What is polyneuropathy

Polyneuropathy develops when your peripheral nerves are damaged in multiple parts of your body, such as affecting the feet on both sides of the body. Symptoms of polyneuropathy can include weakness, numbness, and burning pain.

Peripheral neuropathy, a result of damage to your peripheral nerves, often causes weakness, numbness and pain, usually in your hands and feet. It can also affect other areas of your body.

Your peripheral nervous system sends information from your brain and spinal cord (central nervous system) to the rest of your body. Peripheral neuropathy can result from traumatic injuries, infections, metabolic problems, inherited causes and exposure to toxins. One of the most common causes is diabetes mellitus.

People with peripheral neuropathy generally describe the pain as stabbing, burning or tingling. In many cases, symptoms improve, especially if caused by a treatable condition. Medications can reduce the pain of peripheral neuropathy.

Diabetic polyneuropathy

Diabetic polyneuropathy is a peripheral nerve disorder caused by diabetes or poor blood sugar control. Polyneuropathy or diffuse neuropathy is a nerve disorder which may be categorized as sensory neuropathy, motor neuropathy or autonomic neuropathy.

Neuropathy can be caused by both type 1 and type 2 diabetes.

Types of diabetic polyneuropathy

Diabetic polyneuropathy may be categorized as follows:

1. Sensory neuropathy occurs when nerves which detect touch and temperature are damaged. This form of neuropathy commonly affects the feet and hands.
2. Motor neuropathy results from damage to the nerves affecting muscle movement.
3. Autonomic neuropathy follows if the nerves which control involuntary actions, such as digestion or heart rate are affected.

Over time, people with diabetes who do not control their condition, may develop damage to the nerves around the body.

The most common types of diabetic neuropathy result in problems with sensation in the feet. It can develop slowly after many years of diabetes or may occur early in the disease. The symptoms are numbness, pain, or tingling in the feet or lower legs. The pain can be intense and require treatment to relieve the discomfort. The loss of sensation in the feet may also increase the possibility that foot injuries will go unnoticed and develop into ulcers or lesions that become infected. In some cases, diabetic neuropathy can be associated with difficulty walking and some weakness in the foot muscles. There are other types of diabetic-related neuropathies that affect specific parts of the body. For example, diabetic amyotrophy causes pain, weakness and wasting of the thigh muscles, or cranial nerve infarcts that may result in double vision, a drooping eyelid, or dizziness. Diabetes can also affect the autonomic nerves that control blood pressure, the digestive tract, bladder function, and sexual organs. Problems with the autonomic nerves may cause lightheadedness, indigestion, diarrhea or constipation, difficulty with bladder control, and impotence.

How common is diabetic polyneuropathy?

Incidences are more common in patients with poor control, overweight, have higher levels of blood fat and blood pressure, and are over the age of 40.

The longer a person has diabetes, the greater the risk of developing neuropathies.

Diabetic polyneuropathy may affect up to 50% of people with diabetes ¹.

Symptoms of neuropathy will often first manifest as numbness or pain in the hands, feet, arms or legs (distal symmetric neuropathy).

However, they may also affect the organs, including the heart and sex organs.

Diabetic polyneuropathy causes

The exact effect of glucose on the nervous system is still not known. However, prolonged exposure to higher than normal glucose levels certainly damages the nerves, causing neuropathy.

High levels of triglycerides, a key blood fat which is measured during a cholesterol check, are also associated with the development of nerve damage.

A combination of other causal factors includes:

• High blood pressure
• Smoking
• Alcohol use
• Having chronic liver or kidney disease
• Vitamin B deficiency

Certain medications, including some anti-cancer drugs, are also associated with bringing on neuropathy.

Diabetic polyneuropathy prevention

Maintaining consistently normal blood glucose levels is the best way to prevent diabetic polyneuropathy. Keeping levels stable protects the nerves.

What are the symptoms of diabetic polyneuropathy?

The symptoms of diabetic polyneuropathy are wide-ranging and depend entirely on the form of neuropathy present, and which nerves are being affected.

Common symptoms of diabetic polyneuropathy include:

• Numbness
• Tingling
• Pain

These may be minor at first, and therefore may remain unnoticed as the condition develops gradually. However, in some types of diabetic neuropathy, the onset of the pain will be sudden and severe.

Further symptoms may include:

• Wasting of muscles in feet or hands
• Indigestion, nausea and vomiting
• Diarrhea
• Constipation
• Urinary problems
• Impotence
• Vaginal dryness
• Dizziness
• Weakness of the limbs

How is diabetic polyneuropathy diagnosed?

Diagnosis will occur on the basis of your individual symptoms and a physical exam. Your doctor may test your blood pressure, heart rate, strength, reflexes and sensitivity. Foot examinations are recommended for all diabetics.

Other tests may be applied, such as:

• Nerve conduction studies
• EMG (electromyography) and
• QST (quantitative sensory testing)

Doctors should screen for neuropathy amongst diabetic patients at least once per year.

At an annual check the test for neuropathy will involve the doctor stimulating the foot with a small plastic implement or tuning fork to see if you correctly detect the sensation. Tests to confirm or monitor existing neuropathy may include ultrasound, nerve studies and biopsies, or referral to a specialist neuropathy consultant who may conduct further tests.

Diabetic polyneuropathy treatment

The goal of treating diabetic polyneuropathy is to prevent further tissue damage and relieve discomfort. The first step is to bring blood sugar levels under control by diet and medication. This can help to prevent problems from this diabetic complication.

Diet, exercise or medication may be adjusted to reach these goals. Exercise can be particularly effective, helping the patient to improve circulation, strengthen muscle and lose weight.

Smoking should be stopped and the amount of alcohol consumed should be reduced. Taking regular care of your feet and skin is essential.

Another important part of treatment involves taking special care of the feet by wearing proper fitting shoes and routinely checking the feet for cuts and infections.

Peripheral neuropathy makes your foot incredibly vulnerable – hence foot care and general skin care is very important. Because one of the signs of neuropathy is a loss of feeling, feet should be checked daily for cuts, sores, blisters, bruises and cracked or dry skin. If you notice anything unusual, get to your doctor as soon as possible.

Analgesics, low doses of antidepressants, and some anticonvulsant medications may be prescribed for relief of pain, burning, or tingling. Some individuals find that walking regularly, taking warm baths, or using elastic stockings may help relieve leg pain.

Nerve damage

Nerve damage in the digestive system can lead to constipation, and sometimes diabetic gastroparesis. The oesophagus may become affected, making the swallowing of food difficult. The urinary tract may also be affected, and at the worst stages this can cause urinary incontinence.

Also, neuropathy can decrease sexual response in both men and women. The sweat glands may also be affected, and the body may not be able to control temperature properly. Furthermore, the eyes can suffer problems leaving them less sensitive to changes in light.

Proximal neuropathy

Proximal neuropathy affects the hips, buttocks and thighs, and results in weakness of the legs. This type of neuropathy occurs more regularly in type 2 diabetics and in older people. It can weaken the legs, sometimes to the extent of limiting mobility.

Focal neuropathy

Focal neuropathy is manifested in the rapid weakness of a nerve, or group of nerves, leaving the muscles weak and/or in pain.

Focal neuropathy can affect any nerve in the body, but usually occurs in the torso, leg or head. It can cause a variety of complications, including inability to focus, double vision, aching behind the eye, paralysis, lower back pain, pain in various places throughout the body. It is both unpredictable and painful, and usually affects the elderly.

Diabetic polyneuropathy prognosis

The prognosis for diabetic polyneuropathy depends largely on how well the underlying condition of diabetes is handled. Treating diabetes may halt progression and improve symptoms of the neuropathy, but recovery is slow. The painful sensations of diabetic neuropathy may become severe enough to cause depression in some patients.

Acute inflammatory demyelinating polyneuropathy

Acute inflammatory demyelinating polyneuropathy is the most common variant of Guillain-Barre syndrome in the United States, which is a rare disorder that causes your immune system to attack your peripheral nervous system (PNS). In acute inflammatory demyelinating polyneuropathy, the immune response damages the myelin coating and interferes with the transmission of peripheral nervous system nerve signals. The peripheral nervous system nerves connect your brain and spinal cord with the rest of your body. Damage to the peripheral nervous system nerves makes it hard for them to transmit signals. As a result, your muscles have trouble responding to your brain. No one knows what causes the Guillain-Barre syndrome. Sometimes it is triggered by respiratory infection, the stomach flu (gastroeneteritis), surgery, or a vaccination.

Guillain-Barre syndrome can affect anyone. Guillain-Barré syndrome can strike at any age (although it is more frequent in adults and older people) and both sexes are equally prone to the disorder. Guillain-Barre syndrome is estimated to affect about one person in 100,000 each year.

The first symptom of Guillain-Barre syndrome is usually weakness or a tingling feeling in your legs. The feeling can spread to your upper body. These sensations can quickly spread, eventually paralyzing your whole body. In its most severe form Guillain-Barre syndrome you become almost paralyzed, which is a medical emergency and life-threatening. Most people with Guillain-Barre syndrome must be hospitalized to receive treatment.  You might need a respirator to breathe. Symptoms usually worsen over a period of weeks and then stabilize.

Guillain-Barre syndrome can be hard to diagnose. Possible tests include nerve tests and a spinal tap.

There’s no known cure for Guillain-Barre syndrome, but several treatments can ease symptoms and may include medicines or a procedure called plasma exchange to reduce the duration of the illness.

Two types of treatments can speed recovery and reduce the severity of the illness:

• Plasma exchange (plasmapheresis). The liquid portion of part of your blood (plasma) is removed and separated from your blood cells. The blood cells are then put back into your body, which manufactures more plasma to make up for what was removed. Plasmapheresis may work by ridding plasma of certain antibodies that contribute to the immune system’s attack on the peripheral nerves.
• Immunoglobulin therapy (IVIg). Immunoglobulin containing healthy antibodies from blood donors is given through a vein (intravenously). High doses of immunoglobulin can block the damaging antibodies that may contribute to Guillain-Barre syndrome.

These treatments are equally effective. Mixing them or administering one after the other is no more effective than using either method alone.

Most people recover from Guillain-Barre syndrome, though some may experience lingering effects from it, such as weakness, numbness or fatigue. Recovery can take a few weeks to a few years.

Types of Guillain-Barre syndrome

Once thought to be a single disorder, Guillain-Barre syndrome is now known to occur in several forms. The main types are:

• Acute inflammatory demyelinating polyradiculoneuropathy (AIDP), the most common form in the U.S. The most common sign of acute inflammatory demyelinating polyneuropathy is muscle weakness that starts in the lower part of your body and spreads upward.
• Miller Fisher syndrome, in which paralysis starts in the eyes. Miller-Fisher syndrome is also associated with unsteady gait. Miller-Fisher syndrome occurs in about 5 percent of people with Guillain-Barre syndrome in the U.S. but is more common in Asia.
• Acute motor axonal neuropathy (AMAN) and acute motor-sensory axonal neuropathy (AMSAN) are less common in the U.S. But AMAN and AMSAN are more frequent in China, Japan and Mexico.

The most common type of Guillain-Barre syndrome seen in the United States is acute inflammatory demyelinating polyneuropathy. In two other types of Guillain-Barré syndrome are acute motor axonal neuropathy (AMAN) and acute motor-sensory axonal neuropathy (AMSAN), the axons themselves are damaged by the immune response. Miller-Fisher syndrome is a rare, acquired nerve disease that is a variant of Guillain-Barré syndrome. Miller-Fisher syndrome is characterized by abnormal muscle coordination with poor balance and clumsy walking, weakness or paralysis of the eye muscles, and absence of the tendon reflexes. Like Guillain-Barre syndrome, symptoms may follow a viral illness. Additional symptoms include generalized muscle weakness and respiratory failure. Most individuals with Miller Fisher syndrome have a unique antibody that characterizes the disorder.

Acute inflammatory demyelinating polyneuropathy causes

The exact cause of Guillain-Barre syndrome is not known. Researchers don’t know why it strikes some people and not others. It is not contagious or inherited.

What they do know is that the affected person’s immune system begins to attack the body itself. It is thought that, at least in some cases, this immune attack is initiated to fight an infection and that some chemicals on infecting bacteria and viruses resemble those on nerve cells, which, in turn, also become targets of attack. Since the body’s own immune system does the damage, Guillain-Barre syndrome is called an autoimmune disease (“auto” meaning “self”). Normally the immune system uses antibodies (molecules produced in an immune response) and special white blood cells to protect us by attacking infecting microorganisms (bacteria and viruses). In Guillain-Barré syndrome, however, the immune system mistakenly attacks the healthy nerves.

Most cases usually start a few days or weeks following a respiratory or gastrointestinal viral infection. Occasionally surgery will trigger the syndrome. In rare cases vaccinations may increase the risk of Guillain-Barre syndrome. Recently, some countries worldwide reported an increased incidence of Guillain-Barre syndrome following infection with the Zika virus.

How does nerve damage occur?

Various ideas have been proposed to explain how Guillain-Barre syndrome develops. One explanation is known as the “molecular mimicry/innocent bystander” theory. According to this explanation, molecules on some nerves are very similar to or mimic molecules on some microorganisms. When those microbes infect someone, the immune system correctly attacks them. And if the microbe and myelin look similar, the immune system makes a mistake and attacks the myelin.

Different mechanisms may explain how the molecular mimicry concept may work. When Guillain-Barré syndrome is preceded by a viral or bacterial infection, it is possible that the infecting agent has changed the chemical structure of some nerves. The immune system treats these nerves as foreign bodies and mistakenly attacks them. It is also possible that the virus makes the immune system itself less discriminating and no longer able to recognize its own nerves. Some parts of the immune system—special white blood cells called lymphocytes and macrophages—perceive myelin as foreign and attack it. Specialized white blood cells called T lymphocytes (from the thymus gland) cooperate with B lymphocytes (that originate in bone marrow) to produce antibodies against the person’s own myelin and damage it.

In some forms of Guillain-Barre syndrome, antibodies made by the person to fight a Campylobacter jejuni bacterial infection attack axons in the motor nerves. This causes acute motor axonal neuropathy, which is a variant of Guillain-Barre syndrome that includes acute paralysis and a loss of reflexes without sensory loss. Campylobacter infections can be caused by ingesting contaminated food or from other exposures. The infected person’s body then makes antibodies against Campylobacter. Some Campylobacter molecules resemble molecules in the person’s nerve axons, so when the person’s antibodies fight the Campylobacter bacteria they also attack the look-alike axons. This slows nerve conduction and causes paralysis. Scientists are investigating various Guillain-Barre syndrome subtypes to find why the immune system reacts abnormally in this syndrome and other autoimmune diseases.

Acute inflammatory demyelinating polyneuropathy risk factors

Guillain-Barre syndrome can affect all age groups. But you’re at slightly greater risk if:

• You’re a man
• You’re a young adult

Guillain-Barre syndrome may be triggered by:

• Most commonly, infection with campylobacter, a type of bacteria often found in undercooked poultry
• Influenza virus
• Cytomegalovirus
• Epstein-Barr virus
• Zika virus
• Hepatitis A, B, C and E
• HIV, the virus that causes AIDS
• Mycoplasma pneumonia
• Surgery
• Hodgkin’s lymphoma
• Rarely, influenza vaccinations or childhood vaccinations

Acute inflammatory demyelinating polyneuropathy symptoms

Unexplained sensations often occur first, such as tingling in your feet or hands, or even pain (especially in children), often starting in your legs or back. Children will also show symptoms with difficulty walking and may refuse to walk. These sensations tend to disappear before the major, longer-term symptoms appear. Weakness on both sides of the body is the major symptom that prompts most people to seek medical attention. The weakness may first appear as difficulty climbing stairs or with walking. Symptoms often affect the arms, breathing muscles, and even the face, reflecting more widespread nerve damage. Occasionally symptoms start in the upper body and move down to the legs and feet.

Most people reach the greatest stage of weakness within the first two weeks after symptoms appear; by the third week 90 percent of affected individuals are at their weakest.

In addition to muscle weakness, symptoms may include:

• Difficulty with eye muscles and vision
• Difficulty swallowing, speaking, or chewing
• Pricking or pins and needles sensations in the hands and feet
• Pain that can be severe, particularly at night
• Coordination problems and unsteadiness
• Abnormal heart beat/rate or blood pressure
• Problems with digestion and/or bladder control.

These symptoms can increase in intensity over a period of hours, days, or weeks until certain muscles cannot be used at all and, when severe, the person is almost totally paralyzed. In these cases, the disorder is life-threatening—potentially interfering with breathing and, at times, with blood pressure or heart rate.

The weakness seen in Guillain-Barre syndrome usually comes on quickly and worsens over hours or days. Symptoms are usually equal on both sides of the body (called symmetric). In addition to weak limbs, muscles controlling breathing can weaken to the point that the person must be attached to a machine to help support breathing.

Since nerves are damaged in Guillain-Barre syndrome, the brain may receive abnormal sensory signals from the rest of the body. This results in unexplained, spontaneous sensations, called paresthesias (numbness and tingling), that may be experienced as tingling, a sense of insects crawling under the skin (called formications), and pain. Deep muscular pain may be experienced in the back and/or legs.

Acute inflammatory demyelinating polyneuropathy complications

Guillain-Barre syndrome affects your nerves. Because nerves control your movements and body functions, people with Guillain-Barre may experience:

• Breathing difficulties. The weakness or paralysis can spread to the muscles that control your breathing, a potentially fatal complication. Up to 30 percent of people with Guillain-Barre syndrome need temporary help from a machine to breathe when they’re hospitalized for treatment.
• Residual numbness or other sensations. Most people with Guillain-Barre syndrome recover completely or have only minor, residual weakness, numbness or tingling.
• Heart and blood pressure problems. Blood pressure fluctuations and irregular heart rhythms (cardiac arrhythmias) are common side effects of Guillain-Barre syndrome.
• Pain. Up to half of people with Guillain-Barre syndrome experience severe nerve pain, which may be eased with medication.
• Bowel and bladder function problems. Sluggish bowel function and urine retention may result from Guillain-Barre syndrome.
• Blood clots. People who are immobile due to Guillain-Barre syndrome are at risk of developing blood clots. Until you’re able to walk independently, taking blood thinners and wearing support stockings may be recommended.
• Pressure sores. Being immobile also puts you at risk of developing bedsores (pressure sores). Frequent repositioning may help avoid this problem.
• Relapse. Around 3 percent of people with Guillain-Barre syndrome experience a relapse.

Severe, early symptoms of Guillain-Barre syndrome significantly increase the risk of serious long-term complications. Rarely, death may occur from complications such as respiratory distress syndrome and heart attack.

Acute inflammatory demyelinating polyneuropathy diagnosis

The initial signs and symptoms of Guillain-Barre syndrome are varied and there are several disorders with similar symptoms. Therefore, doctors may find it difficult to diagnose Guillain-Barre syndrome in its earliest stages.

Your doctor is likely to start with a medical history and thorough physical examination.

Your doctor will note whether the symptoms appear on both sides of the body (the typical finding in Guillain-Barré syndrome) and the speed with which the symptoms appear (in other disorders, muscle weakness may progress over months rather than days or weeks). In Guillain-Barre syndrome, deep tendon reflexes in the legs, such as knee jerks, are usually lost. Reflexes may also be absent in the arms. Because the signals traveling along the nerve are slow, a nerve conduction velocity test (NCV, which measures the nerve’s ability to send a signal) can provide clues to aid the diagnosis.

Your doctor may then recommend:

• Spinal tap (lumbar puncture). A small amount of fluid is withdrawn from the spinal canal in your lower back. The fluid is tested for a type of change that commonly occurs in people who have Guillain-Barre syndrome.
• Electromyography. Thin-needle electrodes are inserted into the muscles your doctor wants to study. The electrodes measure nerve activity in the muscles.
• Nerve conduction studies. Electrodes are taped to the skin above your nerves. A small shock is passed through the nerve to measure the speed of nerve signals.

There is a change in the cerebrospinal fluid that bathes the spinal cord and brain in people with Guillain-Barre syndrome. Researchers have found the fluid contains more protein than usual but very few immune cells (measured by white blood cells). Therefore, a physician may decide to perform a spinal tap or lumbar puncture to obtain a sample of spinal fluid to analyze. In this procedure, a needle is inserted into the person’s lower back and a small amount of cerebrospinal fluid is withdrawn from the spinal cord. This procedure is usually safe, with rare complications.

Key diagnostic findings include:

• Recent onset, within days to at most four weeks of symmetric weakness, usually starting in the legs
• Abnormal sensations such as pain, numbness, and tingling in the feet that accompany or even occur before weakness
• Absent or diminished deep tendon reflexes in weak limbs
• Elevated cerebrospinal fluid protein without elevated cell count.This may take up to 10 days from onset of symptoms to develop.
• Abnormal nerve conduction velocity findings, such as slow signal conduction
• Sometimes, a recent viral infection or diarrhea.

Acute inflammatory demyelinating polyneuropathy treatment

There is no known cure for Guillain-Barré syndrome. However, some therapies can lessen the severity of the illness and shorten recovery time. There are also several ways to treat the complications of the disease.

Because of possible complications of muscle weakness, problems that can affect any paralyzed person (such as pneumonia or bed sores) and the need for sophisticated medical equipment, individuals with Guillain-Barré syndrome are usually admitted and treated in a hospital’s intensive care unit.

Acute care

There are currently two treatments commonly used to interrupt immune-related nerve damage. One is plasma exchange (also called plasmapheresis); the other is high-dose immunoglobulin therapy (IVIg). Both treatments are equally effective if started within two weeks of onset of Guillain-Barre syndrome symptoms, but immunoglobulin is easier to administer. Using both treatments in the same person has no proven benefit.

In the process of plasma exchange, a plastic tube called a catheter is inserted into the person’s veins, through which some blood is removed. The blood cells from the liquid part of the blood (plasma) are extracted and returned to the person. This technique seems to reduce the severity and duration of the Guillain-Barré episode. Plasma contains antibodies and plasmapheresis removes some plasma; plasmapheresis may work by removing the bad antibodies that have been damaging the nerves.

Immunoglobulins are proteins that the immune system naturally makes to attack infecting organisms. IVIg therapy involves intravenous injections of these immunoglobulins. The immunoglobulins are developed from a pool of thousands of normal donors. When IVIg is given to people with Guillain-Barre syndrome, the result can be a lessening of the immune attack on the nervous system. The IVIg can also shorten recovery time. Investigators believe this treatment also lowers the levels or effectiveness of antibodies that attack the nerves by both “diluting” them with non-specific antibodies and providing antibodies that bind to the harmful antibodies and take them out of commission.

Miller-Fisher syndrome is also treated with plasmapheresis and IVIg.

Anti-inflammatory steroid hormones called corticosteroids have also been tried to reduce the severity of Guillain-Barré syndrome. However, controlled clinical trials have demonstrated that this treatment is not effective.

You also are likely to be given medication to:

• Relieve pain, which can be severe
• Prevent blood clots, which can develop while you’re immobile

People with Guillain-Barre syndrome need physical help and therapy before and during recovery. Your care may include:

• Movement of your arms and legs by caregivers before recovery, to help keep your muscles flexible and strong
• Physical therapy during recovery to help you cope with fatigue and regain strength and proper movement
• Training with adaptive devices, such as a wheelchair or braces, to give you mobility and self-care skills

Supportive care is very important to address the many complications of paralysis as the body recovers and damaged nerves begin to heal. Respiratory failure can occur in Guillain-Barre syndrome, so close monitoring of a person’s breathing should be instituted initially. Sometimes a mechanical ventilator is used to help support or control breathing. The autonomic nervous system (that regulates the functions of internal organs and some of the muscles in the body) can also be disturbed, causing changes in heart rate, blood pressure, toileting, or sweating. Therefore, the person should be put on a heart monitor or equipment that measures and tracks body function. Occasionally Guillain-Barre syndrome-related nerve damage can lead to difficulty handling secretions in the mouth and throat. In addition to the person choking and/or drooling, secretions can fall into the airway and cause pneumonia.

Recovery

Although some people can take months and even years to recover, most people with Guillain-Barre syndrome experience this general timeline:

• After the first signs and symptoms, the condition tends to progressively worsen for about two weeks
• Symptoms reach a plateau within four weeks
• Recovery begins, usually lasting six to 12 months, though for some people it could take as long as three years

Among adults recovering from Guillain-Barre syndrome:

• About 80 percent can walk independently six months after diagnosis
• About 60 percent fully recover motor strength one year after diagnosis
• About 5 to 10 percent have very delayed and incomplete recovery

Children, who rarely develop Guillain-Barre syndrome, generally recover more completely than adults.

Rehabilitative care

As individuals begin to improve, they are usually transferred from the acute care hospital to a rehabilitation setting. Here, they can regain strength, receive physical rehabilitation and other therapy to resume activities of daily living, and prepare to return to their pre-illness life.

Complications in Guillain-Barre syndrome can affect several parts of the body. Often, even before recovery begins, caregivers may use several methods to prevent or treat complications. For example, a therapist may be instructed to manually move and position the person’s limbs to help keep the muscles flexible and prevent muscle shortening. Injections of blood thinners can help prevent dangerous blood clots from forming in leg veins. Inflatable cuffs may also be placed around the legs to provide intermittent compression. All or any of these methods helps prevent blood stagnation and sludging (the buildup of red blood cells in veins, which could lead to reduced blood flow) in the leg veins. Muscle strength may not return uniformly; some muscles that get stronger faster may tend to take over a function that weaker muscles normally perform—called substitution. The therapist should select specific exercises to improve the strength of the weaker muscles so their original function can be regained.

Occupational and vocational therapy help individuals learn new ways to handle everyday functions that may be affected by the disease, as well as work demands and the need for assistive devices and other adaptive equipment and technology.

Acute inflammatory demyelinating polyneuropathy prognosis

Guillain-Barré syndrome can be a devastating disorder because of its sudden and rapid, unexpected onset of weakness—and usually actual paralysis. Fortunately, 70% of people with Guillain-Barre syndrome eventually experience full recovery. With careful intensive care and successful treatment of infection, autonomic dysfunction and other medical complications, even those individuals with respiratory failure usually survive.

Typically, the point of greatest weakness occurs days to at most 4 weeks after the first symptoms occur. Symptoms then stabilize at this level for a period of days, weeks, or, sometimes months. Recovery, however, can be slow or incomplete. The recovery period may be as little as a few weeks up to a few years. Some individuals still report ongoing improvement after 2 years. About 30 percent of those with Guillain-Barré have residual weakness after 3 years. About 3 percent may suffer a relapse of muscle weakness and tingling sensations many years after the initial attack. About 15 percent of individuals experience long-term weakness; some may require ongoing use of a walker, wheelchair, or ankle support. Muscle strength may not return uniformly.

Ongoing fatigue, pain, and other annoying sensations can sometimes be troublesome. Fatigue is best handled by pacing activities and providing time for rest when fatigue sets in. Those with Guillain-Barré syndrome face not only physical difficulties, but emotionally painful periods as well. It is often extremely difficult for individuals to adjust to sudden paralysis and dependence on others for help with routine daily activities. Individuals sometimes need psychological counseling to help them adapt. Support groups can often ease emotional strain and provide valuable information.

Chronic inflammatory demyelinating polyneuropathy

Chronic inflammatory demyelinating polyneuropathy is a neurological disorder characterized by progressive weakness and impaired sensory function in the legs and arms. Chronic inflammatory demyelinating polyneuropathy, which is sometimes called chronic relapsing polyneuropathy, is caused by damage to the myelin sheath (the fatty covering that wraps around and protects nerve fibers) of the peripheral nerves. Although it can occur at any age and in both genders, chronic inflammatory demyelinating polyneuropathy is more common in young adults, and in men more so than women. It often presents with symptoms that include tingling or numbness (beginning in the toes and fingers), weakness of the arms and legs, loss of deep tendon reflexes (areflexia), fatigue, and abnormal sensations. Chronic inflammatory demyelinating polyneuropathy is closely related to Guillain-Barre syndrome and it is considered the chronic counterpart of that acute disease.

Treatment for chronic inflammatory demyelinating polyneuropathy includes corticosteroids such as prednisone, which may be prescribed alone or in combination with immunosuppressant drugs. Plasmapheresis (plasma exchange) and intravenous immunoglobulin (IVIg) therapy are effective. IVIg may be used even as a first-line therapy. Physiotherapy may improve muscle strength, function and mobility, and minimize the shrinkage of muscles and tendons and distortions of the joints.

Chronic inflammatory demyelinating polyneuropathy causes

Chronic inflammatory demyelinating polyneuropathy is one cause of damage to nerves outside the brain or spinal cord (peripheral neuropathy). Polyneuropathy means several nerves are involved. chronic inflammatory demyelinating polyneuropathy often affects both sides of the body.

Chronic inflammatory demyelinating polyneuropathy is caused by an abnormal immune response. chronic inflammatory demyelinating polyneuropathy occurs when the immune system attacks the myelin cover of the nerves. For this reason, chronic inflammatory demyelinating polyneuropathy is thought to be an autoimmune disease.

Health care providers also consider chronic inflammatory demyelinating polyneuropathy as the chronic form of Guillain-Barré syndrome.

The specific triggers of chronic inflammatory demyelinating polyneuropathy vary. In many cases, the cause cannot be identified.

Chronic inflammatory demyelinating polyneuropathy may occur with other conditions, such as:

• Chronic hepatitis
• Diabetes
• Infection with the bacterium Campylobacter jejuni
• HIV/AIDS
• Immune system disorders due to cancer
• Inflammatory bowel disease
• Systemic lupus erythematosus
• Cancer of the lymph system
• Overactive thyroid
• Side effects of medicines to treat cancer or HIV

Chronic inflammatory demyelinating polyneuropathy symptoms

Chronic inflammatory demyelinating polyneuropathy symptoms include any of the following:

• Problems walking due to weakness or lack of feeling in the feet
• Trouble using the arms and hands or legs and feet due to weakness
• Sensation changes, such as numbness or decreased sensation, pain, burning, tingling, or other abnormal sensations (usually affects the feet first, then the arms and hands)

Other symptoms that can occur with chronic inflammatory demyelinating polyneuropathy include:

• Abnormal or uncoordinated movement
• Problems breathing
• Fatigue
• Hoarseness or changing voice or slurred speech.

Chronic inflammatory demyelinating polyneuropathy possible complications

Complications of chronic inflammatory demyelinating polyneuropathy include:

• Pain
• Permanent decrease or loss of sensation in areas of the body
• Permanent weakness or paralysis in areas of the body
• Repeated or unnoticed injury to an area of the body
• Side effects of medicines used to treat the disorder

Chronic inflammatory demyelinating polyneuropathy diagnosis

Your doctor will perform a physical exam and ask about the symptoms, focusing on the nervous system and muscles.

Tests that may be ordered include:

• Electromyography (EMG) to check the muscles and the nerves that control the muscles
• Nerve conduction tests to check how fast electrical signals move through a nerve
• Nerve biopsy to remove a small piece of a nerve for examination
• Spinal tap (lumbar puncture) to check the fluid that surrounds the brain and spinal cord
• Blood tests may be done to look for specific proteins that are causing the immune attack on the nerves
• Lung function tests to check if breathing is affected

Depending on the suspected cause of chronic inflammatory demyelinating polyneuropathy, other tests, such as x-rays, imaging scans, and blood tests, may be done.

Chronic inflammatory demyelinating polyneuropathy treatment

The goal of treatment is to reverse the attack on the nerves. In some cases, nerves can heal and their function can be restored. In other cases, nerves are badly damaged and cannot heal, so treatment is aimed at preventing the disease from getting worse.

Which treatment is given depends on how severe the symptoms are, among other things. The most aggressive treatment is only given if you have difficulty walking, breathing, or if symptoms don’t allow you to care for yourself or work.

Treatments may include:

• Corticosteroids to help reduce inflammation and relieve symptoms
• Other medicines that suppress the immune system (for some severe cases)
• Plasmapheresis or plasma exchange to remove antibodies from the blood
• Intravenous immune globulin (IVIg), which involves adding large numbers of antibodies to the blood plasma to reduce the effect of the antibodies that are causing the problem.

Chronic inflammatory demyelinating polyneuropathy prognosis

The course of chronic inflammatory demyelinating polyneuropathy varies widely among individuals. Some may have a bout of chronic inflammatory demyelinating polyneuropathy followed by spontaneous recovery, while others may have many bouts with partial recovery in between relapses. Chronic inflammatory demyelinating polyneuropathy is a treatable cause of acquired neuropathy and initiation of early treatment to prevent loss of nerve axons is recommended. However, some individuals are left with some residual numbness or weakness.

Peripheral polyneuropathy

Peripheral polyneuropathy is a type of nerve damage that typically affects the feet and legs and sometimes affects the hands and arms. Peripheral polyneuropathy is very common. Up to one-half of people with diabetes have peripheral neuropathy ².

Peripheral polyneuropathy causes

Over time, high blood glucose, also called blood sugar, and high levels of fats, such as triglycerides, in the blood from diabetes can damage your nerves and the small blood vessels that nourish your nerves, leading to peripheral neuropathy.

Peripheral polyneuropathy prevention

You can prevent the problems caused by peripheral neuropathy by managing your diabetes, which means managing your blood glucose, blood pressure, and cholesterol. Staying close to your goal numbers can keep nerve damage from getting worse.

If you have diabetes, check your feet for problems every day and take good care of your feet. If you notice any foot problems, call or see your doctor right away.

Remove your socks and shoes in the exam room to remind your doctor to check your feet at every office visit. See your doctor for a foot exam at least once a year—more often if you have foot problems. Your doctor may send you to a podiatrist.

What are the symptoms of peripheral polyneuropathy?

If you have peripheral neuropathy, your feet, legs, hands, or arms may feel

• burning
• tingling, like “pins and needles”
• numb
• painful
• weak

You may feel extreme pain in your feet, legs, hands, and arms, even when they are touched lightly. You may also have problems sensing pain or temperature in these parts of your body.

Symptoms are often worse at night. Most of the time, you will have symptoms on both sides of your body. However, you may have symptoms only on one side.

If you have peripheral neuropathy, you might experience:

• changes in the way you walk
• loss of balance, which could make you fall more often
• loss of muscle tone in your hands and feet
• pain when you walk
• problems sensing movement or position
• swollen feet

What problems does peripheral polyneuropathy cause?

Peripheral neuropathy can cause foot problems that lead to blisters and sores. If peripheral neuropathy causes you to lose feeling in your feet, you may not notice pressure or injuries that lead to blisters and sores. Diabetes can make these wounds difficult to heal and increase the chance of infections. These sores and infections can lead to the loss of a toe, foot, or part of your leg. Finding and treating foot problems early can lower the chances that you will develop serious infections.

This type of diabetes-related nerve damage can also cause changes to the shape of your feet and toes. A rare condition that can occur in some people with diabetes is Charcot’s foot, a problem in which the bones and tissue in your foot are damaged.

Peripheral neuropathy can make you more likely to lose your balance and fall, which can increase your chance of fractures and other injuries. The chronic pain of peripheral neuropathy can also lead to grief, anxiety, and depression.

Peripheral neuropathy diagnosis

Doctors diagnose peripheral neuropathy based on your symptoms, family and medical history, a physical exam, and tests. A physical exam will include a neurological exam and a foot exam.

Examination for neuropathy

If you have diabetes, you should get a thorough exam to test how you feel in your feet and legs at least once a year. During this exam, your doctor will look at your feet for signs of problems and check the blood flow and feeling, or sensation, in your feet by:

• placing a tuning fork against your great toes and higher on your feet to check whether you can feel vibration
• touching each foot and some toes with a nylon strand to see if you can feel it—a procedure called a monofilament test
• reviewing your gait, or the patterns you make when you walk
• testing your balance

Your doctor may also check if you can feel temperature changes in your feet.

Tests to diagnose peripheral neuropathy

Your doctor may perform tests to rule out other causes of nerve damage, such as a blood test to check for thyroid problems, kidney disease, or low vitamin B12 levels. If low B12 levels are found, your doctor will do additional tests to determine the cause. Metformin use is among several causes of low vitamin B12 levels. If B12 deficiency is due to metformin, metformin can be continued with B12 supplementation.

Peripheral neuropathy treatment

Doctors may prescribe medicine and other treatments for pain.

Medications for nerve pain

Your doctor may prescribe medicines to help with pain, such as certain types of:

• antidepressants, including:
  • tricyclic antidepressants, such as nortriptyline, desipramine, imipramine, and amitriptyline
  • other types of antidepressants, such as duloxetine, venlafaxine, paroxetine, and citalopram
• anticonvulsants—medicines designed to treat seizures—such as gabapentin and pregabalin
• skin creams, patches, or sprays, such as lidocaine

Although these medicines can help with the pain, they do not change the nerve damage. Therefore, if there is no improvement with a medicine to treat pain, there is no benefit to continuing to take it and another medication may be tried.

All medicines have side effects. Ask your doctor about the side effects of any medicines you take. Doctors don’t recommend some medicines for older adults or for people with other health problems, such as heart disease.

Some doctors recommend avoiding over-the-counter pain medicines, such as acetaminophen and ibuprofen. These medicines may not work well for treating most nerve pain and can have side effects.

Other treatments for nerve pain

Your doctor may recommend other treatments for pain, including:

• physical therapy to improve your strength and balance
• a bed cradle, a device that keeps sheets and blankets off your legs and feet while you sleep

Diabetes experts have not made special recommendations about supplements for people with diabetes. For safety reasons, talk with your doctor before using supplements or any complementary or alternative medicines or medical practices.

Polyneuropathy causes

Not a single disease, peripheral neuropathy is nerve damage caused by a number of conditions. Causes of neuropathies include:

• Alcoholism. Poor dietary choices made by people with alcoholism can lead to vitamin deficiencies.
• Autoimmune diseases. These include Sjogren’s syndrome, lupus, rheumatoid arthritis, Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy and necrotizing vasculitis.
• Diabetes. More than half the people with diabetes develop some type of neuropathy.
• Exposure to poisons. Toxic substances include heavy metals or chemicals.
• Medications. Certain medications, especially those used to treat cancer (chemotherapy), can cause peripheral neuropathy.
• Infections. These include certain viral or bacterial infections, including Lyme disease, shingles, Epstein-Barr virus, hepatitis C, leprosy, diphtheria and HIV.
• Inherited disorders. Disorders such as Charcot-Marie-Tooth disease are hereditary types of neuropathy.
• Trauma or pressure on the nerve. Traumas, such as from motor vehicle accidents, falls or sports injuries, can sever or damage peripheral nerves. Nerve pressure can result from having a cast or using crutches or repeating a motion such as typing many times.
• Tumors. Growths, cancerous (malignant) and noncancerous (benign), can develop on the nerves or press nerves. Also, polyneuropathy can arise as a result of some cancers related to the body’s immune response. These are a form of paraneoplastic syndrome.
• Vitamin deficiencies. B vitamins — including B-1, B-6 and B-12 — vitamin E and niacin are crucial to nerve health.
• Bone marrow disorders. These include abnormal protein in the blood (monoclonal gammopathies), a form of bone cancer (osteosclerotic myeloma), lymphoma and amyloidosis.
• Other diseases. These include kidney disease, liver disease, connective tissue disorders and an underactive thyroid (hypothyroidism).

In a number of cases, no cause can be identified (idiopathic).

Risk factors for polyneuropathy

Peripheral neuropathy risk factors include:

• Diabetes mellitus, especially if your sugar levels are poorly controlled
• Alcohol abuse
• Vitamin deficiencies, particularly B vitamins
• Infections, such as Lyme disease, shingles, Epstein-Barr virus, hepatitis C and HIV
• Autoimmune diseases, such as rheumatoid arthritis and lupus, in which your immune system attacks your own tissues
• Kidney, liver or thyroid disorders
• Exposure to toxins
• Repetitive motion, such as those performed for certain jobs
• Family history of neuropathy.

Polyneuropathy prevention

Manage underlying conditions

The best way to prevent peripheral neuropathy is to manage medical conditions that put you at risk, such as diabetes, alcoholism or rheumatoid arthritis.

Make healthy lifestyle choices

For example:

• Eat a diet rich in fruits, vegetables, whole grains and lean protein to keep nerves healthy. Protect against vitamin B-12 deficiency by eating meats, fish, eggs, low-fat dairy foods and fortified cereals. If you’re vegetarian or vegan, fortified cereals are a good source of vitamin B-12, but talk to your doctor about B-12 supplements.
• Exercise regularly. With your doctor’s OK, try to get at least 30 minutes to one hour of exercise at least three times a week.
• Avoid factors that may cause nerve damage, including repetitive motions, cramped positions, exposure to toxic chemicals, smoking and overindulging in alcohol.

Polyneuropathy symptoms

Every nerve in your peripheral system has a specific function, so symptoms depend on the type of nerves affected. Nerves are classified into:

• Sensory nerves that receive sensation, such as temperature, pain, vibration or touch, from the skin
• Motor nerves that control muscle movement
• Autonomic nerves that control functions such as blood pressure, heart rate, digestion and bladder

Signs and symptoms of peripheral neuropathy might include:

• Gradual onset of numbness, prickling or tingling in your feet or hands, which can spread upward into your legs and arms
• Sharp, jabbing, throbbing, freezing or burning pain
• Extreme sensitivity to touch
• Lack of coordination and falling
• Muscle weakness or paralysis if motor nerves are affected

If autonomic nerves are affected, signs and symptoms might include:

• Heat intolerance and altered sweating
• Bowel, bladder or digestive problems
• Changes in blood pressure, causing dizziness or lightheadedness

Peripheral neuropathy can affect one nerve (mononeuropathy), two or more nerves in different areas (multiple mononeuropathy) or many nerves (polyneuropathy). Carpal tunnel syndrome is an example of mononeuropathy. Most people with peripheral neuropathy have polyneuropathy.

Polyneuropathy complications

Complications of peripheral neuropathy can include:

• Burns and skin trauma. You might not feel temperature changes or pain on parts of your body that are numb.
• Infection. Your feet and other areas lacking sensation can become injured without your knowing. Check these areas regularly and treat minor injuries before they become infected, especially if you have diabetes mellitus.
• Falls. Weakness and loss of sensation may be associated with lack of balance and falling.

Polyneuropathy diagnosis

Peripheral neuropathy has many potential causes. Besides a physical exam, which may include blood tests, diagnosis usually requires:

• A full medical history. Your doctor will review your medical history, including your symptoms, your lifestyle, exposure to toxins, drinking habits and a family history of nervous system (neurological) diseases.
• Neurological examination. Your doctor might check your tendon reflexes, your muscle strength and tone, your ability to feel certain sensations, and your posture and coordination.

Your doctor may order tests, including:

• Blood tests. These can detect vitamin deficiencies, diabetes, abnormal immune function and other indications of conditions that can cause peripheral neuropathy.
• Imaging tests. CT or MRI scans can look for herniated disks, tumors or other abnormalities.
• Nerve function tests. Electromyography records electrical activity in your muscles to detect nerve damage. A probe sends electrical signals to a nerve, and an electrode placed along the nerve’s pathway records the nerve’s response to the signals (nerve conduction studies).
• Other nerve function tests. These might include an autonomic reflex screen that records how the autonomic nerve fibers work, a sweat test, and sensory tests that record how you feel touch, vibration, cooling and heat.
• Nerve biopsy. This involves removing a small portion of a nerve, usually a sensory nerve, to look for abnormalities.
• Skin biopsy. Your doctor removes a small portion of skin to look for a reduction in nerve endings.

Polyneuropathy treatment

Treatment goals are to manage the condition causing your neuropathy and to relieve symptoms. If your lab tests indicate no underlying condition, your doctor might recommend watchful waiting to see if your neuropathy improves.

Medications

Besides medications used to treat conditions associated with peripheral neuropathy, medications used to relieve peripheral neuropathy signs and symptoms include:

• Pain relievers. Over-the-counter pain medications, such as nonsteroidal anti-inflammatory drugs, can relieve mild symptoms. For more-severe symptoms, your doctor might prescribe painkillers. Medications containing opioids, such as tramadol (Conzip, Ultram) or oxycodone (Oxycontin, Roxicodone, others), can lead to dependence and addiction, so these drugs generally are prescribed only when other treatments fail.
• Anti-seizure medications. Medications such as gabapentin (Gralise, Neurontin) and pregabalin (Lyrica), developed to treat epilepsy, may relieve nerve pain. Side effects can include drowsiness and dizziness.
• Topical treatments. Capsaicin cream, which contains a substance found in hot peppers, can cause modest improvements in peripheral neuropathy symptoms. You might have skin burning and irritation where you apply the cream, but this usually lessens over time. Some people, however, can’t tolerate it. Lidocaine patches are another treatment you apply to your skin that might offer pain relief. Side effects can include drowsiness, dizziness and numbness at the site of the patch.
• Antidepressants. Certain tricyclic antidepressants, such as amitriptyline, doxepin and nortriptyline (Pamelor), have been found to help relieve pain by interfering with chemical processes in your brain and spinal cord that cause you to feel pain. The serotonin and norepinephrine reuptake inhibitor duloxetine (Cymbalta) and the extended-release antidepressant venlafaxine (Effexor XR) also might ease the pain of peripheral neuropathy caused by diabetes. Side effects may include dry mouth, nausea, drowsiness, dizziness, decreased appetite and constipation.

Therapies

Various therapies and procedures might help ease the signs and symptoms of peripheral neuropathy.

• Transcutaneous electrical nerve stimulation (TENS). Electrodes placed on the skin deliver a gentle electric current at varying frequencies. TENS should be applied for 30 minutes daily for about a month.
• Plasma exchange (plasmapheresis) and intravenous immune globulin (IVIg). These procedures, which help suppress immune system activity, might benefit people with certain inflammatory conditions. Plasma exchange involves removing your blood, then removing antibodies and other proteins from the blood and returning the blood to your body. In immune globulin therapy, you receive high levels of proteins that work as antibodies (immunoglobulins).
• Physical therapy. If you have muscle weakness, physical therapy can help improve your movements. You may also need hand or foot braces, a cane, a walker, or a wheelchair.
• Surgery. If you have neuropathies caused by pressure on nerves, such as pressure from tumors, you might need surgery to reduce the pressure.

Home remedies

To help you manage peripheral neuropathy:

• Take care of your feet, especially if you have diabetes. Check daily for blisters, cuts or calluses. Wear soft, loose cotton socks and padded shoes. You can use a semicircular hoop, which is available in medical supply stores, to keep bedcovers off hot or sensitive feet.
• Exercise. Regular exercise, such as walking three times a week, can reduce neuropathy pain, improve muscle strength and help control blood sugar levels. Gentle routines such as yoga and tai chi might also help.
• Quit smoking. Cigarette smoking can affect circulation, increasing the risk of foot problems and other neuropathy complications.
• Eat healthy meals. Good nutrition is especially important to ensure that you get essential vitamins and minerals. Include fruits, vegetables, whole grains and lean protein in your diet.
• Avoid excessive alcohol. Alcohol can worsen peripheral neuropathy.
• Monitor your blood glucose levels. If you have diabetes, this will help keep your blood glucose under control and might help improve your neuropathy.

Alternative medicine

Some people with peripheral neuropathy try complementary treatments for relief. Although researchers haven’t studied these techniques as thoroughly as they have most medications, the following therapies have shown some promise:

• Acupuncture. Inserting thin needles into various points on your body might reduce peripheral neuropathy symptoms. You might need multiple sessions before you notice improvement. Acupuncture is generally considered safe when performed by a certified practitioner using sterile needles.
• Alpha-lipoic acid. This has been used as a treatment for peripheral neuropathy in Europe for years. Discuss using alpha-lipoic acid with your doctor because it can affect blood sugar levels. Other side effects can include stomach upset and skin rash.
• Herbs. Certain herbs, such as evening primrose oil, might help reduce neuropathy pain in people with diabetes. Some herbs interact with medications, so discuss herbs you’re considering with your doctor.
• Amino acids. Amino acids, such as acetyl-L-carnitine, might benefit people who have undergone chemotherapy and people with diabetes. Side effects might include nausea and vomiting.

1. Association of glycaemia with macrovascular and microvascular complications of Type 2 diabetes: prospective observational study. British Medical Journal 2000; 321: 405-412.
2. Pop-Busui R, Boulton AJ, Feldman EL, et al. Diabetic neuropathy: a position statement by the American Diabetes Association. Diabetes Care. 2017;40(1):136–154.