A focused exercise regimen improves clinical measures of balance in patients with peripheral neuropathy

OBJECTIVE

To determine the effect of a specific exercise regimen on clinical measures of postural stability and confidence in a population with peripheral neuropathy (PN).

DESIGN

Prospective, controlled, single blind study.

SETTING

Outpatient clinic of a university hospital.

PARTICIPANTS

Twenty subjects with diabetes mellitus and electrodiagnostically confirmed PN.

INTERVENTION

Ten subjects underwent a 3-week intervention exercise regimen designed to increase rapidly available distal strength and balance. The other 10 subjects performed a control exercise regimen.

MAIN OUTCOME MEASURES

Unipedal stance time, functional reach, tandem stance time, and score on the activities-specific balance and confidence (ABC) scale.

RESULTS

The intervention subjects, but not the control subjects, showed significant improvement in all 3 clinical measures of balance and nonsignificant improvement on the ABC scale.

CONCLUSION

A brief, specific exercise regimen improved clinical measures of balance in patients with diabetic PN. Further studies are needed to determine if this result translates into a lower fall frequency in this high-risk population.

Neuromuscular rehabilitation and electrodiagnosis. 3. Generalized peripheral neuropathy

This self-directed learning module provides an updated tool for establishing the differential diagnosis and subsequently designing a cost-effective workup for patients with peripheral neuropathy. It is part of the chapter on neuromuscular rehabilitation and electrodiagnosis in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Medication intervention for neuropathic pain is reviewed by medication class with recommendations for starting doses and review of side-effect profiles. This article also reviews the current treatment standards for a patient with juvenile-onset diabetes, including recommendations for glucose control, management of nephropathy and retinopathy, and care of foot complications.

Diabetic peripheral neuropathy and quality of life

The quality of life (QOL) of 79 people with type 1 and type 2 diabetes and 37 non-diabetic controls was assessed using the Nottingham Health Profile (NHP). The NHP consists of six domains assessing energy, sleep, pain, physical mobility, emotional reactions and social isolation. Symptomatic diabetic neuropathy was present in 41 of the patients. The neuropathy patients had significantly higher scores (impaired QOL) in 5/6 NHP domains than either the other diabetic patients (p < 0.01) or the non-diabetic (p < 0.001) controls. These were: emotional reaction, energy, pain, physical mobility and sleep. The diabetic patients without neuropathy also had significantly impaired QOL for 4/6 NHP domains compared with the non-diabetic control group (p < 0.05) (energy, pain, physical mobility and sleep). This quantification of the detrimental effect on QOL of diabetes, and in particular of chronic symptomatic peripheral diabetic neuropathy, emphasizes the need for further research into effective management of these patients.

[The use of white and yellow turpentine baths with diabetic patients]

In patients with insulin-dependent diabetes mellitus while and yellow turpentine baths produced a positive effect on carbohydrate metabolism. White baths were more effective in respect to lipid metabolism, blood viscosity, produced a good effect on plasmic hemocoagulation factors. Both while and yellow turpentine baths were beneficial for capillary blood flow: initially high distal blood flow in patients with prevailing distal polyneuropathy decreased while in patients with macroangiopathy initially subnormal blood flow increased. Both white and yellow turpentine baths promoted better pulse blood filling of the lower limbs and weaker peripheral resistance of large vessels. In patients with non-insulin-dependent diabetes mellitus white and yellow turpentine baths contributed to normalization of carbohydrate metabolism. Yellow baths were more effective in lowering lipids. White baths induced inhibition of platelet aggregation but had no effect on coagulation, yellow baths promoted a reduction of fibrinogen but had no effect on platelet aggregation. Yellow baths produced more pronounced effect than white ones on blood viscosity and microcirculation. Both yellow and white baths stimulated pulse blood filling, corrected peripheral resistance of large and small vessels of the lower limbs.

[The use of transcutaneous electrostimulation in the treatment of diabetic angioneuropathy]

Transcutaneous electrostimulation (Amplipul's-4 unit) was used in 29 patients with diabetes mellitus and diabetic angioneuropathy. The impact was directed to three fields a session: paravertebral, musculus gastrocnemius, feet. Rheographically, a good clinical response with improvement of peripheral circulation was achieved.

Gait pattern alteration by functional sensory substitution in healthy subjects and in diabetic subjects with peripheral neuropathy

OBJECTIVE

To evaluate the ability of diabetic and nondiabetic individuals to learn to use a lower extremity sensory substitution device to cue gait pattern changes.

DESIGN

Case-control study.

SETTING

Gait laboratory.

PARTICIPANTS

Thirty diabetic persons and 20 age- and education-matched nondiabetic controls responded to advertisements for study participation.

INTERVENTION

Participants walked on a treadmill at three speeds (1, 2, and 2.5mph) with auditory sensory feedback to cue ground contact greater than 80% duration of baseline.

MAIN OUTCOME MEASUREMENTS

The variables measured included gait cycle (steps per minute) and number of times per minute that any step during a trial exceeded 80% duration of ground contacted compared with a measured baseline step length for each speed.

RESULTS

Persons in both groups were able to rapidly and significantly alter their gait patterns in response to signals from the sensory substitution device, by changing their gait cycles (nondiabetic group, F(17,124) = 5.27, p < .001; diabetic group, F(5,172) = 3.45, p < .001). Post hoc analyses showed early gait cycle modification and error reduction among both groups. The nondiabetic group learned to use the device significantly more quickly than the diabetic group during the slow (1mph, t = 3.57, p < .001) and average (2mph, t = 2.97, p < .05) trials. By the fast (2.5mph) ambulation trial, both groups were performing equally, suggesting a rapid rate of adjustment to the device. No technical failures from gait trainer malfunction occurred during the study.

CONCLUSIONS

Diabetic persons with neuropathy effectively used lower extremity sensory substitution, and the technology is now available to manufacture a durable, effective lower extremity sensory substitution system.

[Clinical aspects and therapy of Bureau-Barrière syndrome. Observations of 17 cases with review of the literature]

Bureau-Barrière syndrome can affect various organ systems. It is defined by the triad: painless ulcers at mechanically irritated and hyperkeratotic plantar areas of the feet, sensitive polyneuropathy of the lower legs and osteolysis in the forefoot area. The condition mainly affects middle-aged men suffering from alcoholism, liver disease, obesity or metabolic disorders such as diabetes mellitus. Successful treatment of the Bureau-Barrière syndrome requires an interdisciplinary approach.

Exercise training in individuals with diabetic retinopathy and blindness

Limited guidelines exist for rehabilitation programs for individuals with diabetes mellitus, blindness, and associated autonomic neuropathy. Abnormalities in autonomic function have been postulated to interfere with exercise conditioning and may predispose individuals to exercise-induced hypoglycemia. Twenty-nine individuals with diabetes mellitus underwent standardized noninvasive testing for the evaluation of cardiovascular autonomic function and graded exercise before entering a rehabilitation program. Inadequate responses of heart rate to respiratory variation were observed in 28 patients, abnormal heart rate responses to postural maneuvers were seen in 23, and postural hypotension was noted in nine. Individuals with symptomatic postural hypotension were able to exercise using a stationary bicycle, but developed hypotensive episodes on walking or prolonged standing. Blood glucose consistently decreased by a mean of 76 (+/- 9) mg/dl after each exercise session, even though low levels of exercise were performed (2.9 +/- 0.2 metabolic equivalents, for 28 +/- 1 min). There was no relationship between the degree of autonomic neuropathy and the level of blood glucose fall. There was, however, a significant correlation (r = -0.59, p = 0.001) between the decrease in blood glucose level and the amount of regular insulin used in the routine morning dose. Precautions were taken to avoid hypoglycemia, and insulin and diet were adjusted accordingly to prevent severe hypoglycemic reactions.

The neuropathic foot--a management scheme: a case report

The purpose of this case report is to present a management approach that was effective in the healing and long-term care of a neuropathic plantar ulcer in a patient with diabetes mellitus. The report demonstrates that a successful management program must go beyond the stage of healing and include patient education and techniques for reducing plantar pressures to prevent the recurrence of plantar ulcers.

Diabetic neuro-osteoarthropathy. Rehabilitation of a patient with both ankle joints involved and associated skin problems

Neuro-osteoarthropathy in diabetes mellitus is not rare. The case of a 53-year-old diabetic with involvement of both ankle joints and multiple associated skin problems complicating rehabilitation management is discussed. By applying a team approach, closely monitoring the patient's skin and joint problems, and treating them at an early stage by adaptive shoes and orthoses, we found that function could be sustained at an optimal level for a prolonged period. In addition to prevention of ulceration, modifying the weight bearing or temporarily non-weight bearing is the treatment of choice. Amputation is to be considered only as a last resort.

Teaching Braille reading to tactilely impaired, blind adults with diabetes: case report

Whether diabetic adults with diminished tactile sensitivity can learn braille for use in daily living was investigated. Three subjects, two of whom are followed up from a recent study in which they learned grade 1 braille, learned to apply their braille knowledge to the reading of labels and telephone numbers. Characteristics of these adults and their training program are discussed. One implication of this study is that, although blind persons with diabetes and impaired tac tile sensitivity present a challenge, their condition should not necessarily be an excuse for denying braille training.

Diabetic peripheral neuropathy: review of literature and case study

Diabetic peripheral neuropathy is a secondary manifestation of diabetes mellitus. The purpose of this review of literature and case study is to increase the clinical physical therapist's understanding of diabetic peripheral neuropathy.

Myocardial performance of disabled patients in a rehabilitation program

Thirty-two patients with heart disease in addition to another disability were monitored continuously with the ten-hour electrocardiographic (ECG) tape. Eighteen of the 32 patients manifested abnormalities of rate, rhythm or ST-segment depression. Patients with arrhythmia eventually did better than those with other ECG abnormalities because drug therapy was successful in abolishing the abnormal rhythm in most cases. Those patients with excessive tachycardia did poorly as a group in so far as their rehabilitation program was concerned. This technique of continuous ECG monitoring may be helpful in assessing myocardial performance in these patients and in defining the prescription for rehabilitation therapy.