Interview: Dr. Steve Edelman on Peripheral Neuropathy
by David Edelman

Click Here to view the article on DiabetesDaily.com

I recently spoke to Dr. Steven Edelman about Take the Next Step, a campaign to educate about peripheral neuropathy. Neuropathy is nerve damage that results in tingling, pain, and finally loss of all sensation in the limbs. It affects 26% of people with diabetes.

Dr. Edelman is an award-winning endocrinologist, speaker, professor, and founder of Taking Control of Your Diabetes (TCOYD). TCOYD is a non-profit that puts on educational and motivational conferences for people with diabetes all across the country. If you've never been, I highly recommend looking for a TCOYD event in your area.

Hello, Dr. Edelman. Let's start at the beginning. How does neuropathy first manifest itself? How do I know if I have it?
It sometimes it starts off with numbness, and sometimes tingling. You develop an awareness that you have this weird sensation. At this stage, it affects people mainly at night. During the day, they're busy running around and it's not that severe because they're distracted. Then when they lay down at night they are bothered. Even their bedsheets can feel feel bothersome. A lot of people use a metal arched bar that keeps the sheets from rubbing on their feet.

That's a lot of sensitivity!
Yes. And it can be hypersensitivity in the beginning. Then it goes through an extremely painful stage after that. The classic description is sharp, stabbing pain, lightning bolt electricity pains that shoot through your limbs. It's pretty painful and drives people pretty much crazy.

Where exactly does someone feel neuropathy?
Diabetic peripheral neuropathy is called peripheral because it typically affects what we call the stocking and glove distribution. If it really gets bad and progresses up towards the knees, then it starts to affect the hands. But primarily it affects both feet. If someone comes to me and says I have a pain in my left big toe, and everything else is fine, I'm thinking this is not neuropathy. But if they come to me and say, I have this numbness and tingling and it's in both of my feet, and it seems to be getting worse and it really bugs me at night, I am concerned.

How does neuropathy progress after the tingling begins?
Anyone that experiences chronic pain is going to have all kinds of issues, including depression. In addition to the standard neuropathy drugs, we have to give people fairly heavy duty narcotics. But as the neuropathy gets worse, people become totally numb. Now they're happy that their pain went away, but they've entered a very dangerous state of not feeling anything. These are the people that might step on the tack or get infection and not know it. By the time they get attention, it's at a point of no return.

This is basically where all the amputations come from in diabetes. If you don't feel something, that's dangerous. People who are in extreme pain, although they have a miserable lifestyle, are at least always looking at their feet, they're always rubbing their feet. And they're the ones that don't lose their feet. But if they progress, and a lot of them do, that's when people lose their feet.

As neuropathy progresses, is there anything you can do? Can keeping a close eye on your feet prevent amputation or is it virtually inevitable once you lose feeling?
It definitely does not have to end up in amputation. Now remember, neuropathy is a nerve problem. It doesn't have anything to do with blood vessels or your immune system. You have to follow those instructions that you've always seen: examine your feet every night if you're diabetic. You know, it's a stupid recommendation for most diabetics, but it's a great recommendation for people that don't feel anything. So they should look at their feet every night, maybe put on some lotion, look in their shoes, and make sure they don't have any sores because they're not going to feel it.

If they do get a sore, go to a podiatrist. And if your blood sugars are good, then you're going to heal better than if your blood sugars are markedly elevated. Your vascular system is typically intact, and you just have to be very cautious that you do not get a sore and let it fester.

That's a very debilitating, and frustrating progression. 
That's why TCOYD agreed to help spread the word. PDN is a major problem. We want to bring awareness to the important fact that his is a treatable complication and that people may need to get extra help.

I imagine it takes a long time to develop neuropathy. Do you find most of you patients have had diabetes for 25 years before it develops?
Actually, it can be much sooner than that. To give you a little more information than maybe you want, there's a lot of different causes of neuropathy. Diabetes happens to be the most common. Smoking, vitamin deficiencies, and toxins can cause it. Believe it or not, neuropathy sometimes presents itself before a person with type 2 diabetes is even diagnosed if they've had high blood sugars for a long time. For type 1s, this scenario would be pretty unusual. I definitely would not say 25 years. I'd say 5 to 10 years would be more like it.

How do you know if you are at risk for neuropathy? Are there certain numbers you should strive for?
it's clearly been shown that prevention is in blood sugar control. If you're staying below 7 most of your diabetic life, you're in pretty good shape. And if you get neuropathy then, it might be due to a different cause. So I think less than 7 is important, but 7.5 is probably still a safe range. 

You've had diabetes for 39 years. Have you had any neuropathy issues?
Yes. I have a little bit of neuropathy in my feet. Every once in awhile I get a numbness or tingling, but it's at a point where it doesn't bother me all the time. The first ten years I had diabetes, I had really bad control. The next 20 years were mediocre. But the last ten, I've had really good control, especially after I got my DexCom continuous glucose monitor.

In addition to neuropathy, I have really bad gastroparesis where I try not to overeat and sometimes I get heartburn. Sometimes I get a little symptoms of joint mobility problems, like trigger fingers and stuff. So I've had my share of issues. But I'll say this: I've learned to jump on these problems so they don't adversely affect my quality of life except for a small part of the time.

When you say you have less neuropathy sensitivity, do you feel that your ten years of good control has helped improve your symptoms?
Yes, it has helped for sure. At the worst case scenario, it has totally stabilized. Every once in a while I get a weird stabbing pain in my feet that comes and goes really fast. It's probably a little bit of neuropathy, but it's not too bad.

Exercise is so incredibly important when you have diabetes in terms of maintaining your cardiovascular health, controlling your blood sugars, and traditional exercise benefits. When someone has diabetic neuropathy, I imagine that can make a lot of different exercises very difficult. Do you have recommendations for things people can do once they start getting along with neuropathy?
Yes, I do. First of all, I am going to say something about Kim Lyons who will be guest blogging tomorrow. She's not just another pretty face. When I first was asked to join her for this project, I'm looking at her picture and saying, "Hey, I'll do it!" But it turns out that Kim is exceptional at engaging with people and sharing exercises that are really practical. We've had her at three of our conferences and put her right in the health fair. She gives them exercises that they can do whether they have painful neuropathy or just overweight or arthritis. So she is really excellent. And you're right, exercise is not only an antidepressant but especially for people with type 2, so important for them.

Let's say you were a runner and developed neuropathy. You feel like there's so much sensitivity that you can't run anymore. What kind of exercises would you recommend? Is there a philosophy that you could promote to someone in that situation?
There's a lot of options. First, I would just say there's no one perfect exercise for everybody with neuropathy. Water aerobics are a great option, but not everyone can get to a pool. There are exercises you can do in your chair. There are good stretching exercises. Then there are things like the elliptical stepper and the exercycle. So, yes, there are a lot of very different options.

If you want to get really specific, I would check out Kim's website, kimlyons.com. The bottom line is that there is an exercise for everybody that can improve their diabetes. And this will have a secondary beneficial effect on any complication including neuropathy. There's always an exercise for everybody. I don't care about the weight or anything else.

One last comment. If I had peripheral neuropathy, I could easily say I'm in too much pain. I'm not going to exercise. But you would not believe the response Kim gets from people who previously did not think there was a good exercise for them. Exercise is such an important part of diabetes management and it actually helps take their mind off the neuropathy pain at least for awhile.

Dr. Edelman, thank you very much for speaking with us. I look forward to Kim's guest blog post tomorrow.
Thank you. Please be sure to get in touch with any follow-up questions!

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