If your patient maintains better blood glucose control, her pain and other symptoms may decrease. As nerve cells regenerate with improved blood glucose levels, your patient’s pain may worsen initially, but it will decrease over time.To prevent foot complications, your patient may need to use lamb’s wool padding to protect her feet from trauma. The physician may also refer her to a podiatrist, who will assess her feet regularly and gently file any callused areas, if necessary. Your patient may also need a referral to an orthotic or other foot care specialist to fit her for custommade shoes, molded insoles, or other orthotic devices to protect her feet. In some cases, your patient may require bed rest or crutches. Some patients with foot ulcers have casts applied so that they can walk while the ulcers heal. The cast redistributes foot pressure so that the ulcerated area bears much less weight than it would normally.

For pain associated with peripheral neuropathy, the physician may prescribe:

• a nonnarcotic analgesic, such as ibuprofen or sulindac
• tramadol hydrochloride
• phenytoin or carbamazepine
• a tricyclic antidepressant, such as amitriptyline, alone or with a phenothiazine derivative
• mexiletine
• topical capsaicin 0.075%.

Narcotic analgesics usually aren’t prescribed because peripheral neuropathy is a chronic condition, and the patient would risk developing an addiction. However, other therapeutic options may include transcutaneous electrical nerve stimulation therapy or referral to a pain control clinic.

Curing Steps for Patients

If your patient experiences painful paresthesia, especially at night, tell her to stretch gently or to get up and walk around. Also, teach her how to safely massage her feet and legs, and explain that this sometimes helps to block pain sensations. If appropriate, teach your patient how to safely use the TENS unit. Teach her about guided imagery, meditation, progressive relaxation techniques, exercise, and therapeutic massage.

Teach your patient the importance of foot care, and review safety measures she can take to prevent trauma. For instance, advise her to avoid prolonged standing and strenuous weight-bearing exercises. Tell her to wear well-cushioned, properly fitting shoes and to walk in well-lit areas where the ground is smooth.

If your patient has decreased temperature sensation, advise her to prevent severe burns by checking the water temperature with a part of her body that’s sensitive to temperature, such as forearm. If she experiences abnormal cold sensations, advise her to wear thin gloves in the spring or fall. When temperatures drop, she should wear heavier, insulated gloves. Tell her that mittens may be warmer than gloves. If cold feet are a problem, tell her to wear comfortable insulated socks with her shoes.

Review with your patient the name, dosage, action, and adverse effects of all her prescribed drugs. If she’s using topical capsaicin, tell her to wear gloves when she applies it, avoid contact with her eyes, and wash her hands immediately after application. Also, warn her that she may experience transient burning of the affected area after applying capsaicin.

Encourage your patient to avoid drinking alcohol. Explain that alcohol abuse may contribute to the progression of peripheral neuropathy. If appropriate, refer your patient to a counselor or to Alcoholics anonymous. If she smokes, encourage her to stop. Explain that cigarette smoking can worsen her condition and that stopping may slow its progress.

Explain that your patient should have her feet inspected at least four times a year and that a physician should perform a thorough physical examination and neurologic assessment at least once a year.