Page 194 Guide to Pain Management in Low-Resource Settings

182 Gaman Mohammed

a biothesiometer, but to get results that can be com- • Wrapping the feet with a cloth soaked in cold water
pared to others, the monofi lament needs to be calibrat- • Gentle foot massage
ed to make sure it is exerting a force of 10 grams. • Electromagnetic nerve stimulation or other local
counterirritation (e.g., capsaicin cream)

Pearls of wisdom

• Managing painful diabetic neuropathy continues
to be a challenge in developing countries where
resources are scarce and access to health care fa-
cilities is limited.
• Diabetic patients often have poor follow-up or
are seeking treatment at a late stage, when com-
Advanced testing can be done using a biothesi- plications associated with neuropathy have al-
ometer. A probe is applied to a specifi ed part of the foot, ready set in.
usually on the big toe. Th e probe can be made to vibrate • On the other hand, primary care physicians may
at increasing intensity by turning a dial. Th e person be- lack adequate knowledge and skills to screen for
ing tested indicates as soon as he or she can feel the vi- and treat diabetic neuropathy.
bration, and the reading on the dial at that point is re- • However, with basic knowledge on diabetic neu-
corded. Th e biothesiometer can have a reading from 0 to ropathy and appropriate management of diabetes,
50 volts. It is known that the risk of developing a neuro- and with the help of simple screening tools such
pathic ulcer is much higher if a person has a biothesiom- as tuning forks and monofi laments, early diagno-
eter reading greater than 30–40 volts, if the high reading sis and improved management of diabetic neu-
cannot be explained by age. ropathy are possible.
• Since a diverse range of mechanism cause pain in
What are the pharmacological diabetic neuropathy, treatment principles should
treatment options for painful include a multifaceted approach aiming at im-
proving glucose control, targeting the underlying
diabetic neuropathy? pathological factors, and treating the symptoms.
• Painkillers are selected according to the princi-
See Chapter 20 on Management of Postherpetic Neu-
ples of treating neuropathic pain.
ralgia for pharmacological analgesic treatment options,
• Since pain often has a continuous burning quality,
since the same principles for treatment of neuropathic
gabapentin or amitriptyline—possibly combined
pain apply.
with a weak opioid—are typical choices for phar-
macological management of pain.
What are complimentary • Th e eff ectiveness of nonpharmacological treat-
approaches in management of ment options should not be underestimated.
painful diabetic neuropathy?

References
Sometimes the simple things maybe very eff ective; pa-
tients sometimes fi nd out what works for they and may [1] Sorensen L, Wu M, Constantin D, Yue K. Diabetic foot disease: an in-
be very inventive. Techniques often reported by patients teractive guide. International Consensus on the Diabetic Foot.
[2] Zachary T, Bloomgarden MD. Clinical diabetic neuropathy. Diabetes
to be very eff ective are: Care 2005;28:2968–74.
• Immersing the feet in a bucket of cold water
• Placing the feet on a cold cement fl oor