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Neuropathy in Diabetes
Not a Knee-Jerk Diagnosis
Neuropathic symptoms in patients with diabetes occur commonly and are most often a consequence of the diabetes. Up to 10% of patients with diabetes and neuropathy have an etiology other than diabetes as a cause of their nerve dysfunction. Herein we present a case of vasculitic neuropathy initially misdiagnosed as diabetic neuropathy that led to separate amputations of two toes. This case emphasizes the importance of considering alternative, potentially treatable, causes of peripheral neuropathy in patients with diabetes. (J Am Podiatr Med Assoc 98(4): 322–325, 2008)
Painful peripheral neuropathy is a common complication of diabetes mellitus that can affect almost every tissue of the body. In the absence of a curative therapy for this disorder, pharmacologic or nonpharmacologic tools, or a combination of both, can be used to provide relief of symptoms. This article reviews medications currently used to manage painful diabetic neuropathy. The pathogenesis of painful diabetic neuropathy is described as a basis for understanding medication selection. The literature describing the pharmacologic properties of medications used to treat painful diabetic neuropathy is also reviewed. Comparisons of medication dosages, frequencies, and adverse effects are offered to help with selection of the most appropriate agent for each individual patient. (J Am Podiatr Med Assoc 97(5): 394–401, 2007)
BACKGROUND:METHODS:RESULTS:CONCLUSIONS:
Surgical Treatment of Peripheral Neuropathy
Outcomes from 100 Consecutive Decompressions
Since 1992 it has been reported that patients with diabetes mellitus recover sensibility and obtain relief of pain from neuropathy symptoms by decompression of lower-extremity peripheral nerves. None of these reports included a series with more than 36 diabetic patients with lower-extremity nerves decompressed, and only recently has a single report appeared of the results of this approach in patients with nondiabetic neuropathy. No previous report has described a change in balance related to restoration of sensibility. A prospective study was conducted of 100 consecutive patients (60 with diabetes and 40 with idiopathic neuropathy) operated on by a single surgeon, other than the originator of this approach, and with the postoperative results reviewed by someone other than these two surgeons. Each patient had neurolysis of the peroneal nerve at the knee and the dorsum of the foot, and the tibial nerve released in the four medial ankle tunnels. After at least 1 year of follow-up, 87% of patients with preoperative numbness reported improved sensation, 92% with preoperative balance problems reported improved balance, and 86% whose pain level was 5 or greater on a visual analog scale from 0 (no pain) to 10 (the most severe pain) before surgery reported an improvement in pain. Decompression of compressed lower-extremity nerves improves sensation and decreases pain, and should be recommended for patients with neuropathy who have failed to improve with traditional medical treatment. (J Am Podiatr Med Assoc 95(5): 451–454, 2005)
Improved Sensitivity in Patients with Peripheral Neuropathy
Effects of Monochromatic Infrared Photo Energy
The medical records of 1,047 patients (mean age, 73 years) with established peripheral neuropathy were examined to determine whether treatment with monochromatic infrared photo energy was associated with increased foot sensitivity to the 5.07 Semmes-Weinstein monofilament. The peripheral neuropathy in 790 of these patients (75%) was due to diabetes mellitus. Before treatment with monochromatic infrared photo energy, of the ten tested sites (five on each foot), a mean ± SD of 7.9 ± 2.4 sites were insensitive to the 5.07 Semmes-Weinstein monofilament, and 1,033 patients exhibited loss of protective sensation. After treatment, the mean ± SD number of insensate sites on both feet was 2.3 ± 2.4, an improvement of 71%. Only 453 of 1,033 patients (43.9%) continued to have loss of protective sensation after treatment. Therefore, monochromatic infrared photo energy treatment seems to be associated with significant clinical improvement in foot sensation in patients, primarily Medicare aged, with peripheral neuropathy. Because insensitivity to the 5.07 Semmes-Weinstein monofilament has been reported to be a major risk factor for diabetic foot wounds, the use of monochromatic infrared photo energy may be associated with a reduced incidence of diabetic foot wounds and amputations. (J Am Podiatr Med Assoc 95(2): 143–147, 2005)
Peripheral neuropathy can be a devastating complication of diabetes mellitus. This article describes surgical decompression as a means of restoring sensation and relieving painful neuropathy symptoms. A prospective study was performed involving patients diagnosed as having type 1 or type 2 diabetes with lower-extremity peripheral neuropathy. The neuropathy diagnosis was confirmed using quantitative sensory testing. Visual analog scales were used for subjective assessment before and after surgery. Treatment consisted of external and as-needed internal neurolysis of the common peroneal, deep peroneal, tibial, medial plantar, lateral plantar, and calcaneal nerves. Subjective pain perception and objective sensibility were significantly improved in most patients who underwent the described decompression. Surgical decompression of multiple peripheral nerves in the lower extremities is a valid and effective method of providing symptomatic relief of neuropathy pain and restoring sensation. (J Am Podiatr Med Assoc 95(5): 446–450, 2005)
Angiopathy, immunopathy, and neuropathy are the key components responsible for diabetic foot complications. The authors report on the current theories of metabolic and structural causes of diabetic neuropathy.
Background:
Studies have established a positive association between peripheral neuropathy and diabetes mellitus. The purpose of the present investigation is to determine the predictor variables for demographic characteristics of individuals with diabetes mellitus and peripheral neuropathy.
Methods:
Frequency and χ2 statistic analyses were conducted on the data to determine significance of predictor variables.
Results:
Among individuals with and without diabetes mellitus, men are more at risk to develop complications related to peripheral neuropathy, such as foot insensate areas and numbness in extremities. Diabetic individuals older than 61 years are at higher risk than other age groups. Among diabetic patients with peripheral neuropathy, women are more likely to have emotional disorders such as panic, anxiety disorder, and depression than men of the same age or younger.
Conclusions:
Predictor variables will assist clinicians in better diagnosing peripheral neuropathy, contributing to more effective treatments and shortening of healing time. Diagnostic measures to be taken into consideration include race, age, education, marital status, duration of diabetes mellitus, numbness in hands or feet, participation in moderate physical activity, and use of tobacco. (J Am Podiatr Med Assoc 103(5): 355–360, 2013)
Topical Ketamine Cream in the Treatment of Painful Diabetic Neuropathy
A Randomized, Placebo-controlled, Double-blind Initial Study
Background:
Painful diabetic neuropathy remains a difficult pathologic condition to manage effectively despite numerous pharmacologic interventions. A randomized, placebo-controlled, double-blind study was undertaken to determine whether topical 5% ketamine cream is effective in reducing the pain of diabetic neuropathy.
Methods:
Seventeen diabetic patients completed the study. The Michigan Neuropathy Screening Instrument was used to determine whether the neuropathy was likely caused by the diabetic condition. Hemoglobin A1c levels were measured before treatment. Patients applied 1 mL of either ketamine cream or placebo cream for 1 month. The intensity of seven different pain characteristics was evaluated before and after treatment. A two-way repeated analysis of variance design was used to test for differences between treatments and within patients (time).
Results:
We found no significant treatment main effect, but pain improved significantly over time in both groups. There was no statistical interaction effect (treatment ×time) in any of the pain characteristics, indicating that pain improved in the two treatment groups similarly with time.
Conclusions:
The 5% topical ketamine cream was no more effective than was placebo in relieving pain caused by diabetic neuropathy. (J Am Podiatr Med Assoc 102(3): 178–183, 2012)
Forty-nine consecutive subjects with established diabetic peripheral neuropathy were treated with monochromatic near-infrared photo energy (MIRE) to determine if there was an improvement of sensation. Loss of protective sensation characterized by Semmes-Weinstein monofilament values of 4.56 and above was present in 100% of subjects (range, 4.56 to 6.45), and 42 subjects (86%) had Semmes-Weinstein values of 5.07 or higher. The ability to discriminate between hot and cold sensation was absent (54%) or impaired (46%) in both groups prior to the initiation of MIRE treatment. On the basis of Semmes-Weinstein monofilament values, 48 subjects (98%) exhibited improved sensation after 6 treatments, and all subjects had improved sensation after 12 treatments. Therefore, MIRE may be a safe, drug-free, noninvasive treatment for the consistent and predictable improvement of sensation in diabetic patients with peripheral neuropathy of the feet. (J Am Podiatr Med Assoc 92(3): 125-130, 2002)
