Testing for Autonomic and Peripheral Sensory Neuropathy

The panelists conclude their discussion on diabetic neuropathy by describing the methods they use to test for the autonomic and peripheral sensory neuropathic pain condition and the complications their patients tend to experience during treatment.

While examining for potential diabetic neuropathy, Jeffrey A. Gudin, MD, asks his patients to remove their shoes and socks and then presses a tuning fork against their feet and hands to test vibration and temperature perception, since “pain and temperature tend to run in those same spinal-thalamic pathways.” In addition to those tests, Joseph Pergolizzi, MD, says clinicians should look for “tropic changes, hair loss, (and) if there’s any type of atrophy, so you can tell maybe the severity if there are other things going on.”

Once a diabetic neuropathy diagnosis is made, Christopher Gharibo, MD, recommends prescribing an “around-the-clock” treatment such as once-a-day tramadol and tricyclic antidepressants because “the temporal nature of this pain is that it’s constant.”

However, Gudin notes that “just (those) medications alone cause constipation, nausea, sedation, and these patients we know have the underlying disease of diabetes, which comes along with its own host of cardiovascular and other systemic comorbidity.”

Adding hyperlipidemia, hypercholesterolemia, hypertension, and erectile dysfunction to the list of typical comorbidities, Pergolizzi says diabetic neuropathy patients are often “on a 3-gallon Ziploc bag worth of drugs,” so he believes physicians “have to simplify that process in order to get real compliance (and) have to understand the temporal relevance of the pain.”

“If you do not address that continuous chronic pain, you’re going to have functional deficits, and your activities of daily living are going to suffer, and your quality of life and your patient satisfaction is going to become very problematic,” Pergolizzi explains. “You’re getting this down spiraling vicious circle.”