This is Airing Pain, a programme brought to you by Pain Concern, the UK charity providing information and support for those of us living with pain and for those who care for us. I'm Paul Evans and this edition of Airing Pain has been funded by a grant from the Champ Trust and Foundation Scotland. 2020 has been designated the Global Year for the Prevention of Pain by the International Association for the Study of Pain. Their campaign is focusing on protecting against the onset of pain, preventing pain from becoming chronic or recurring and reducing the long-term consequences of pain. Well, in this edition of Airing Pain, we'll be looking at all three of those tiers through one condition that we're all, young and old, susceptible to getting.
Diabetes. There is a kind of paradox and patients of mine ask me, they say, Doctor, I don't understand, my feet are numb, so I touch them and I can't feel anything, but they are continuously painful. And regardless of what causes your chronic pain, we look at the benefits of sharing experience with like-minded people. Particularly if you're newly diagnosed or you've got a problem which you've not had before, the chances are when you come to the group, somebody will have experience of it. The Scottish Diabetes Survey in 2018 estimated that there were over 304,000 people with a diagnosis of diabetes in Scotland. That's over 5% of the population.
Between 10 and 15% of those had type 1 diabetes, with type 2 accounting for the remainder. Chronic complications arising from diabetes are numerous, but include eyesight problems, kidney function, nerve damage or neuropathy, and more. But before we get to that, the two types of diabetes, type 1 and type 2, why the distinction? Professor Dave Bennett is Professor of Neurology at the University of Oxford. He's also consultant in neurology at Oxford University Hospital's Foundation Trust.
Type 1 diabetes usually is the type of diabetes that comes on in children or young adults. It's probably triggered by the immune system, and it's direct damage to the pancreas, which is the part of the body that produces insulin, so that you get virtually no insulin being produced. And the issue there is that people with type 1 diabetes, they really need to be treated with insulin. So that's key to their survival, and they would get very high blood glucose without insulin. Type 2 diabetes, not exclusively, but it tends to have a later age of onset. The underlying basis of the disease is different. It's probably a combination of producing maybe less insulin.
not the kind of complete lack of insulin production that you see in type 1, but less, and also the body being less responsive to the insulin, something called insulin resistance. So particularly the muscles are very important in the way you respond to insulin. And it's that generic general resistance to insulin that is the source of the problem. And type 2 diabetes, certainly when it's initially diagnosed, you don't have to be treated with insulin because you've got some basic insulin being produced, often initially treated with oral medication and with diet. And then some people, if they have particularly difficulty with glucose control, may ultimately be treated with insulin, but it's not an absolutely essential part of the treatment from the beginning. Well, Steve Sims, who lives in Cardiff, has type 2 diabetes.
And he does take insulin. The major effect from diabetes is having to take more note of what I eat. The fact that in restaurants for instance they won't tell you quite often what's in it. So it makes it difficult to judge then what you can eat and can't eat. It's carbohydrates that you have to be careful of, isn't it? I wouldn't say you've got to be careful of, again, I would say you've got to be aware of it, of what the carbohydrate content of a meal is. Well, I'm type 2 diabetes as well, a fairly new type 2 diabetes. And my GP sent me on an expert programme, it's called the expert programme. And the biggest shock to me when I started this programme was we walked into the room with about 15 of us. I was taken by a diabetes specialist, nurse and a nutritionist. The biggest shock was the packet of biscuits on the table in front of me. And you go in and you think...
Oh, this is going to be a thou shalt not cause. Well, we all need carbohydrates because we convert that into glucose and that's what gives us the energy for our muscles, etc. So we've got to have so much. The problem is that with, I would say, the British diet or Western diets, perhaps, it does have a tendency to be carbohydrate loaded. You've only got to think of a pub meal. What you would eat at home perhaps might contain 30 or 40 grams of carbs. Most pub meals are 80 or 90 grams of carbs. For some reason or other, within our culture, we've had a tendency to look at carbohydrates, possibly because in the past, I suppose,
We were all involved in a lot more manual labour than we are now. So you've actually burnt it off, which was the point of eating it. But we've still got that habit, you know, the nice roast dinner and all the rest of it. You know, I've known people who have a treat every day and then wonder why their diabetes is out of control or why their weight's going up. Well, no, you don't have a treat every day. You have a reasonable diet.
And as any dietician will tell you, you just stick to a reasonably low-fat, high-fibre diet. When I did my expert course, that's one thing that surprised me. The dieticians and the diabetes specialist nurses that we had there were a lot more open-minded. So if you said to them, you know, I have problems walking any distance because I've got problems with my legs, their attitude was, yeah, okay, fine. Let's look at what problems that's causing. We've got to be able to do it. So they said, well, all right, don't walk very far.
So walk a little bit and stop, walk a little bit and stop. Which is, if I'm open about what I have a tendency to do, or I use a walking stick or something to help take the weight off. But they were willing to look at that and incorporate that into what they said. You have to look at the whole human being, not just our condition. We talked about the expert programme, the education programme that we've both done, presumably you like me, at the start of your diabetes journey. I did one recently as well. Did you? Yeah, they brought in a new one, which is specifically for people on insulin.
And that was a real eye-opener. It's totally changed how I treat my diabetes now. I was injecting twice a day. I now inject five times a day. But I inject to what I eat. And that was the difference in that course. Explain that to me. I use an app on the phone. The dreaded technology comes in again. And I can work out the carbohydrate within a meal. I've got it set up so that I can then use that information. I check my blood glucose levels. I will then put that information in on the app. It will then tell me, with the carbohydrate, how much insulin I need for that meal.
So I can then adjust with fast-acting insulin for that meal. I don't take insulin. I'm just wondering, does that give the sort of permission to do whatever you like, to eat whatever you like, or is there an education side of it that, hang on, you still have to be careful? You can fall into the trap of just working out what's in there and, as I said, take as much insulin as you want. You can do that on your occasion, obviously, but no, part and parcel of the course.
You still need to look at what you're eating. But it appreciates the fact that, for instance, if you go out for a meal, you haven't got a lot of control over what actually ends up on your plate. There's a psychological element in it as well, as it's giving me more control over my own life. So rather than the diabetes controlling what's going on, I have some control over the diabetes. So I can recommend the expert course, to be honest. Anybody with diabetes should get on it. Well, this is something I'm learning too. There are actually three versions of the expert course, and expert is spelt X-P-E-R-T. Not to be confused with the expert patient programme.
So, one course is for the prevention of diabetes. It's an intensive lifestyle programme aimed at reducing risk of developing type 2 diabetes for people at higher risk. The next course is for people who have type 1 or type 2 diabetes. That's the one both I and Steve went on and I can thoroughly recommend it. And then there's the course that Steve mentioned and recommends for people with type 1 or type 2 diabetes and who are treated with insulin.
Ask your GP or practice nurse for more details or go to the website diabetes.co.uk education for more details of the expert course and other diabetes management programmes. Well, of the complications that can occur with diabetes that I mentioned earlier, it's neuropathy and the pain that comes with it that I want to focus on. Professor Dave Bennett. Neuropathy generally relates to the peripheral nervous system and the way you can think about that is your peripheral nervous system connects motor neurons which are going to drive your muscles from the spinal cord to the muscle so that they provide the signal that makes your muscle contract and so that you can move. And the peripheral nerves also carry information back from your sensory nerve fibers that respond to sensory stimuli, such as brushing the skin or putting the skin on something hot. And they carry that information back again via the nerves back to the spinal cord. It's a way of connecting, ultimately, your brain and spinal cord to the body. So peripheral being, I presume, the peripheries. The periphery is actually anything outside the brain and the spinal cord, because your central nervous system refers to the brain and the spinal cord. Now, how does diabetes cause neuropathy?
So that's a good question, actually. And I wish I could sit here and give you one very clear answer. Understanding the mechanisms is still somewhat debated. We know certain things about it. So diabetes is a problem relating to control of your blood glucose. And if you have diabetes, then you either produce less of a hormone called insulin, which is needed to lower blood glucose, or your body is resistant to the effects of insulin. And the end result of that is your average over the course of a day, someone with diabetes, their blood glucose is higher than the general population.
And we know that there's a relationship between how high that blood glucose is and your risk of getting neuropathy. So partly the risk of neuropathy is related to what we call glycemic control, which is the medical word for what your blood glucose is on average. But there are other factors as well. So we also know that if you have particularly high levels of lipids, by which I mean things like cholesterol, that is also. a risk factor for diabetic neuropathy. So we know something about the risk factors. What we don't really know is the exact mechanisms of the disease. Now, there's theories. So one of the theories is actually one of the generic issues with diabetes is that the small blood vessels don't function as well as they should. So a good example of that is some people with diabetes get diabetic retinopathy. And that is a problem, essentially, of the blood vessels within the retina in the eye. And that's why people with diabetes need regular eye checks. Well, the nerve, like any other tissue in the body, has blood vessels in it. And the health of the nerve is dependent on how good that blood supply by those blood vessels is. So one likely problem in diabetes...
is an issue with the blood supply to the nerves. But there are other factors. So the fact that you have this high glucose, that can then give rise to modifications of proteins in your body and change in the metabolism that particularly impacts on the way that nerves work. And so, for instance, an analogy would be we were sitting in an auditorium today that was about 40 metres long. And if your peripheral neuron, like your sensory neuron, if you were to say that that is the size of that auditorium, what we call the axon, which is the bit that carries the electrical signals, which connects to this, for instance, the skin or the muscle, the analogous situation would be the axon goes all the way to Paris. Now, that is a big challenge.
for something to get cargoes, such as everything you need to keep your nerve healthy, all that distance. And one of the things that can happen in diabetes is that the support of those axons begins to fail because of the changes in metabolism and the altered blood supply. And that's one of the key events that causes diabetic neuropathy. So explain how it develops and what it feels like. The symptoms of diabetic neuropathy, usually the symptoms that patients notice, are to do with sensation.
And the typical features that they might have, because of this challenge, which we did speak about, is nerves, one of the things they need to do is get kind of the nutritive functions, the transport of all the things those nerves need to survive, need to go over a very long distance. That then makes sense. Actually, it's the longest nerves in diabetes that are affected first. So, in fact, the place that most people with diabetes first notice a problem is their feet. And what they would notice, for instance, is that their feet may feel numb. And that numbness may very gradually, over months or years, kind of spread up towards the ankles, or if it was severe, up towards the knees. They may notice pins and needles. So that sensation, if you've crossed your leg for...
period of time which is quite unpleasant actually and they may not cross the leg and they may just notice that spontaneously and also pain which is again usually most commonly in the feet it can be a kind of have a nasty kind of burning quality to it usually it's more severe at night than it is during the day if the neuropathy progresses they might notice problems in other parts of the body such as the hands which again are relatively long nerves but usually it's the feet where we see the first problem professor dave bennett Steve Sims has diabetic neuropathy. It's not just pain. You also have the other effect, which is I have very little feeling in my feet. I'm not getting the sensations from my feet that tell me that I'm balanced. So that was the first effect I had with it. So this is why I've got handrails put on these steps and on the steps in the front, so that at least I can maintain my balance. Again, if I'm walking, I have a tendency, you know, if I'm walking any distance, use a walking stick, mainly because it gives me another point of reference. That was the first effect I found with neuropathy.
The pain came later. It's a difficult pain to explain because it's random. It always hits the same areas, but it doesn't always feel the same. Sometimes it can be just sort of a minor niggle. Other times it can be that strong, it will bring tears to your eyes. And it might last anything from a couple of seconds to three, four, five hours. But then it'll suddenly stop. It'll just turn itself off.
That is probably one of the most difficult things to deal with. Not too bad during the day when you're up and about, because changing your weight around, moving around, can ease it. Most of mine's in the feet. You can get it in the hands as well, most of the periphery nerves. But it's at night is the worst. Whether or not having weight on your feet actually makes any difference to pain or whether it's a distraction from the pain. You can take painkillers as I do at night sometimes if it's really playing me up.
The trouble is that they will only dull it. They won't get rid of it. They'll just dull it off. Mind you, sometimes you can turn around as I do. I normally take paracetamol. I can take two paracetamol. In the moment I take them, it switches itself off. It is that random. It's really difficult. You know, I've had odd occasions where I probably had about half an hour of sleep through the night because what will happen is it will suddenly calm down so you drift off to sleep. Ten minutes later, it starts back up again. I end up with a few different types of pain as well. On my left foot, it's as if somebody's driving a spike up between my little toe and the toe next to it. Literally driving it into my foot between the toes.
And then that pain will grow until it grows down the side of my foot. When I spoke to one of the nurses about it, she said, well, what it's doing is it's actually following the track of the nerve. On my right foot, I end up with two or three different effects. Sometimes it's like a prickling across the top of my foot. And again, that pain will grow. I also get on the side of that foot, like a friction burn. Sometimes if I turn over so I take pressure off that foot, that will go. That's one of the problems with it. It's random. And I found out something else about it some time ago. I actually passed out when I was giving blood.
And they thought I might have had a heart attack, because many years ago I did have a heart attack, so my ECG's a bit weird. Talking to one of the doctors afterwards, as it was, I just passed out, it was warm, and I just keeled over. But he said the thing they were worried about is because of the neuropathy, you may not suffer with pain from a heart attack. It can affect the nerves around the heart as well. That I wasn't aware of until he said, and to some extent I wish he hadn't told me. Yes, it's nice to have information, but can you tone it down a bit on occasions? Of course, one of the difficult issues of diabetes at the same time as you may have a...
diabetic neuropathy is that some patients with diabetes have problems with the blood supply to the legs and you can have this combination of where there's not enough blood going to the feet and at the same time you've got loss of sensation in the feet and that's why you might hear this term the diabetic foot that's why you will hear the doctors say it's very important you look after your feet because you number one you could injure the feet and not feel it someone that doesn't have diabetes you might walk along the floor and might just stub the toe or might stand on something sharp you know they would know that there was a problem there someone with diabetes might have something in their shoe rubbing or get a nasty blister and they're completely unaware of it and then the second thing is at the same time as getting these injuries their body's less good at healing itself particularly because the blood supply to the feet is not as good so you're more likely to get infections or ulcers on the feet. And that's why it can be this difficult combination of both neuropathy and what we call peripheral vascular disease and diabetes that people really need to look after their feet. I guess this is why in my annual diabetes checkup, the diabetes nurse tickles my feet. Absolutely. And puts a tuning fork on it. Can you feel it? Yes. So she's saying the tickle of the feet, it's probably not a tickle with her fingers, is it? It's probably a little monofilament. So it's a little filament. And she touched that filament of the skin and says, can you feel that? So there she's checking for sensation. So that's seeing that the sensory nerve fibers can carry that information. If you think about it, they're carrying transmitting information from the skin.
to the spinal cord and then ultimately up to the brain. She's testing two different types of nerve fibers. So you have a kind of nerve fibers that will carry information about touch. And then there's also nerve fibers that can detect rapidly changing vibrations. That's what the tuning fork is doing. It's causing that vibration. And she's checking that you can feel the vibration on the toe as well. So it's great that she's doing that. And the idea is she's screening for diabetic neuropathy. And obviously, the measure that you would take if someone had diabetic neuropathy is you may look again at how can we optimize your, what we call your glycemic control, your blood sugar control, and also measures to really looking after the feet, making sure that your shoes, that you're checking the feet at the end of the day, that you might need to go and see her.
podiatrists to keep an eye on the feet, those kind of measures. So having established what diabetic neuropathy is, how do you treat it? I would love to sit here and say to you, if someone has diabetic neuropathy, we've invented a tablet. You take that tablet and it's going to make your nerves regrow. But I can't. That has not been invented yet. So there is research into that and some of that we've discussed at this conference, but we don't have anything yet that makes nerves regrow. There have been clinical trials of tablets to try and help diabetic neuropathy. Unfortunately, so far, all of those clinical trials of tablets for diabetic neuropathy have essentially failed. So trials that optimize glycemic control have worked, particularly for type 1 diabetes, but trials of trying to take a new tablet to prevent diabetic neuropathy have not worked. But trials of weight loss and exercise...
are showing signals of success. There's really quite a good evidence base that keeping fit and doing exercise is incredibly good for your nerves. I mean, it kind of makes sense, but there is actually some scientific evidence for that. And actually, they've literally counted the number of nerve fibers in the skin, then got some sort of exercise program, lose weight, and three months later, the number of nerve fibers in the skin has increased. And so people need to take that on board. Probably the worst thing you can do is stop exercising, have a sedentary lifestyle. That is not good for your nerve function. We're not talking about reversing.
No, I am. In terms of exercise, I am. I'm saying you're taking people that have a low nerve count and then you're getting them to exercise and the nerve count increases. For both forms of diabetes? Most of that data is on type 2 diabetes, as far as I'm aware. If somebody does have pain as a result of their diabetes, or perhaps they don't know it as a result of their diabetes, if somebody has pain and they are diabetic, what should they do?
worth going to see your GP about that I mean there are a number of causes of pain in diabetes that is not always related to peripheral neuropathy so sometimes people get pain because they're not getting enough blood supply to the feet sometimes you're at high risk of getting an ulcer and an infection but let's assume that they someone has pain has diabetic neuropathy and as a consequence of that they've developed pain typically the pain would be in the feet and usually both feet and people often describe it as a not always but they often describe it as a burning pain and it may be accompanied by the other sensory symptoms that there is a kind of paradox and patients of mine ask me they say a doctor I don't understand my feet are numb so I touch them and I can't feel anything but they are continuing painful the reason for that paradox is that the feet are numb because the nerve fibers have as it were degenerated back from the skin so they're no longer connecting where they should be to the skin unless there's something damaging the body your pain fibers are completely silent But when they're not connected to where they should be, they just start firing all the time. And that is almost like an illusion to the brain. So you can't feel things because they're not connected to the skin, but the brain is getting this input all the time. So you're getting this feeling of continuous pain. So that's the source of that paradox. If people are getting those kind of symptoms, well, number one, obviously, if they're not already been diagnosed with diabetic enopathy, it's worth them being examined by the doctor and looking for clinical signs of diabetic enopathy. And we've discussed about the general issues about diet and blood glucose control. Then also there are tablets that we can use medications to try and...
damp down that pain. So that pain is what we call neuropathic pain. And all that means is it's pain that's due to damage of the nervous system, sensory nervous system. That's all that neuropathic pain means. But most of those tablets, what we're trying to do, if you think about it, you've got too much electrical traffic in the sensory nervous system. And essentially those tablets are trying to damp down that electrical traffic. That's the way of thinking about it. And so there's an array of medications that can be used and that can be prescribed by your GP.
To give you some examples, they're tablets that are generically called gabapentinoids, are one group, and there's another group of tablets that were actually initially developed as antidepressants. But not only are they antidepressants, they're actually analgesics. They clearly reduce pain as well. Sometimes a kind of misconception of patients is, I went to the doctor, I've got this pain in my feet, and my doctor just thinks I'm depressed, and he just fobbed me off with an antidepressant. That is not the case. What I'm trying to explain is these tablets, although if you were to look them up in the medical text, they would say that antidepressants, there is good evidence that they're also painkillers, particularly effective for neuropathic pain, and that's why your doctor's prescribing them. What I do know, what I have been told, is...
Yes, control by diet, which is what I do, or you go on to medication. But if you ignore diabetes, it is very, very serious. You cannot ignore it. I think that's a very good point. It's difficult because it's to do with human nature. And the issue is that you may not feel particularly unwell. Your doctor may tell you that you've got diabetes, but actually say, well, in myself, you know, I'm getting around, I'm going to work. I'm not really seeing lots of problems. What is the problem? And of course, the issue is, is you're storing up lots of problems.
for the future. So diabetic neuropathy, which in its initial phases may be very subtle. You might have a very mild diabetic neuropathy and virtually not know it's there. But of course, that may then progress. So numbness of the feet, severe pain in the feet. Some patients have trouble with what's called the autonomic system, which is needed to control your blood pressure and the way you handle food. Some people may get problems with their eyes. And again, initially, there will be a very trained doctor looking at the back of the eye and might say, well, I can see some subtle changes. And the patient will say, well, I don't notice any problem at all. But in five years' time, they could have threatened.
to their sight, to their vision, because of the problems with diabetes. Same thing with the kidneys. And again, initially, you might not notice any problem, but if this was left untreated, you might have complete kidney failure and need to go on dialysis or have what's called a renal transplant. So it's difficult, because you're saying to people at the early stages, you need to take this seriously and try and address it as you can, because you want to prevent all these problems in the future. Whilst, of course, human nature say, well, I feel fine now. Do I really need to worry about it? It's such a simple thing to test for.
Definitely be aware if people have symptoms, if they're finding that they're passing urine a lot, if they're having to drink a lot, they're always thirsty, maybe people are getting lots of infections, skin infections that they wouldn't normally get, particularly if there's a family history of diabetes, particularly if there are some issues with some weight gain, say, over the last few years, it's worth getting tested for diabetes, because we are in an epidemic. The rates of diabetes are going up and up and up. And you can make these early changes to your health, but in the long run are going to make a massive difference. I'll be blunt, the biggest risk factor, the reason that we have a diabetes epidemic is obesity and weight gain. So people can take measures to try and eat a healthy diet.
keep to a healthy what we call body mass index. You can do simple calculators online, actually, where you can calculate your own BMI and it will tell you whether you're in the kind of optimal range, whether you're underweight, whether you're overweight, whether you're obese and what your risk is. And, you know, it's really worth thinking about that because then you could entirely prevent the problem. I'm not saying that all diabetes is due to obesity. That's not the case. There are a number of causes. But it is one of the risk factors that people can do something about. We can't fight our genetics. Our genetics are given to us by our parents and there's nothing we can do about that. But I'm just talking about things that people can do that can make a difference and that is to have a healthy lifestyle. Professor Dave Bennett of the University of Oxford.
As always, I'll just remind you that whilst we in Pain Concern believe the information and opinions on airing pain are accurate and sound based on the best judgments available, you should always consult your health professional on any matter relating to your health and well-being. He or she is the only person who knows you and your circumstances and therefore the appropriate action to take on your behalf. You can find all the resources to support the management of chronic pain, including details of pain concerns, videos, leaflets, all editions of these Airing Pain programmes and Pain Matters magazine at painconcern.org.uk. So another reminder at the end of this edition of Airing Pain is to say that help and support to manage any chronic pain condition is available from many quarters, not just from healthcare professionals, but in patient support groups. You can find a diabetes support group in your area at the Diabetes UK website, which is diabetes.org.uk. And Steve Sims is Secretary of the Cardiff Diabetes Group.
By going to a support group, you will find people there with experience of the condition, particularly if you're newly diagnosed or you've got a problem which you've not had before. The chances are when you come to the group, somebody will have experience of it. They won't give you medical advice. That's the last thing that we're there for. But we might tell you to get back in touch with your diabetes care team. You need to talk this out with them. Or in some cases, it's a matter of, yeah, well, I'm afraid that comes with the territory. We also have the carers come to the group as well.
without my wife it would be anywhere yet they're forgotten with any chronic condition your carers are one of the most important parts of your treatment your support they're vital