Christine Manga, a diabetes nurse educator, clarifies what diabetic amyotrophy is and the necessary information you need to know.

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Diabetic amyotrophy is also known as proximal diabetic neuropathy, ischaemic mononeuropathy, diabetic lumbosacral plexopathy, Bruns-Garland syndrome, to name but a few.

In 1890, neurologist Ludwig Bruns first described the condition in people with diabetes, usually poorly controlled. In 1955, another neurologist, Hugh Garland coined the term amyotrophy. For this article I will refer to it as diabetic amyotrophy.

What is diabetic amyotrophy?

Diabetic amyotrophy is a rare episodic and progressive form of diabetic neuropathy. It’s characterised by loss of unilateral (sometimes bilateral) proximal motor function, atrophy (wasting, shrinking) of muscles in the front upper legs, sensation of severe burning, weakness, and pain.

An extreme aching pain in the hips, thighs and buttocks are almost always present. This is often followed by weakness. Anywhere between 35 – 50% of affected people will report unintended weight loss. Getting up from a sitting position becomes difficult. This condition can be disabling with some people requiring wheelchair assistance for a time. Progression of diabetic amyotrophy is quick, taking a few months.

Causes

The causes are not fully understood. Possible causes include but are not limited to:

• A sudden reduction in blood glucose levels of a person with chronically raised blood glucose levels
• Initiation of anti-hyperglycaemic treatment
• An immune mediated vasculitis causing ischaemic (insufficient blood supply) damage to the nerves, and it has also been referred to as idiopathic.

Who is at risk?

Almost 50% of people with diabetes will experience diabetic neuropathy. However, diabetic amyotrophy only affects approximately 0.8 – 1% of people with diabetes. It affects more people with Type 2 diabetes compared to Type 1.

Onset is usually during middle age but can be seen in younger individuals. Males over the age of 50 with Type 2 diabetes are the most frequently affected. Duration and severity of diabetes are not predisposing factors. People with good glucose control can also experience diabetic amyotrophy.

How is diabetic amyotrophy diagnosed?

Diagnosis usually consists of a thorough history taking and physical examination especially of the lower limbs as well as reflex testing. To exclude other conditions with similar symptoms, such as nerve compression, a process of elimination is used.

A lumbar puncture, nerve conduction studies, and MRI scans may be performed. A blood workup will be done to assess diabetes control, vitamin deficiencies and inflammation markers.

Treatment

Treatment is pain management. However, it does not respond to conventional pain medication, rather anti-epileptic, antidepressants, such as amitriptyline, and nerve pain treatments. Recently steroidal medication has been used. It appears to increase recovery time but also causes an increase in blood glucose levels. There is still not enough evidence for its use. Good glucose control is to be strived for.

An improvement in diet, physical exercise, such as physio, and stopping smoking and alcohol aid in recovery. The physiotherapy can aid in nerve restoration.

Diabetic amyotrophy can lead to anxiety and depression. Education is of utmost importance, hence explaining the progression to possible severe disability, paraplegia, and extreme pain. Although, it will not reverse diabetic amyotrophy, regular foot examinations for injury, wounds and infection will prevent further complications. The goal of treatment is to improve quality of life.

Prognosis

Diabetic amyotrophy is self-limiting and the likelihood of full recovery is probable. The entire process takes a few months up to about two years. Sometimes, but not often up to three years. Reassurance and encouragement that it will resolve is vital.

Prevention

There is no precise way to prevent diabetic amyotrophy. The principles used to prevent general diabetes complications should be adhered to, including smoking cessation, good glucose control, limit alcohol intake, maintain a healthy BMI and regular check-ups with your doctor, dietitian, and educator.

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Lynette Lacock, an occupational health sister, highlights the role of the podiatrist in the healthcare team for those living with diabetes.

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You may not be aware of how important it is as a person with diabetes to take care of your feet. Since diabetes can cause poor circulation and neuropathy, it’s essential to have your feet and lower extremities examined by a podiatrist regularly.

Podiatrists are doctors who treat conditions of the lower limbs, including feet and ankles. Therefore, they are the best healthcare professional to see routinely to prevent any future problems relating to feet and diabetes.

The saying prevention is better than cure rings true in this case.  Wounds are often difficult to treat when you have diabetes due to poor blood flow. You need to be vigilant when it comes to preventing sores and infections and you also need to be on the lookout for blisters or sores caused by ill-fitting shoes. If you have even a mild neuropathy in your feet, your shoes may not feel tight even though they are damaging your skin.

What can podiatrists assist you with?

• Routine foot exams

It’s crucial for all people with diabetes to have a professional exam of their feet and lower extremities on an annual basis. A trained podiatrist will be able to see things that you may have not noticed.

• Early detection and prevention

Detecting a blister or treating an open wound when it first happens is the key to preventing the problem from getting worse. Most people with diabetes have problems with poor circulation and neuropathy. Neuropathy is caused by nerve damage due to uncontrolled blood glucose. It causes you to have less feeling or sensation in an extremity. If you can’t feel that your shoe is too tight or rubbing in an area, then you can develop a blister or wound without even knowing about it.

• Mechanical assessment

A podiatrist can watch your gait or the way you walk to see if there is anything out of the ordinary. If there is, they can recommend a specialised shoe or orthotic to help prevent any damage from happening.  

• Foot wound and ulcer care

If you do get a wound or ulcer, the podiatrist is the best person to treat it. You may also need a course of antibiotics which they can also prescribe. Don’t ignore a blister, wound or open ulcer.  These are difficult to treat in people with diabetes and you want to take care of it immediately to prevent it from getting any worse. 

• Surgical procedures

Podiatrist can also perform any surgical procedures necessary to treat lower extremity deformities or to debride dead tissue to allow an existing wound to heal.

Multi-disciplinary care

Although podiatrists are the foot specialists, they are part of a team that works together treating diabetic foot and lower extremity problems. They collaborate with vascular surgeons if they feel you need to be referred because of poor circulation. And if they are aware that you are having problems controlling your blood glucose, they may refer you to an endocrinologist. They all form a team that play a part in keeping you healthy.

Now that you understand the role of the podiatrist, make an appointment to see one. Don’t put it off until something is seriously wrong. Rather try to prevent complications before they happen by having routine check-ups and keeping your blood glucose under control.

References

• https://www.cdc.gov/diabetes/professional-info/health-care-pro/diabetes-podiatrist-health.html#:~:text=Podiatrists%20play%20a%20key%20role,exams%20and%20treatment%20if%20needed.
• https://jfootankleres.biomedcentral.com/articles/10.1186/s13047-020-0380-8
• https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/diabetes-foot-care
• https://www.apma.org/diabetescare

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Dr Rakesh Newaj shares the tell-tale signs of the skin that can be indicative of underlying diabetes.

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Diabetes, a multi-faceted condition marked by the body’s inability to regulate blood glucose levels effectively, can exert profound effects on various organs.

Most of the time, it’s discovered fairly late, when other organ complications, prompts the medical practitioner to do a blood glucose test. At this stage, some of the damage caused by unregulated blood glucose is usually irreversible. Fortunately, the skin, serving as a visible interface with the external environment, often reflects internal metabolic disturbances, offering valuable insights for diagnosis and management.

Acanthosis nigricans

One prominent cutaneous manifestation indicative of insulin resistance and impending diabetes is acanthosis nigricans. This condition manifests as velvety, hyperpigmented patches of skin, typically observed in areas such as the neck, axillae, and facial regions.

Despite rigorous hygiene practices, the distinct texture persists, prompting individuals to seek evaluation for underlying insulin resistance and diabetes. Treatment strategies encompass a holistic approach, including meticulous blood glucose control, regular physical activity, weight management interventions, and, in some cases, adjunctive therapies like chemical peels to address cosmetic concerns.

Dry skin

Individuals grappling with poorly-controlled diabetes often contend with troublesome dermatological issues, such as dry skin, particularly prevalent on the shins, accompanied by intense itching. This tends to be very persistent with bouts of scratching that leads to injuries on the skin.

Effective management entails meticulous blood glucose regulation alongside targeted interventions, such as the application of specialised moisturising creams, to alleviate discomfort and prevent complications. Sometimes the use of antihistamines and steroid creams can be very helpful in easing symptoms.

Skin tags

Moreover, the presence of multiple skin tags in regions like the neck, face, axillae, or groin may signal an underlying association with diabetes, often also linked to obesity. These tags can appear over a short period of time and can be very unsightly.

Treatment modalities typically involve the removal of these skin tags through cautery procedures, aiming to alleviate discomfort or improve the cosmetic look.

Skin infections

Diabetic individuals, owing to compromised immunity and metabolic dysregulation, frequently encounter recurrent skin infections. Bacterial infections commonly present as multiple sores scattered across the body, necessitating prompt medical attention and targeted antimicrobial therapy.

Conversely, rashes in skin folds should raise suspicion of fungal infections, such as candida. Another very common fungus infection in people with diabetes is called pityriasis versicolor. It appears as hypo or hyperpigmented patches mainly on the back and chest regions.

Addressing these infections may involve antifungal medications and meticulous hygiene practices to prevent recurrence. Additionally, diabetic individuals may contend with recurring vaginal yeast infections and oral thrush, warranting comprehensive management strategies tailored to individual needs.

Delayed wound healing

Prolonged hyperglycaemia can culminate in systemic complications, including impaired circulation and nerve damage, precipitating delayed wound healing and the development of diabetic ulcers.

In severe cases, chronic poor glycaemic control may precipitate toe gangrene, necessitating aggressive interventions, including amputations, to forestall further complications.

Diabetic dermopathy

Diabetic dermopathy is characterised by brownish skin discoloration on the shin. This type of skin lesion is fairly common and starts as pale macules which become darker in colour with time.

Many patients are unaware of its implications and try to ignore it at first till it becomes a cosmetic disturbance. The brown patches pose a therapeutic challenge to doctors due to their stubborn nature.

Diabetic blister

Sometimes patients present with a single blister on the lower leg, without a history of trauma. The blister appears overnight and can be fairly big. This is called a diabetic blister and warrants a full investigation to exclude the disease.

Necrobiosis lipoidica

Necrobiosis lipoidica can be considered as one of the cutaneous markers of diabetes. It presents as yellow atrophic patches, most often on the shins. Sometimes a red-brown rim may indicate activity at the border. Ulceration may also occur and is very slow to heal. There can be reduced sensation to fine touch in the affected area. The affected person needs to see a dermatologist to confirm the diagnosis and treat this condition.

Comprehensive management

While various other rare cutaneous signs may serve as harbingers of underlying diabetes, consultation with healthcare professionals is paramount for accurate diagnosis and comprehensive management. By adopting a multi-disciplinary approach encompassing lifestyle modifications, pharmacotherapy, and preventive measures, individuals can mitigate the impact of diabetes on skin health and overall well-being.

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