properties. opioid medications are recommended as second or third-line treatment for dpn. medical devices monochromatic infrared photo energy treatment (mire) has been shown to be an effective therapy in reducing and often eliminating pain associated with diabetic neuropathy. the studied wavelength of 890 nm is able to penetrate into the subcutaneous tissue where it acts upon a specialized part of the cell called the cytochrome c. the infrared light energy prompts the cytochrome c to release nitric oxide into the cells. the nitric oxide in turn promotes vasodilation which results in increased blood flow that helps nourish damaged nerve cells. once the nutrient rich blood is able to reach the affected areas (typically the feet, lower legs and hands) it promotes the regeneration of nerve tissues and helps reduce inflammation thereby reducing and/or eliminating pain in the area. transcutaneous electrical nerve stimulation (tens) and interferential current (ifc) use a painless electric current and the physiological effects from low frequency electrical stimulation to relieve stiffness, improve mobility, relieve neuropathic pain, reduce oedema, and heal resistant foot ulcers. physical therapy physical therapy may help reduce dependency on pain relieving drug therapies. certain physiotherapy techniques can help alleviate symptoms brought on from diabetic neuropathy such as deep pain in the feet and legs, tingling or burning sensation in extremities, muscle cramps, muscle weakness, sexual dysfunction, and diabetic foot. gait training, posture training, and teaching these patients the basic principles of off-loading can help prevent and/or stabilize foot complications such as foot ulcers. off-loading techniques can include the use of mobility aids (e.g. crutches) or foot splints. gait re-training would also be beneficial for individuals who have lost limbs, due to diabetic neuropathy, and now wear a prosthesis. exercise programs, along with manual therapy, will help to prevent muscle contractures, spasms and atrophy. these programs may include general muscle stretching to maintain muscle length and a person's range of motion. general muscle strengthening exercises will help to maintain muscle strength and reduce muscle wasting. aerobic exercise such as swimming and using a stationary bicycle can help peripheral neuropathy, but activities that place excessive pressure on the feet (e.g. walking long distances, running) may be contraindicated. exercise therapy has been shown to increase the blood flow to the peripheral nerves, can improve gait function. heat, therapeutic ultrasound, hot wax are also useful for treating diabetic neuropathy. pelvic floor muscle exercises can improve sexual dysfunction caused by neuropathy. electric stimulation of the plantar aspect of the foot showed improved balance and sensation when performed daily. other low-quality evidence supports a moderate-large beneficial effect of botulinum toxin injections. there is insufficient evidence to draw firm conclusions for the utility of the cannabinoids nabilone and nabiximols. prognosis the mechanisms of diabetic neuropathy are poorly understood. at present, treatment alleviates pain and can control some associated symptoms, but the process is generally progressive. as a complication, there is an increased risk of injury to the feet because of loss of sensation (see diabetic foot). small infections can progress to ulceration and this may require amputation. epidemiology globally diabetic neuropathy affects approximately 132 million people as of 2010 (1.9% of the population). diabetes is the leading known cause of neuropathy in developed countries, and neuropathy is the most common complication and greatest source of morbidity and mortality in diabetes. it is estimated that neuropathy affects 25% of people with diabetes. diabetic neuropathy is implicated in 50–75% of nontraumatic amputations. the main risk factor for diabetic neuropathy is hyperglycemia. in the dcct (diabetes control and complications trial, 1995) study, the annual incidence of neuropathy was 2% per year but dropped to 0.56% with intensive treatment of type 1 diabetics. the progression of neuropathy is dependent on the degree of glycemic control in both type 1 and type 2 diabetes. duration of diabetes, age, cigarette smoking, hypertension, height, and hyperlipidemia are also risk factors for diabetic neuropathy.