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Clinical Review State of the Art

Neuropathic pain: mechanisms and their clinical implications

BMJ 2014; 348 doi: (Published 05 February 2014) Cite this as: BMJ 2014;348:f7656

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Re: Neuropathic pain: mechanisms and their clinical implications

Neuropathy is one of the common complications observed among diabetic patients. Studies have reported wide variations in the prevalence of diabetic neuropathy globally. Review of epidemiologic studies showed the prevalence of diabetic neuropathy to be approximately 30% in hospital patients and 20% in the community (1). Halawa et al (2) reported a high prevalence of painful neuropathy (65.3%) in adult outpatients with type 1 and 2 diabetes in Saudi Arabia using DN4 tool. Bansal et al (3) carried out a cross-sectional study in a tertiary care hospital and reported that 29.2% diabetic patients had neuropathy using the combination of more than one abnormal result of 10-g monofilament, pinprick sensations and ankle reflexes. Estimation of true prevalence of diabetic neuropathy accurately is impossible because of lack of uniformity in the criteria for diagnosis, limited community based studies, and neuropathy remains undiagnosed in a large population of diabetes patients (4).

Diabetic neuropathy affects sensory, autonomic, and motor neurons of the peripheral nervous system resulting in involvement of various organs of the body. This leads to various modes of presentation of symptoms in neuropathy. Sensorimotor neuropathy affects large and small afferent nerve fibers to varying degrees, resulting in mixed symptoms and sensory loss. Large afferent nerve fibers are responsible for proprioception (spatial limb location), cold, and vibration sensation; small afferent fibers are responsible for perception of touch, and warmth sensation (5). The common complaints in peripheral neuropathy are burning, tingling, aching, cold sensation, lancinating pain, numbness, or pain from normal touch (allodynia), such as clothing, brushing the skin etc. (5-7). It is generally observed that minority patients experience neuropathic pain and symptoms are not reported until the complications are severe or irreversible.

Other manifestations of neuropathy include that of gastroesophageal reflux disease (GERD) viz. early satiety, cramping, bloating, heartburn, nausea, vomiting, and loss of appetite (8); erectile dysfunction, impotence in males,diminished libido in females (9); neurogenic bladder resulting in the inability to sense bladder fullness or initiate micturition, urinary retention, and overflow incontinence (9).

The varied presentations in symptoms and signs need to be educated to the patients so that identification of complications especially neuropathy could be done at an early stage. Diabetics need to regularly visit the physicians to detect the complications. The role of diabetic educators including nurses in this regard is of paramount importance. Health care providers including diabetic patients are equal partners in the early detection and management of diabetic neuropathy.


1. Shaw JE, Zimmet PZ. The epidemiology of diabetic neuropathy. Diabetes Rev. 1999; 7:245-52.
2. Halawa MR, Karawagh A, Zeidan A, Mahmoud AE, Sakr M, Hegazy A. Prevalence of painful diabetic peripheral neuropathy among patients suffering from diabetes mellitus in Saudi Arabia. Curr Med Res Opin. 2010 ;26(2):337-43.
3. Bansal D, Gudala K, Muthyala H, Nayakallu R, Bhansali A.Prevalence and risk factors of development of peripheral diabetic neuropathy in type 2 diabetes mellitus in a tertiary care setting. DOI: 10.1111/jdi.12223
4. Vinik AI, Holland MT, Le Beau JM et al. Diabetic neuropathies. Diabetes Care. 1992; 15:1926-75.
5. Vinik AI, Park TS, Stansberry KB et al. Diabetic neuropathies. Diabetologia. 2000; 43:957-73.
6. UK Prospective Diabetes Study Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. Lancet. 1998; 352:837-53.
7. Adler AI, Boyko EJ, Ahroni JH et al. Risk factors for diabetic peripheral sensory neuropathy. Diabetes Care. 1997; 20: 1162-7.
8. Vinik AI, Erbas T, Stansberry K. Gastrointestinal, genitourinary, and neurovascular disturbances in diabetes.Diabetes Rev. 1999; 7:3758-81.
9. Ziegler D. Cardiovascular autonomic neuropathy: clinical manifestations and measurement. Diabetes Rev. 1999; 7:342-57.

Reeta Devi
Assistant Professor,
School of Health Sciences, Indira Gandhi National Open University
Maidan Garhi, New Delhi-110068.

Mongjam Meghachandra Singh
Department of Community Medicine
Maulana Azad Medical College, New Delhi-110002.

Bimla Kapoor
Former Director,
School of Health Sciences, Indira Gandhi National Open University
Maidan Garhi, New Delhi-110068.

Competing interests: No competing interests

22 May 2014
Reeta Devi
Assistant Professor,
Mongjam Meghachandra Singh, Bimla Kapoor
School of Health Sciences, Indira Gandhi National Open University, New Delhi
School of Health Sciences, IGNOU, New Delhi; Co-author- Department of Community Medicine, Maulana Azad Medical College, New Delhi