Peripheral neuropathies in diabetes

Development and Comparative Efficacy of Lagos Neuropathy Protocol for Improving Recovery of Symptom and Functional Independence Performance in Individuals with Diabetic Peripheral Sensorimotor Polyneuropathy

BACKGROUND

Diabetic peripheral sensorimotor polyneuropathy (DPSP) has been treated with sketchy outcomes and available approaches are not applicable for self-administration. This study developed protocol for managing symptoms of DPSP and assessed its comparative efficacy.

METHODS

Study developed Lagos Neuropathy Protocol (LNP) through existing concept in DPSP and tested its safety, clinical applicability, and ease of self-administration. Its efficacy was compared with Buerger-Allen Exercise (BAE) by involving 31(11males) with DPSP, randomized into LNP and BAE and treated for 10-week. Toronto Clinical Scoring System was used to diagnose DPSP while Diabetic Neuropathy Examination was used to diagnose distal polyneuropathy. Sensory/pressure perception was assessed using 10 g-monofilament while Short Physical Performance Battery, Bergs Balance Scale and Visual Analogue Scale was used to assess functional performance, strength and balance, and pain respectively.

RESULTS

LNP has three domains: sensory/pressure/proprioception, strength/balance, and pain/swelling. Most (80%) of the participants rated the LNP as excellently safe while the rest (20%) rated as very good in safety. All the participants rated LNP excellent in terms of self-administration and suitability for clinical use without adverse effect. The mean age of the participants for the comparative phase was 66.20±9.48years while their length of diagnoses of diabetes was 15.80±13.35years. About a third (32.5%) had DPSP. Both LNP and BAE had significant improvement (p<0.05) in sensory/pressure perception, pain, strength and balance, and functional performance but LNP had better significant improvement.

CONCLUSION

LNP is safe, good for self-administration, clinically applicable and efficacious in improving sensory/pressure perception, balance, pain and functional performances in individuals with DPSP.

Skin pH is lower in type 1 diabetes subjects and is related to glycemic control of the disease

BACKGROUND

Diabetes is a systemic disease affecting many organs, including skin. Skin may reflect the condition of internal organs. The aim of our study was to measure skin pH in type 1 diabetes mellitus (T1DM) patients and in healthy controls and to evaluate the association between metabolic control of diabetes and skin acidity in T1DM patients.

MATERIALS AND METHODS

The study was conducted on 105 patients with T1DM and 53 age- and sex-matched healthy people. Skin surface pH was measured in three different areas of the body (cheek, forearm, and foot) in diabetes patients and healthy controls. The results were compared for patients' and controls' clinical characteristics and for patients' metabolic control and also evaluated according to the presence of complications of diabetes.

RESULTS

Patients with T1DM had lower skin pH compared with the control group in three measured areas: within the cheek (5.49 ± 0.42 vs. 5.69 ± 0.31; P = 0.001), forearm (5.41 ± 0.46 vs. 5.73 ± 0.69; P = 0.004), and foot (5.20 ± 0.53 vs. 5.41 ± 0.41; P = 0.008). In the multiple linear regression skin pH was negatively correlated with fasting plasma glucose on the cheek (β = -0.34, P = 0.0004), forearm (β = -0.30, P = 0.0009), and foot (β = -0.18, P = 0.04). Diabetes patients with glycated hemoglobin (HbA1c) ≥ 8% had significantly lower skin pH than patients with better glycemic control (HbA1c < 8%). However, we observed a statistically significant difference only on the foot (5.09 ± 0.50 vs. 5.34 ± 0.55; P = 0.019).

CONCLUSIONS

Skin surface pH is lower in individuals with diabetes, and it is negatively related to actual and chronic hyperglycemia.

Neuropathic arthropathy of the foot with and without superimposed osteomyelitis: MR imaging characteristics

PURPOSE

To determine retrospectively the magnetic resonance (MR) findings associated with pedal neuropathic arthropathy with and without superimposed osteomyelitis and to identify any useful discriminating features.

MATERIALS AND METHODS

Investigational review board approval was obtained and allowed review of records and images without informed consent. HIPAA compliance was observed. Contrast-enhanced MR images in patients with diabetic neuropathic arthropathy of the foot were examined by two reviewers in consensus. Affected joints were examined for marrow, articular, periarticular, and soft-tissue findings. Presence of superimposed osteomyelitis was documented. A subgroup that had undergone MR before infection was evaluated for comparison; chi(2) and t tests were used to evaluate the associations.

RESULTS

Of 128 neuropathic joints in 63 patients (24 female, 39 male; aged 31-78 years), 43 had superimposed osteomyelitis. Effusion was common in all neuropathic joints, but thin rim enhancement was more common in noninfected joints (62% vs 21%, P < .001) and diffuse joint fluid enhancement was more common with infection (47% vs 26%, P = .052). Subluxation, bone proliferation, fragmentation, and erosion were seen in both groups, but intraarticular bodies were more common in noninfected joints (53% vs 12%, P < .001). In the periarticular soft tissues, edema, enhancement, and ulceration were common in both groups. Fluid collections in the soft tissues were more commonly associated with infected joints (95% vs 48%, P < .001) and, when present next to an infected joint, were larger than those next to noninfected neuropathic joints (2.6 cm(2) [range, 0.3-8.6 cm(2)] vs 1.6 cm(2) [range, 1.0-2.4 cm(2)]). Soft-tissue fat replacement (68% vs 36%, P = .002) and sinus tracts (84% vs 0%, P < .001) were also more common with infection. In the marrow, periarticular signal intensity abnormality was common in both groups, but the extent was greater with infection. Subchondral cysts were seen almost exclusively in noninfected joints (76% vs 2%, P < .001). Similar results were obtained in the subgroup of 21 joints (15 patients) with both pre- and postinfection MR images.

CONCLUSION

Sinus tract, replacement of soft-tissue fat, fluid collection, and extensive marrow abnormality are MR imaging features indicating superimposed infection. Thin rim enhancement of effusion, presence of subchondral cysts, or intraarticular bodies indicate absence of infection.

MR imaging of the diabetic foot

Diabetes is a common disease with potentially devastating complications affecting the foot and ankle. Ischemia and infarction, neuropathic osteoarthropathy, callus, ulceration, and infection result from the underlying neurologic and vascular disease. The MR imaging appearance of these complications is discussed. Recognition of these MR imaging patterns is important for formulation of an appropriate treatment plan.

Regional musculoskeletal conditions: foot and ankle disorders

Foot pain is very common, especially in women, owing to inappropriate footwear. Overuse, repetitive strain and minor, easily forgettable injuries may result in chronic foot and ankle pain. Rheumatoid arthritis, spondyloarthropathies and gout frequently affect the foot, often as a first presentation. Charcot's joints and foot infections are not rare in diabetes. The rheumatologist should be familiar with foot disorders, either localized or as manifestations of generalized disease. History taking, physical examination, identification of the source of pain by intra-articularly given local anaesthetics and imaging methods should be used to reveal the underlying disorder. Correct diagnosis and efficient therapy-including local steroid injections, physiotherapy, orthoses, surgery-are necessary not only for treatment but also for preventing biomechanical chain reactions. This chapter gives an overview of the epidemiology, diagnosis and treatment of foot pain and foot disorders caused by both local and generalized diseases.

Lower-extremity wounds. 2. Management options

Various disorders and risk factors prevent wound healing in patients with peripheral vascular disease. These mostly can be treated with non-pharmacological interventions, such as smoking cessation and diabetes management.

Diabetic neuropathy: diagnosis and treatment for the pain management specialist

Diabetic neuropathy is the name used by clinicians to describe a heterogeneous group of diseases that affect the autonomic and peripheral nervous systems of patients suffering from diabetes mellitus. This article provides the pain management specialist with an overview of the pathophysiology and current trends in the diagnosis and treatment of these diseases. Because of the significant morbidity and suffering associated with diabetic neuropathy, this article emphasizes practical steps to prevent, treat, and manage diabetic neuropathy to assist the pain management specialist in caring for patients suffering from this common malady.