while learning in the clinical branches,
pharmacology and therapeutics, continues. There is a disconnection between
these clinical and nonclinical subjects. Since the details of mechanisms and basic
information are no longer available, the doctors are at loss in explaining anything
about the disorder of the patient in an understandable and satisfying manner.
For some good reasons, I have been associated with and talking or teaching about
diabetic neuropathy since 2000 CE. The numbers taught are really large and widely
spread over India, South East Asia, and other places. In doing so I believe I have
gained some insight into what needs to be taught and how. A few important ele-
ments of this insight are to retain as my primary focus an understanding of the
basics of anatomy, physiology, and pathology in dealing with the clinical issues at
hand. The second is on developing critical clinical reasoning and its verbal articula-
tion. Unless the clinical skills are combined with the basics, the all-important diag-
nosis can never be achieved and rational care is impossible. The area of Diabetic
Neuropathy is one such area where this could be facilitated for the betterment of
vii
viii Preface
patients and the professionals. It is widely prevalent but poorly understood; one has
to deal with it within a much larger canvas of clinical practice at many levels of
complexity. To equip the doctors, this book has been penned.
Pune, Maharashtra, India Sanjeev Kelkar
December 2019
Acknowledgments
I am grateful to Novo Nordisk and Novo Nordisk Education Foundation (NNEF)
and to the Managing Director and Trustee Dr. Anil Kapur, who recognized the need
for an intensive effort to improve the status of Diabetic Foot Care in India for the
first time. Dr. Kapur gave it a huge push initially and entrusted me to develop this
field. He was also the key figure behind the creation of Diabetic Foot Society of
India (DFSI), a unique body in the world, now recognized for its work all over, and
has contributed greatly for the betterment of this area.
I am grateful to the University of Newcastle Australia and its faculty for includ-
ing Diabetic Nerve and Foot Disorders as an important component of the Problem-
Based Learning Courses it conducted with NNEF—Dr. Jean McPherson, Dr. Judith
Scott, Dr. Richard Gibson, Dr. Kerry Bowen, and the pro-vice-chancellor Dr. John
Marley. This effort gave a great boost to the work of DFSI also.
Three sets of people have done a great deal of work in this field to whom I wish
to express my gratitude. From NNEF, Mr. M V Prasad’s support in high-quality
reference work has simply been incredible for this volume; Mrs. Anandhi Singh, my
efficient secretary in NNEF, handled the immensely complicated logistics of these
works and relieved me to concentrate on many other aspects like teaching programs,
organizing conferences, and formatting support material for learning for this work
and for Diabetes Education for professionals intimately connected with it.
The staff of the University of Newcastle, Ms. Judy Melville, Mrs. Carolyn
Holland, and Mrs. Kathy Byrne, traveled enormous distances every 2 months for
five long years to do the work, ever smiling and lifting the burden of these
activities.
Diabetic neuropathy and foot work has also progressed largely in different parts
of the country by those who organized 17 National Conferences in as many years of
existence of DFSI. The national and international faculty have contributed to the
knowledge process greatly.
Last and the most important person I wish to acknowledge is Dr. Arun Bal, pre-
miere diabetic foot surgeon of India, the capacity builder of the army of diabetic
foot professionals, honored and awarded by the world bodies, and the founder presi-
dent of DFSI. I worked all these years as a competent manager under his benign
generalship and learned all that I could. He is the brick and mortar of DFSI. There
are many others who worked for this cause in DFSI, named and unnamed to whom
I extend my gratitude in bringing out this work.
ix
Contents
Part I A natomy and Pathophysiology of Diabetic Nerves
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2 Functional Anatomy of the Cranial, Peripheral,
and Autonomic Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.2 Cranial Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.2.1 General Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.2.2 Afflictions of Optic Tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.2.3 Oculomotor Nerves III, IV, and VI in Diabetes . . . . . . . . . . . 8
2.2.4 Pupillary Abnormalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.2.5 Facial Neuropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.2.6 Treatment and Prognosis of Facial Neuropathy . . . . . . . . . . . 9
2.2.7 Tenth Cranial Nerve Vagus . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.3 Diabetic Peripheral and Autonomic Neuropathies . . . . . . . . . . . . . . . 10
2.3.1 Diabetic Sensory Neuropathies . . . . . . . . . . . . . . . . . . . . . . . 10
2.3.2 Diabetic Somatic Motor Neuropathies. . . . . . . . . . . . . . . . . . 10
2.3.3 Diabetic Autonomic Neuropathies . . . . . . . . . . . . . . . . . . . . . 10
2.4 Functional Anatomy of Diabetic Somatic Peripheral
Neuropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.4.1 Diabetic Somatic Sensory Peripheral Neuropathy . . . . . . . . . 11
2.4.2 Classification, Anatomy, and Functions of
Sensory Receptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.5 Classification of Nerve Fibers: General . . . . . . . . . . . . . . . . . . . . . . . 12
2.5.1 Alternative Classification Used by Neurophysiologists . . . . . 13
2.6 General Principles and Sensory Physiology . . . . . . . . . . . . . . . . . . . 14
2.6.1 Adaptation, Accommodation, and Inactivation
of the Stimulus and Impulse . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.6.2 Nerve Fibers, Transmission of Different Signals,
and Their Physiologic Significance . . . . . . . . . . . . . . . . . . . . 14
2.7 Sensory Perception of Touch, Pressure, and Vibration
and the Nerve Ending Distribution . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.7.1 Meissner’s Corpuscle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
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xii Contents
2.7.2 Merkel’s Discs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.7.3 Hair End Organ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.7.4 Ruffini’s End-Organs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.7.5 The Pacinian Corpuscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.8 Transmission of Tactile Signals in Peripheral Nerve Fibers . . . . . . . 17
2.8.1 Anatomy and the Transmission of the Dorsal
Column–Medial Lemniscal System . . . . . . . . . . . . . . . . . . . . 17
2.8.2 Signals and Functions Carried in the Dorsal
Column–Medial Lemniscal System . . . . . . . . . . . . . . . . . . . . 18
2.8.3 Pressure and Vibratory Sensation Through the
Dorsal Columns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.8.4 Anatomy and Transmission in the Anterolateral
Pathway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.8.5 Signals and Functions Carried in the
Antero-Lateral System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.9 Functional Anatomy of Autonomic Nerves . . . . . . . . . . . . . . . . . . . . 19
2.9.1 Segmental Distribution of the Sympathetic
Nerve Fibers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.10 Functional Anatomy of Central Autonomic Nervous System . . . . . . 20
2.10.1 Sympathetic Nerve Fibers in the Skeletal Nerves . . . . . . . . . 20
2.10.2 Functional Anatomy of the Parasympathetic
Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.10.3 Preganglionic and Postganglionic Parasympathetic
Neurons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.10.4 Sympathetic and Parasympathetic “Tone” . . . . . . . . . . . . . . . 22
2.10.5 Tone Caused by Basal Secretion of Epinephrine
and Norepinephrine by the Adrenal Medullae . . . . . . . . . . . . 22
2.11 Effect of Loss of Sympathetic or Parasympathetic
Tone After Denervation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.11.1 Denervation Super-Sensitivity of Sympathetic
and Parasympathetic Organs . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.11.2 Sympathetic Stimulation and Skeletal Stimulation . . . . . . . . 23
2.11.3 Muscarinic and Nicotinic Receptors . . . . . . . . . . . . . . . . . . . 23
3 Pathogenesis of Diabetic Neuropathies . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3.1 Pathological Hallmarks of Diabetic Neuropathy . . . . . . . . . . . . . . . . 25
3.2 Epidemiological Features of Diabetic Peripheral Neuropathy . . . . . 25
3.2.1 Few Main Clinical Features of Diabetic
Sensorimotor Polyneuropathy . . . . . . . . . . . . . . . . . . . . . . . . 26
3.2.2 Confirmatory Evidence of Peripheral Neuropathy . . . . . . . . 26
3.3 Pathogenetic Mechanisms in Development of Diabetic
Neuropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
3.3.1 Hyperglycemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26