Sumner CJ, Sheth S, Griffin JW, et al. Herniated or bulging discs can sometimes press on the spinal cord and on the nerve roots. Two styles of acupuncture for treating painful diabetic neuropathy--a pilot randomised control trial. The PNS did report that, of all the pathological measures, the myelinated fiber density is probably most useful as it correlates with the clinical deficit and electrophysiological findings (33,217). [54]. The cardinal features are outlined in table 8. 2005 Feb. 48(2):252-63. Most patients recover spontaneously in 3-6 months. Non-diabetic lumbosacral radiculoplexus neuropathy | Brain | Oxford (Video used with permission from the Nerve and Muscle Center of Texas.) Apfel SC: Nerve growth factor for the treatment of diabetic neuropathy: what went wrong, what went right, and what does the future hold? 2010 Feb 3. The symptoms often follow a dermatomal distribution, and can cause pain and numbness that wraps around to the front of your body. The susceptibility to ulnar nerve entrapment at the elbow or common peroneal nerve entrapment at the fibular head is not definitely increased among patients with diabetes. 12:671257. Test protective sensation with 5.07 Semmes-Weinstein monofilament, briefly applying the tip perpendicular to the plantar surface of the foot, using sufficient force (10 g) to buckle the monofilament. Sun SF, Streib EW: Diabetic thoracoabdominal neuropathy: clinical and electrodiagnostic features. Russell et al. Progressive polyradiculoneuropathy in diabetes: correlation of [QxMD MEDLINE Link]. In general, treatments in this category do not treat symptoms and are mostly experimental and not therefore available for clinical usage at present. It is clear that care must be taken in interpreting studies of painful neuropathy. A common staging scale of diabetic polyneuropathy is as follows Schady W, Abuaisha B, Boulton AJM: Observations on severe ulnar neuropathy in diabetes. Imaging tests, such as an X-ray, CT scan or MRI scan, are used to better see the structures in the problem area. Median nerve entrapment at the wrist (carpal tunnel syndrome) is more common in patients with diabetes and can be treated in the same manner as in patients without diabetes. Diabetic Somatic Neuropathies - American Diabetes Association Abbott CA, Vileikyte L, Williamson S, et al. Prepublished online April 11, 2011. As well as resulting in relief of neuropathic symptoms, improvements were noted in QSTs and electrophysiological investigations. A number of therapeutic choices are available for the management of symptomatic DPN, although few if any of these will influence the natural history of neuropathy. The first clinical trials of ARIs in DN took place 25 years ago, and currently only one agent is available in one country (Epalrestat in Japan) (269). Putative mechanisms by which these drugs relieve pain include inhibition of norepinephrine and/or serotonin reuptake at synapses of central descending pain control systems and, more recently, the antagonism of N-methyl-d-aspartate receptors, which mediate hyperalgesia and allodynia (280). Therapy for Diabetes Mellitus. Endocrinol Metab Clin North Am. Background An abdominal pseudohernia is a rare clinical entity that consists of an abnormal bulging of the abdominal wall that can resemble a true hernia but does not have an associated underlying fascial or muscle defect. Anticonvulsants have been used in the management of neuropathic pain for many years (287,288). A classification system by Thomas [QxMD MEDLINE Link]. Treatment of neuropathic pain in a patient with diabetic neuropathy using transcutaneous electrical nerve stimulation applied to the skin of the lumbar region. [QxMD MEDLINE Link]. Prim Care Diabetes. Painful truncal radiculoneuropathies are a recognised complication of diabetes, unrelated to duration of disease and, as in this case, may be the presenting feature. Sosenko JM, Boulton AJM, Kubrusly DB, Jagdish K, Weintraub BA, Skyler JS: The vibratory perception threshold in young diabetic patients: associations with glycemia and puberty. Sao Paulo Med J. Mexilitine is a class 1B antiarrhythmic agent and a structural analog of lignocaine. Coppini DV, Wellmer A, Weng C, Young PJ, Anand P, Snksen PH. Studies in this area must carefully differentiate those with chronic painful symptoms from those who develop painful symptoms more acutely early in the course of diabetes. J Gen Intern Med. Arezzo JC, Zotova E: Electrophysiologic measures of diabetic neuropathy: mechanism and meaning. Front Endocrinol (Lausanne). Zenarestat Study Group. Dyck PJ and Thomas PK. 2001 Nov. 8(6):520-4. Wilson JD. Nevertheless, achieving near-normoglycemia should be the aim in both the prevention of and the first step of managing DPN. Malik RA, Williamson S, Abbott CA, Carrington AL, Iqbal J, Schady W Boulton AJM: Effect of angiotensin-converting enzyme (ACE) inhibitor trandalopril on human diabetic neuropathy: randomised double-blind controlled trial. Abdominal pseudohernia: a manifestation of diabetic truncal There isoftencoexistingdiabeticdistalsymmetrical polyneuropathy. A hypothesis can be entertained that longer nerves are more susceptible to the metabolic consequence of diabetes. In. Bertora P, Valla P, Dezuanni E: Prevalence of subclinical neuropathy in diabetic patients: assessment by study of conduction velocity distribution within motor and sensory nerve fibres. . [Full Text]. [QxMD MEDLINE Link]. 25(3):565-9. New masking guidelines are in effect starting April 24. 1998 Oct. 21(10):1749-52. 2020 Jan 4. This was associated with a between-group difference of 4.0 m/s for the peroneal nerve and 3.9 m/s for the sural nerve. Have the patient walk on the heels and toes; heel-toe walking tests not only distal lower-extremity strength but balance, as well. American Diabetes Association, American Academy of Neurology: Report and recommendations of the San Antonio Conference on Diabetic Neuropathy (Consensus Statement). Oculomotor Nerve Disease - an overview | ScienceDirect Topics [Full Text]. Huang CC, Chen TW, Weng MC, Lee CL, Tseng HC, Huang MH. Diabetic truncal radiculoneuropathy affects middle-aged to elderly patients, especially males. Diabetic truncal radiculoneuropathy can occur in type 1 or 2 diabetes, start in middle or older age, and have an acute onset; it is not progressive like distal symmetric polyneuropathy, but resembles diabetic cachexia in the way it often remits. Testing for peripheral neuropathy begins with assessment of gross light touch and pinprick sensation. Motor neuropathy may occur along with sensory neuropathy (sensorimotor neuropathy). [Full Text]. The discussion of most of these approaches will be brief, as mention is also made in section 3: pathogenesis of diabetic neuropathy. Gimbel JS, Richards P, Portenoy RK: Controlled-release oxycodone for pain in diabetic neuropathy: a randomized controlled trial. In, This site uses cookies. Too late. McLennan SV, Martell SK, Yue DK: Effects of mesangium glycation on matrix metalloproteinase activities: possible role in diabetic nephropathy. Kumar D, Alvaro Ms, Julka IS: Diabetic peripheral neuropathy: effectiveness of electrotherapy and amitriptyline for symptomatic relief. Most of the early trials can be summarized as: Too small. One cause of trepopnea is unilateral diaphragmatic paralysis, which in itself is an uncommon diagnosis. Testing for orthostatic hypotension is particularly important in patients with longstanding diabetes mellitus. The SLVDS (261) found that DPN was related to age, diabetes duration, HbA1c, and insulin use. Navarro X, Sutherland DE, Kennedy WR: Long-term effects of pancreatic transplantation on diabetic neuropathy. Neurology. Pan Q, Li Q, Deng W, et al. Callaghan BC, Little AA, Feldman EL, Hughes RA. 82(4):909-29. Therapy for Diabetes Mellitus. Many other physical therapies have been proposed. [QxMD MEDLINE Link]. The relationship between obstructive sleep apnea and intra-epidermal nerve fiber density, PARP activation and foot ulceration in patients with type 2 diabetes. Several randomized clinical trials have supported the use of these agents in the management of neuropathic pains. This seeming paradox is at least partially explained by the pathological complexity of DPN. Prevalence of and Risk Factors for Peripheral Neuropathy in Chinese Patients With Diabetes: A Multicenter Cross-Sectional Study. These researchers also validated a scoring system to document and monitor neuropathy in the clinic. Fried LF, Forrest KY, Ellis D, Chang Y, Silvers N, Orchard TJ: Lipid modulation in insulin-dependent diabetes mellitus: effect on microvascular outcomes. The prevalence by staged severity of various types of diabetic neuropathy, retinopathy, and nephropathy in a population-based cohort: the Rochester Diabetic Neuropathy Study. Boulton AJM, Kubrusly DB, Bowker JH, Skyler JS, Sosenko JM: Impaired vibratory perception and diabetic foot ulceration. Neurology. Dyck PJ, Kennedy WR, Kesserwani H, Melanson M, Ochoa J, Shy M, Stevens JC, Suarez GA, OBrien PC: Limitations of quantitative sensory testing when patients are biased toward a bad outcome. Watson CPN, Moulin D, Watt-Watson J, Gordon A, Eisenhoffer J: Controlled-release oxycodone relieves neuropathic pain: a randomized controlled trial in painful diabetic neuropathy. The symptoms often follow a dermatomal distribution, and can cause pain and numbness that wraps around to the front of your body. 25(2):243-54. JAMA. [QxMD MEDLINE Link]. Klein R, Klein BEK, Moss SE: Relation of glycemic control to diabetic microvascular complications in diabetes mellitus. Blood pressure and heart rate measurements with the patient supine and upright are compared. Meijer JW, Smit AJ, Sondersen EV, Groothoff JW, Eisma WH, Links TP: Symptom scoring systems to diagnose distal polyneuropathy in diabetes: the Diabetic Neuropathy Symptom Score. Boulton AJM, Knight G, Drury J, Ward JD: The prevalence of symptomatic, diabetic neuropathy in an insulin-treated population. Surgery is typically used to reduce the pressure on the nerve root by widening the space where the nerve roots exit the spine. Stevens JC, Smith BE: Cranial reflexes. [QxMD MEDLINE Link]. Grandis M, Nobbio L, Abbruzzese M, Banchi L, Minuto F, Barreca A, Garrone S, Mancardi GL, Schenone A: Insulin treatment enhances expression of IGF-I in sural nerves of diabetic patients. Amano S, Kaji Y, Oshika T, Oka T, Machinami R, Nagai R, Horiuchi S: Advanced glycation end products in human optic nerve head. 2021 Jan. 45 (1):115-9. 23(6):750-3. [QxMD MEDLINE Link]. Finally, DPN is clearly associated with certain risk factors. Diabetes Care. The definitive risk factors that have been identified have biological plausibility for involvement in the pathogenesis of DPN. This section has discussed the epidemiology of DPN according to the end points that were utilized in studies rather than according to risk factors. It was the discovery of the panaxonal marker, protein gene product 9.5, that allowed the direct visualization of epidermal nerve fibers. 2000. Oral treatment with alpha-lipoic acid improves symptomatic diabetic polyneuropathy: the SYDNEY 2 trial. In a large epidemiologic study that utilized combined end points, Pirart (258) followed a number of patients for the development of neuropathy over many years. Fernyhough P, Gallagher A, Averill SA: Aberrant neurofilament phosphorylation in sensory neurons of rats with diabetic neuropathy. Please confirm that you would like to log out of Medscape. Reflexes in the affected limb may be depressed or absent. O'Brien SP, Schwedler M, Kerstein MD. The DCCT Research Group: Factors in development of diabetic neuropathy. Gastrointestinal autonomic neuropathy may produce the following symptoms 1997 Nov. 15(4):959-71. Bennett GJ, Dworkin RH, Nicholson B. Anticonvulsant Therapy in the Treatment of Neuropathic Pain. Diabetic neuropathies: clinical manifestations and current - Nature In this later study, when patients with painful neuropathy were compared with those with painless neuropathy, those with painful symptoms had poorer control, more excursions to hyper- and hypoglycemic levels, and greater blood glucose flux as assessed by a number of measures. [QxMD MEDLINE Link]. Samii A, Unger J, Lange W: Vascular endothelial growth factor expression in peripheral nerves and dorsal root ganglia in diabetic neuropathy in rats. Gastol J, Kapusta P, Polus A, et al. In. The dosage of either one of these two drugs required for symptomatic relief is similar (25150 mg daily); to avoid undue drowsiness, the dose can be taken once a day in the evening. New York: Churchill Livingstone; 2000. [Full Text]. Your spine is made of many bones called vertebrae, and your spinal cord runs through a canal in the center of these bones. This heterogeneity has led to multiple kinds of assessments and multiple end points in studies of DPN, including symptoms, signs, QST, and electrophysiology. Watkins PJ: Pain and diabetic neuropathy. [Guideline] Colberg SR, Sigal RJ, Yardley JE, et al. In a recent review of all the trials of gabapentin for neuropathic pain, it was concluded that dosages of 1,8003,600 mg per day of this agent were effective; the side-effect profile also seems superior to that of the tricyclic drugs (291). Motor problems may include distal, proximal, or more focal weakness. Kohara N, Kimura J, Kaji R, Goto Y, Ishii J, Takiguchi M, Nakai M: F-wave latency serves as the most reproducible measure in nerve conduction studies of diabetic polyneuropathy: multicentre analysis in healthy subjects and patients with diabetic polyneuropathy. 1) has been proven in a large prospective study to be predictive of insensate foot ulceration: those with NDS 6 have a sixfold increased risk of developing an ulcer (52). Corneal confocal microscopy detects improvement in corneal nerve morphology with an improvement in risk factors for diabetic neuropathy. JAMA. Although diabetes is a common condition, there is the . The findings of this study are consistent with the hypothesis that pain can decrease with the pathological progression of DPN. Pascoe MK, Low PA, Windebank AJ: Subacute diabetic proximal neuropathy. These tissues include bones of the spinal vertebrae, tendons and intervertebral discs. Tesfaye S, Stevens LK, Stephenson JM and the Eurodiab IDDM study group: Prevalence of diabetic peripheral neuropathy and its relation to glycaemic control and potential risk factors: the Eurodiab IDDM complication study. Updates in diabetic peripheral neuropathy. Bodman MA, Varacallo M. Peripheral Diabetic Neuropathy. Studies with the antioxidant -LA have provided evidence of potential efficacy for this agent, which may well be beneficial for both neuropathic symptoms and modifying the natural history of DPN (62,63,64). Diabetes Res Clin Pract. Diabet Med. Waldman SD. Ziegler D, Hanefeld M, Ruhnau KJ, Hasche H, Lobisch M, Schutte K, Kerum G, Malessa R: Treatment of symptomatic diabetic polyneuropathy with the antioxidant alpha-lipoic acid: a 7-month multicentre randomized controlled trial (ALADIN III Study). Positive Topline Results for Cannabinoid-Based Med for Nerve Pain, Spinal Cord Stimulation May Help Diabetic Neuropathy, Breast Cancer Survivors Need Comprehensive Care Plans. Gastrointestinal Disturbances. [QxMD MEDLINE Link]. Dyck PJ, OBrien PC: Quantitative sensation testing in epidemiological and therapeutic studies of peripheral neuropathy. They usually remit without recurrence within 18 months of onset. If you log out, you will be required to enter your username and password the next time you visit. Tesfaye S, Malik RA, Harris N, Jakubowski JJ, Modie C, Rennie IG, Ward JD: Arterio-venous shunting and proliferating new vessels in acute painful neuropathy of rapid glycaemic control (insulin neuritis). Diabetes and Endocrinology Clinical Management. Vileikyte L: Psychological aspects of diabetic peripheral neuropathy. 2005 Aug. 31(2):62-7. This section will specifically examine data that pertain to manifestations of DPN. Boulton, MD, FRCP, Division of Endocrinology, University of Miami School of Medicine, P.O. 63(11):2104-10. In the most common presentation of diabetic neuropathy with symmetrical sensorimotor symptoms, minor weakness of the toes and feet may be seen; severe weakness is uncommon and should prompt. Neurology. Front Endocrinol (Lausanne). A Cross-Sectional Study in Patients with Type 2 Diabetes and Healthy Controls. Mononeuritis Multiplex | American Association of Neuromuscular - AANEM Diabetes Care. Because this relatively benign entity has an extensive differential diagnosis, proper recognition of this condition is necessary to avoid an exhaustive evaluation that could lead to unnecessary surgical and radiologic interventions. Selective serotonin-reuptake inhibitors (SSRIs) inhibit presynaptic reuptake of serotonin but not norepinephrine. [QxMD MEDLINE Link]. The loss of sensation in the feet predisposes to development of foot ulcers and gangrene. Karpitskaya Y, Novak CB, Mackinnon SE: Prevalence of smoking, obesity, diabetes mellitus and thyroid disease in patients with carpal tunnel syndrome. Diabetic thoracic radiculoneuropathy presents as burning, stabbing, boring, beltlike, or deep aching pain that usually begins unilaterally and may subsequently become bilateral. Abbott CA, Carrington AL, Ashe H, Bath S, Every LC, Griffiths J, Hann AW, Hussein A, Jackson N, Johnson KE, Ryder CH, Torkington R, Van Ross ER, Whalley AM, Widdows P, Williamson S, Boulton AJM, North-West Diabetes Foot Care Study: The North-West Diabetes Foot Care Study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort. Too short. [QxMD MEDLINE Link]. 2009 Oct. 6(4):A114. Mayfield JA, Reiber GE, Sanders LJ, Janisse D, Pogach LM: Preventive foot care in people with diabetes. 2021 Jun 1. Although the degree of association was to some extent dependent on the multivariate modeling, neuropathy was consistently related to age, duration, HbA1c, and severe ketoacidosis. Isner JM, Ropper A, Hirst K: VEGF gene transfer for diabetic neuropathy. Diabetic Truncal NeuropathyClinical and Radiological Image The first clinical sign that usually develops in diabetic symmetrical sensorimotor polyneuropathy is decrease or loss of vibratory and pinprick sensation over the toes. The importance of DPN in the etiopathogenesis of foot ulceration has been confirmed in several prospective studies (50,182,196). In an exploratory study, Eaton et al. 1:168-188. Diabetic Radiculoneuropathy: Clinical patterns of sensory loss and Diabetic truncal radiculoneuropathy. NGF Study Group. Abdominal pseudohernia: a manifestation of diabetic truncal Certain conventional cardiovascular disease risk factors, including lipid and blood pressure indexes, have been identified as risk factors for DPN. Pittenger GL, Malik RA, Burcus N, Boulton AJ, Vinik AI: Specific fiber deficits in sensorimotor diabetic polyneuropathy correspond to cytotoxicity against neuroblastoma cells of sera from patients with diabetes. As discussed in section 3, there is accumulating evidence to support the role of oxidative stress in the pathogenesis of neuropathy. It is generally agreed that DN should not be diagnosed on the basis of one symptom, sign, or test alone: a minimum of two abnormalities (from symptoms, signs, nerve conduction abnormalities, quantitative sensory tests, or quantitative autonomic tests) is recommended by Dyck ( 21 ). Hilz MJ, Axelrod FB, Hermann K, Haertl U, Duetsh M, Neundorfer B: Normative values of vibratory perception in 530 children, juveniles and adults aged 379 years. Abad F, Diaz-Gomez NM, Rodriguez I, Perez R, Delgado JA: Subclinical pain and thermal sensory dysfunction in children and adolescents with type 1 diabetes mellitus. Hotta N, Toyota T, Matsuoka K, Shigeta Y, Kikkawa R, Kaneko T, Takahashi A, Sugimura K, Koike Y, Ishii J, Sakamoto N, the SNK-860 Diabetic Neuropathy Study Group: Clinical efficacy of fidarestat, a novel aldose reductase inhibitor, for diabetic peripheral neuropathy: a 52-week multicenter placebo-controlled double-blind parallel group study. In analyses of risk factors in their study, Harris et al. These reports also included. Neurology. Diabetes Reviews. Preliminary data suggest that treatment with a PKC- inhibitor might ameliorate measures of nerve function in DPN (278). Most of the pharmacological and other interventions that will be described have no effect on the natural history of neuropathy, which is of progressive loss of nerve function. Several controlled studies combined in meta-analyses seem to provide some evidence of efficacy in diabetic neuropathic pain (299). 2008 Mar-Apr. Although this strategy helps to confine studies only to individuals who truly have painful neuropathy, it carries the implicit assumption that pain in itself does not occur as a sole manifestation of DPN. [57] Dyck et al described case report forms for recording symptoms and signs of neuropathy that might be useful in longitudinal follow-up of individual patients. Dyck PJ, O'Brien PC. Zeng L, Alongkronrusmee D, van Rijn RM. 2006 Feb. 29(2):340-4. Diabetes Care. JAMA. Indeed, one study has shown an association of vibration perception with an interaction of height and degree of hyperglycemia (254). Young MJ, Veves A, Walker MG, Boulton AJM: Correlations between nerve function and tissue oxygenation in diabetic patients: further clues to the aetiology of diabetic neuropathy? Neurology Treatment Update. Bangladesh Med Res Counc Bull. More recently, the combination of amitriptyline and transcutaneous electrotherapy has been described in those who failed on tricyclic monotherapy. Caccia MR, Salvaggi A, Dezuanni E: An electrophysiological method to assess the distribution of the sensory propagation velocity of the digital nerve in normal and diabetic subjects. Perkins BA, Olaleye D, Zinman B, Bril V. Simple screening tests for peripheral neuropathy in the diabetes clinic. Miranda-Palma B, Basu S, Mizel MD, Sosenko JM, Boulton AJM: The monofilament as the gold standard for foot ulcer risk screening: a reappraisal (Abstract). In those patients with atypical presentations (e.g., rapidly progressing motor deficits), alternative diagnoses, such as CIDP, should be considered. 1 2 It is characterised by pain and/or dysaesthesia involving one or more dermatomes of the trunk with characteristic night-time worsening and, at times, subsequent abdominal bulging. Mayfield JA, Sugarman JR: The use of Semmes-Weinstein monofilament and other threshold tests for preventing foot ulceration and amputation in people with diabetes. [QxMD MEDLINE Link]. 22(5):625-30. Nangle MR, Cotter MA, Cameron NE: Effects of rosuvastatin on nitric oxide-dependent function in aorta and corpus cavernosum of diabetic mice: relationship to cholesterol biosynthesis pathway inhibition and lipid lowering. The sensory modalities and the methodologies utilized for their assessments should be considered in interpreting the data presented below, since nerve fibers may be differentially affected, and as indicated above, techniques can vary considerably. Paisley AN, Abbott CA, van Schie CHM, Boulton AJM: A comparison of the Neuropen against standard quantitative sensory threshold measures for assessing peripheral nerve function. 2005 Apr. Diabetic and non-diabetic lumbosacral radiculoplexus neuropathy Radiculopathy describes a range of symptoms produced by the pinching of a nerve root in the spinal column. Enhanced glucose control for preventing and treating diabetic neuropathy. Loss of balance, especially with the eyes closed, and painless injuries due to loss of sensation are common. Younger DS, Rosoklija G, Hays AP, Trojaborg W, Latov N: Diabetic peripheral neuropathy: a clinical and immunohistological analysis of sural nerve biopsies. Haq RU, Pendlebury WW, Fries TJ, Tandan R: Chronic inflammatory demyelinating polyradiculoneuropathy in diabetic patients. In cases of very severe painful neuropathy that are partially resistant to tricyclic drugs, a combination of the tricyclics with other agents, such as major tranquilizers, may be useful (282). Dejgard A, Petersen P, Kastrup J: Mexilitene for the treatment of chronic painful diabetic neuropathy. Medscape Medical News. 1 Its clinical and electrodiagnostic features have been well described by various authors. Despite this, there are still areas in which knowledge is deficient. Curr Rev Pain. Painful diabetic polyneuropathy: epidemiology, pain description, and quality of life. Stewart JD: Diabetic truncal neuropathy: topography of the sensory deficit. Media Associated Disorders Chronic inflammatory demyelinating polyneuropathy Diabetic autonomic neuropathy Diabetic femoral neuropathy A summary of some of the drugs that have been studied in clinical trials are listed in Table 6: further details are provided in Section 3B. Distal symmetrical sensorimotor polyneuropathy affects sensory, motor, and autonomic functions in varying degrees, with sensory abnormalities predominating. [QxMD MEDLINE Link]. Radiculopathy - Mayo Clinic Orthopedics & Sports Medicine Although the overall prevalence of Charcot neuroarthropathy in the diabetic population is low, a study of a randomly selected neuropathic population reported radiological evidence of Charcot neuroarthropathy in 16% of patients (309), suggesting a key role of neuropathy in the pathogenesis of this condition. In, The Axon: Structure, Function and Pathophysiology. Spinal discs act as cushions between your vertebrae. Diabetes Care. NCV can improve with effective therapy (51) or with transplantation (216). Radiculopathy treatment will depend on the location and the cause of the condition as well as many other factors. ; 1997. Can J Neurol Sci. 2009. Diabetes Reviews. Although some have advocated the use of nonsteroidal anti-inflammatory drugs in symptomatic neuropathy, there is little evidence to support their use. Richards BW, Jones FR, Younge BR: Causes and prognosis in 4,278 cases of paralysis of the oculomotor, trochlear and abducens cranial nerves. 2005 Jan 27. Those who fulfilled the 126 mg/dl fasting glucose criterion, on average, had elevated vibration and thermal thresholds at screening for diabetes.