Peripheral nerves require an adequate blood supply, intact glucose and lipid metabolism, and mitochondrial function for their optimal function, all of which can be disturbed in diabetes (Sloan et al, 2021). The pathophysiological mechanisms of the DSPN are multifactorial. Pathophysiological mechanisms of painful DSPN Chronic pain results in low mood as a consequence of the impact that pain has on an individual’s ability to function, resulting in a reduced quality of life and an inability to maintain employment (Jensen et al, 2007). Peripheral neuropathic pain is known to have a significant impact on health-related quality of life, and individuals with painful DSPN are often profoundly disabled. Pain is typically worse at night and some individuals report pain on weight-bearing. People with DSPN report increased pain with a painful stimulus (hyperalgesia) as well as pain due to stimuli that do not normally provoke pain (allodynia). Painful DSPN impacts significantly on quality of life, and symptoms include a burning type of pain, electric shock-type pains and a cold, aching pain. Meng and colleagues (2015) found genetic alterations associated with neuronal excitability in individuals suffering with painful DSPN. Risk factors for painful DSPN are poorly understood and associations have been reported with the duration of diabetes, HbA 1c and body weight (Raputova et al, 2017). Painful DSPN – risk factors and epidemiology This article briefly outlines the epidemiology and pathophysiology of painful DSPN, focusing on current medical management, and aims to highlight the evidence and underutilised role of spinal cord stimulation (SCS) in the management of painful DSPN. The prevalence of painful DSPN has been estimated to be between 13% and 35% (Ponirakis et al, 2019). Diabetic sensorimotor peripheral neuropathy (DSPN) is a complication of diabetes and is the main precipitating factor for diabetic foot complications (Sloan et al, 2021). It has been estimated that 700 million people globally will have diabetes by the year 2045 (Saeedi et al, 2019). Robust referral pathways between diabetes services and pain centres that implant spinal cord stimulators are essential in order to ensure safe, appropriate, fiscally neutral and equitable access to this therapy. Spinal cord stimulation is approved by NICE for the management of peripheral neuropathic pain, and randomised controlled trials have demonstrated significant benefit with this therapy in painful DSPN. 77% of individuals will discontinue medication treatment for painful DSPN within one year because of intolerable side effects or lack of efficacy. The NNT for antidepressants ranges from 4.2 to 30.2, with a NNH of 11.8. The number needed to treat (NNT) to achieve 50% pain reduction with gabapentin ranges from 3.3 to 45.3, and the number needed to harm (NNH) is 13.9. The current management of painful DSPN is symptomatic, utilising antiepileptic and antidepressant medications. Twenty percent of individuals with diabetes will develop painful diabetic sensorimotor peripheral neuropathy (DSPN).
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