nerve damage

Nerve Damage Beyond the Hands and Feet

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Managing diabetes effectively can help protect you from autonomic neuropathy, a type of nerve damage that affects digestion, breathing, and blood pressure.

If you live with diabetes, particularly diabetes with chronically high A1C levels, you are at risk for nerve damage, or neuropathy. There are two main categories of neuropathy that are common diabetes-related complications. One is peripheral neuropathy, or nerve damage to the hands and feet. The other is autonomic neuropathy, or damage to the nervous system that controls involuntary processes.

Learn more about autonomic neuropathy as a diabetes complication, as well as risk factors, prevention measures, screening methods, and treatment options to manage the condition as recommended by the ADA’s most current standards of care.

What is autonomic neuropathy, and how does it relate to diabetes?

Autonomic neuropathy is a group of symptoms that occur when there is nerve damage to the nerves that manage automatic, involuntary body functions. Chronically high blood glucose levels can damage the small blood vessels that transport blood to the nerves, leading to disrupted signals between the brain and the nervous system. Autonomic neuropathy affects the nerves in your autonomic nervous system, or the part of your nervous system that controls muscles in the body’s organs, such as the heart, blood vessels, lungs, gastrointestinal and urinary tract, sex organs, and sweat glands. It’s estimated that around a third of people with diabetes will experience autonomic neuropathy.

Symptoms of diabetic autonomic neuropathy

Autonomic neuropathy encompasses a diverse group of signs and symptoms. These include dizziness, dry eyes, mouth or skin; and rapidly feeling full after eating (gastroparesis). It can also cause a wide array of health problems.

Depending on which of your body’s automatic functions are affected, symptoms of this type of neuropathy may include the following:

Heart-related issues

Heart-related issues can include any of the following symptoms:

  • A racing heart while at rest (tachycardia)
  • Dizziness or lightheadedness and fainting when going from a sitting or lying down position to standing up due to low blood pressure (orthostatic hypotension/postural hypotension)
  • Increased or decreased amount of sweating

Gastrointestinal issues

Issues may involve any portion of the gastrointestinal tract from the esophagus all the way down to the bowels, and may include gastroparesis, or slowed emptying of the stomach that can cause early fullness, bloating, nausea and vomiting. A telltale sign of gastroparesis is difficult-to-manage glucose levels and upper GI symptoms like abdominal pain, nausea and vomiting with no other cause. The diagnosis can be made by measuring how quickly food empties from the stomach. Other GI problems include constipation, diarrhea, or inability to control bowel movements.

Genital and urinary tract issues

In men, this may include erectile dysfunction, which is the inability to maintain an erection for sexual intercourse. In women, it may include decreased sexual desire and arousal, pain during intercourse and inadequate lubrication. In both men and women, bladder dysfunction can include incontinence, urgency, and frequency.

Prevention of autonomic neuropathy

As is true for the prevention or delay of most diabetes-related problems, there are actions to take daily. Keeping your glucose, blood pressure and lipids at safe levels can aid in the prevention of diabetic autonomic neuropathy. You should also get comprehensive screenings as detailed below, and take note of any symptoms that may suggest autonomic nerve damage.

It’s important to recognize the symptoms of autonomic neuropathies, and to report any signs of a nerve-related problem to your healthcare provider. If you have a problem that requires further testing and evaluation, be proactive by putting together an action plan with your provider for treatment and follow up.

Risk factors for diabetes-related autonomic neuropathy

Your chance of developing diabetes-related autonomic neuropathy correlates closely with certain factors, such as:

  • Chronically high blood glucose levels
  • Widely fluctuating glucose levels
  • Consistently high blood pressure
  • Abnormal levels of blood lipids, like LDL cholesterol and triglycerides
  • Having excess weight or obesity
  • Advanced-stage chronic kidney disease
  • Smoking

How often to screen for diabetic autonomic neuropathy

Get an annual assessment for signs and symptoms of autonomic neuropathy if you have type 2 diabetes or have had type 1 diabetes for 5 years or more and have other complications, particularly kidney disease and peripheral neuropathy. These routine checks are recommended in the ADA’s most recent Standards of Care supplement on retinopathy, neuropathy, and foot care.

A healthy lifestyle as prevention for diabetic autonomic neuropathy

To avoid autonomic neuropathy as a potential complication, put a plan in place to practice regular diabetes self-care. In addition to getting and keeping glucose levels, lipids, and blood pressure in a desired target range, try to live the healthiest possible lifestyle that you can. This includes getting regular physical activity, choosing and eating healthy foods, maintaining healthy eating habits, quitting or not smoking, consuming no more than one alcoholic drink per day for women and two for men, and taking medications as prescribed.

Treatment for diabetic autonomic neuropathy symptoms

There are few specific treatments for diabetes-related nerve damage that completely resolve the problem. For this reason, both glucose management as well as early detection and action are key to preventing and slowing the progression of diabetic neuropathy.

Management of an autonomic neuropathy generally focuses on reducing symptoms and improving quality of life but does not remedy nerve damage.

Treatment for heart-related issues

Treatment for heart-related issues focuses on minimizing symptoms through medication and lifestyle changes.

Treatment for gastroparesis

Certain medications may help improve stomach emptying and control nausea and vomiting. Changes to the diet, such as choosing foods that are low in fiber and fat, eating small frequent meals and chewing food thoroughly before swallowing, also help address gastroparesis.

Treatment for sexual dysfunction

Treatment for erectile dysfunction can include use of one of the medications that enables the maintenance of an erection, or a vacuum device or penile prosthesis. For women, over-the-counter lubricants can help address sexual side effects.

Recommendations in this article are aimed at adults with type 1 and type 2 diabetes and exclude children and adolescents as well as pregnant people with diabetes. Discuss your targets with your healthcare providers; recommendations may vary based on a number of personal factors.

Does Nerve Damage Contribute to Long-COVID Symptoms?

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Summary: Researchers report some patients with long-COVID have lasting nerve damage that appears to be caused by infection-triggered immune dysfunction.

Source: Mass General

During the COVID-19 pandemic, some people infected with the SARS-CoV-2 virus continue to experience “long-COVID” symptoms persisting at least three months after recovery from COVID, even after mild cases. These include difficulty getting through normal activities, faintness and rapid heart rate, shortness of breath, cognitive difficulties, chronic pain, sensory abnormalities, and muscle weakness.

A new study led by researchers at Massachusetts General Hospital (MGH) and the National Institutes of Health suggests that some patients with long-COVID have long-lasting nerve damage that appears caused by infection-triggered immune dysfunction.

The study, newly published in Neurology: Neuroimmunology & Neuroinflammation, included 17 patients with COVID (16 with mild cases) who met WHO criteria for long-COVID. They had been evaluated and treated in 10 U.S. states/territories.

Evaluations revealed evidence of peripheral neuropathy in 59%. Typical symptoms of neuropathy nerve damage include weakness, sensory changes, and pain in the hands and feet as well as internal complaints including fatigue.

“This is one of the early papers looking into causes of long-COVID, which will steadily increase in importance as acute COVID wanes,” says lead author Anne Louise Oaklander, MD, Ph.D., an investigator in the Department of Neurology at MGH.

This shows a man in a facemask
A new study led by researchers at Massachusetts General Hospital (MGH) and the National Institutes of Health suggests that some patients with long-COVID have long-lasting nerve damage that appears caused by infection-triggered immune dysfunction. Image is in the public domain

“Our findings suggest that some long-COVID patients had damage to their peripheral nerve fibers, and that damage to the small-fiber type of nerve cell may be prominent.”

Oaklander notes that if patients have long-COVID symptoms that aren’t otherwise explained and aren’t improving, they might benefit from discussing neuropathy with their doctor or seeing a neurologist or neuromuscular specialist.

“Research from our team and others is clarifying what the different types of post-COVID neuropathy are, and how best to diagnose and treat them,” says Oaklander.

“Most long-COVID neuropathies described so far appear to reflect immune responses to the virus that went off course. And some patients seem to improve from standard treatments for other immune-related neuropathies.” She cautioned that there hasn’t been enough time to conduct clinical trials to rigorously test specific treatments , however.

Co-authors include Alexander J. Mills, BS, Mary Kelley, DO, Lisa S. Toran MD, Bryan Smith, MD, Marinos C. Dalakas, MD, and Avindra Nath, MD.

Background and Objectives 

Recovery from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection appears exponential, leaving a tail of patients reporting various long COVID symptoms including unexplained fatigue/exertional intolerance and dysautonomic and sensory concerns. Indirect evidence links long COVID to incident polyneuropathy affecting the small-fiber (sensory/autonomic) axons.

Methods 

We analyzed cross-sectional and longitudinal data from patients with World Health Organization (WHO)-defined long COVID without prior neuropathy history or risks who were referred for peripheral neuropathy evaluations. We captured standardized symptoms, examinations, objective neurodiagnostic test results, and outcomes, tracking participants for 1.4 years on average.

Results 

Among 17 patients (mean age 43.3 years, 69% female, 94% Caucasian, and 19% Latino), 59% had ≥1 test interpretation confirming neuropathy. These included 63% (10/16) of skin biopsies, 17% (2/12) of electrodiagnostic tests and 50% (4/8) of autonomic function tests. One patient was diagnosed with critical illness axonal neuropathy and another with multifocal demyelinating neuropathy 3 weeks after mild COVID, and ≥10 received small-fiber neuropathy diagnoses. Longitudinal improvement averaged 52%, although none reported complete resolution. For treatment, 65% (11/17) received immunotherapies (corticosteroids and/or IV immunoglobulins).

Discussion 

Among evaluated patients with long COVID, prolonged, often disabling, small-fiber neuropathy after mild SARS-CoV-2 was most common, beginning within 1 month of COVID-19 onset. Various evidence suggested infection-triggered immune dysregulation as a common mechanism.

Can Diabetes Cause Muscle Cramps?

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cramps in people with diabetes

A recent study looked at links between muscle cramp frequency and severity and nerve fiber measures in patients with type 1 and type 2 diabetes.

Persons with type 1 and 2 diabetes as well as healthy controls were given an evaluation and their large and small nerve fibers were assessed. Details about their muscle cramps were noted. There were 37 control subjects, 51 patients with type 1 diabetes and 69 with type 2 diabetes.

Muscle Cramps a Diabetes Complication?

The researchers state in their study paper that “Muscle cramps were the most frequent symptom captured by the Toronto Clinical Neuropathy Score (TCNS) in all groups, up to 78% in patients with [type 2 diabetes].” They also explained that in only those with type 1 diabetes, muscle cramp frequency and severity was tied to clinical, large, and small nerve fiber measures.

They concluded that muscle cramps are common diabetes and are associated with clinical and both small and large nerve fiber measures in type 1 diabetes, “suggesting that their origin and propagation might extend beyond the motor nerve,” wrote the study authors.

For the study, those with type 2 diabetes were older and had more muscle cramps, more severe cramps, and worse clinical and small and large nerve fiber measures when compared with those with type 1 diabetes. They also had worse nerve function, but this could have been due to the patients with type 1 diabetes being younger than those with type 2 in the study.

Researchers added that “These findings are in line with previous studies, describing muscle cramps in a large spectrum of polyneuropathies, including sensory and small fiber polyneuropathies (Lopate et al., 2013; Maxwell et al., 2014; Abraham et al., 2016), suggesting that the cause of muscle cramps may extend beyond the motor nerve.”