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Annals of Palliative Medicine Mar 2023Painful diabetic peripheral neuropathy (DPN) affects approximately 6-34% of all patients with diabetes. DPN-induced pain reduces the quality of life and makes daily... (Review)
Review
BACKGROUND AND OBJECTIVE
Painful diabetic peripheral neuropathy (DPN) affects approximately 6-34% of all patients with diabetes. DPN-induced pain reduces the quality of life and makes daily activities difficult. Distal symmetric polyneuropathy (DSPN) is the most common type of DPN. Here we review the pathophysiology, diagnosis, and treatment of DPN.
METHODS
A MEDLINE database (PubMed) search was conducted for English-language articles dealing with the effect of DPN that were published until April 1, 2022. To identify potentially relevant articles, the following key search phrases were combined: 'diabetes mellitus', 'diabetes', 'neuropathy', 'polyneuropathy', 'diabetic neuropathies', 'peripheral neuropathy', 'diabetic polyneuropathy', 'pathophysiology', 'diagnosis', and 'treatment'.
KEY CONTENT AND FINDINGS
In a biopsy study of the sural nerve, damage to C and Aδ fibers were seen in patients who had recent onset of pain in their feet consisting of tingling, burning, and prickling, followed by initial demyelination/remyelination of large fibers. DPN is characterized by a pattern of distal-to-proximal axonal loss with symptoms. Hyperglycemia and dyslipidemia are the primary causes of DPN in patients with type 1 and 2 diabetes, respectively. The pattern of pain from DPN is described as "glove and stocking". DPN-induced pain is described as burning, electric, sharp, and dull aching with various pain intensities. DPN is a diagnosis of exclusion; diagnosis is made with a thorough medical history, physical examination, and clinical testing to rule out other causes of pain. Anticonvulsants (pregabalin and gabapentin), antidepressants (duloxetine, venlafaxine, and amitriptyline), opioids (tramadol, tapentadol, and oxycodone), and topical capsaicin are commonly administered to treat DPN. The combination of two or three of these pharmacological agents better resolves pain at lower doses and with fewer side effects.
CONCLUSIONS
Clinicians should have sufficient knowledge of DPN to ensure its accurate diagnosis and appropriate treatment. This review provides clinicians with the necessary knowledge of the pathophysiology, diagnosis, and treatment of painful DPN.
Topics: Humans; Diabetic Neuropathies; Diabetes Mellitus, Type 1; Quality of Life; Diabetes Mellitus, Type 2; Pain
PubMed: 36786097
DOI: 10.21037/apm-22-693 -
Nutrients Jan 2021To investigate the effect of normalizing vitamin B12 (B12) levels with oral B12 (methylcobalamin) 1000 μg/day for one year in patients with diabetic neuropathy (DN). (Randomized Controlled Trial)
Randomized Controlled Trial
AIM
To investigate the effect of normalizing vitamin B12 (B12) levels with oral B12 (methylcobalamin) 1000 μg/day for one year in patients with diabetic neuropathy (DN).
PATIENTS AND METHODS
In this prospective, double-blind, placebo-controlled trial, 90 patients with type 2 diabetes on metformin for at least four years and both peripheral and autonomic DN were randomized to an active treatment group (n = 44) receiving B12 and a control group (n = 46) receiving a placebo. All patients had B12 levels less than 400 pmol/L. Subjects underwent measurements of sural nerve conduction velocity (SNCV), sural nerve action potential (amplitude) (SNAP), and vibration perception threshold (VPT), and they performed cardiovascular autonomic reflex tests (CARTs: mean circular resultant (MCR), Valsalva test, postural index, and orthostatic hypotension). Sudomotor function was assessed with the SUDOSCAN that measures electrochemical skin conductance in hands and feet (ESCH and ESCF, respectively). We also used the Michigan Neuropathy Screening Instrument Questionnaire and Examination (MNSIQ and MNSIE, respectively) and questionnaires to evaluate quality of life (QoL) and level of pain (pain score).
RESULTS
B12 levels increased from 232.0 ± 71.8 at baseline to 776.7 ± 242.3 pmol/L at follow-up, < 0.0001, in the active group but not in the control group. VPT, MNSIQ, QoL, pain score, SNCV, SNAP, and ESCF significantly improved in the active group ( < 0.001, = 0.002, < 0.0001, < 0.000, < 0.0001, < 0.0001, and = 0.014, respectively), whereas CARTS and MNSIE improved but not significantly. MCR, MNSIQ, SNCV, SNAP, and pain score significantly deteriorated in the control group ( = 0.025, = 0.017, = 0.045, < 0.0001, and < 0.0001, respectively).
CONCLUSIONS
The treatment of patients with DN with 1 mg of oral methylcobalamin for twelve months increased plasma B12 levels and improved all neurophysiological parameters, sudomotor function, pain score, and QoL, but it did not improve CARTS and MNSIE.
Topics: Cholesterol; Creatinine; Diabetes Mellitus, Type 2; Diabetic Neuropathies; Dietary Supplements; Double-Blind Method; Female; Folic Acid; Follow-Up Studies; Glycated Hemoglobin; Humans; Hypoglycemic Agents; Linear Models; Male; Middle Aged; Prospective Studies; Quality of Life; Triglycerides; Vitamin B 12
PubMed: 33513879
DOI: 10.3390/nu13020395 -
EFORT Open Reviews Jan 2022Even though fifth metatarsal fractures represent one of the most common injuries of the lower limb, there is no consensus regarding their classification and treatment,... (Review)
Review
Even though fifth metatarsal fractures represent one of the most common injuries of the lower limb, there is no consensus regarding their classification and treatment, while the term 'Jones' fracture has been used inconsistently in the literature. In the vast majority of patients, Zone 1 fractures are treated non-operatively with good outcomes. Treatment of Zone 2 and 3 fractures remains controversial and should be individualized according to the patient's needs and the 'personality' of the fracture. If treated operatively, anatomic reduction and intramedullary fixation with a single screw, with or without biologic augmentation, remains the 'gold standard' of management; recent reports however report good outcomes with open reduction and internal fixation with specifically designed plating systems. Common surgical complications include hardware failure or irritation of the soft tissues, refracture, non-union, sural nerve injury, and chronic pain. Patients should be informed of the different treatment options and be part of the decision process, especially where time for recovery and returning to previous activities is of essence, such as in the case of high-performance, elite athletes.
PubMed: 35073515
DOI: 10.1530/EOR-21-0025 -
BioMed Research International 2020Stretching is an important part of post ankle sprain rehabilitation, as well as an effective exercise for improving general ankle-joint performance. But the combination... (Randomized Controlled Trial)
Randomized Controlled Trial
Effectiveness of Low-Frequency Stimulation in Proprioceptive Neuromuscular Facilitation Techniques for Post Ankle Sprain Balance and Proprioception in Adults: A Randomized Controlled Trial.
Stretching is an important part of post ankle sprain rehabilitation, as well as an effective exercise for improving general ankle-joint performance. But the combination of stretching alongside low-frequency stimulation has not yet been extensively studied. Therefore, the purpose of the present randomized controlled trial was to compare the combined effects of low-frequency transcutaneous electrical nerve stimulation (TENS) with proprioceptive neuromuscular facilitation (PNF) on strength, balance, and proprioception among individuals with post ankle sprain. Sixty male subjects with lateral ankle sprain were selected and randomly allocated to three groups: group 1, group 2, and the control group (CG). Subjects in group 1 received the PNF stretching technique combined with TENS. TENS stimulation was provided using two electrodes placed 5 cm apart directly on the triceps sural muscle of the affected leg and a biphasic current with a symmetrical waveform at 50 Hz for 15 seconds, tuned for a 3-second ramp up time and a 30-second rest time with a 250-microsecond pulse duration was given with PNF stretching. Subjects in group 2 received the PNF stretching technique alone. Both group 1 and group 2 received these treatments for 4 weeks (4 days/week); follow-up assessments were administered in the third and fifth weeks. CG received no treatment; outcome measures alone were assessed. Outcome measures comprised pain, balance, flexibility, proprioception, range of motion, muscle strength, and functional limitation. A mixed-model ANOVA showed significant interaction (time and group) and the time effect for all the outcome measures ( ≤ 0.05). Group 1 (PNF-TENS) showed significant improvement for all the outcome variables compared to the other groups. The present study showed PNF stretching combined with TENS for the triceps sural muscle to trigger muscle contraction during the muscle contraction phase of the PNF stretch, compared against PNF stretching alone, produced significant improvements in ankle function for post ankle sprain subjects.
Topics: Adult; Ankle; Ankle Injuries; Humans; Male; Muscle Stretching Exercises; Postural Balance; Proprioception; Range of Motion, Articular; Transcutaneous Electric Nerve Stimulation; Young Adult
PubMed: 33029528
DOI: 10.1155/2020/9012930 -
Diabetes Care Feb 2022Intensive glycemic control reduces the risk of kidney, retinal, and neurologic complications in type 1 diabetes (T1D), but whether it reduces the risk of lower-extremity... (Clinical Trial)
Clinical Trial
Risk of Foot Ulcer and Lower-Extremity Amputation Among Participants in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study.
OBJECTIVE
Intensive glycemic control reduces the risk of kidney, retinal, and neurologic complications in type 1 diabetes (T1D), but whether it reduces the risk of lower-extremity complications is unknown. We examined whether former intensive versus conventional glycemic control among Diabetes Control and Complications Trial (DCCT) participants with T1D reduced the long-term risk of diabetic foot ulcers (DFUs) and lower-extremity amputations (LEAs) in the subsequent Epidemiology of Diabetes Interventions and Complications (EDIC) study.
RESEARCH DESIGN AND METHODS
DCCT participants (n = 1,441) completed 6.5 years on average of intensive versus conventional diabetes treatment, after which 1,408 were enrolled in EDIC and followed annually over 23 years for DFU and LEA occurrences by physical examination. Multivariable Cox proportional hazard regression models estimated associations of DCCT treatment assignment and time-updated exposures with DFU or LEA.
RESULTS
Intensive versus conventional glycemic control was associated with a significant risk reduction for all DFUs (hazard ratio 0.77 [95% CI 0.60, 0.97]) and a similar magnitude but nonsignificant risk reduction for first-recorded DFUs (0.78 [0.59, 1.03]) and first LEAs (0.70 [0.36, 1.36]). In adjusted Cox models, clinical neuropathy, lower sural nerve conduction velocity, and cardiovascular autonomic neuropathy were associated with higher DFU risk; estimated glomerular filtration rate <60 mL/min/1.73 m2, albuminuria, and macular edema with higher LEA risk; and any retinopathy and greater time-weighted mean DCCT/EDIC HbA1c with higher risk of both outcomes (P < 0.05).
CONCLUSIONS
Early intensive glycemic control decreases long-term DFU risk, the most important antecedent in the causal pathway to LEA.
Topics: Amputation, Surgical; Blood Glucose; Diabetes Mellitus, Type 1; Diabetic Foot; Extremities; Glycated Hemoglobin; Humans; Risk Factors
PubMed: 35007329
DOI: 10.2337/dc21-1816 -
International Journal of Molecular... Jul 2019Arsenic (As) contamination affects hundreds of millions of people globally. Although the number of patients with chronic As exposure is large, the symptoms and long-term... (Review)
Review
Arsenic (As) contamination affects hundreds of millions of people globally. Although the number of patients with chronic As exposure is large, the symptoms and long-term clinical courses of the patients remain unclear. In addition to reviewing the literature on As contamination and toxicity, we provide useful clinical information on medical care for As-exposed patients. Further, As metabolite pathways, toxicity, speculated toxicity mechanisms, and clinical neurological symptoms are documented. Several mechanisms that seem to play key roles in As-induced neurotoxicity, including oxidative stress, apoptosis, thiamine deficiency, and decreased acetyl cholinesterase activity, are described. The observed neurotoxicity predominantly affects peripheral nerves in sensory fibers, with a lesser effect on motor fibers. A sural nerve biopsy showed the axonal degeneration of peripheral nerves mainly in small myelinated and unmyelinated fibers. Exposure to high concentrations of As causes severe central nervous system impairment in infants, but no or minimal impairment in adults. The exposure dose-response relationship was observed in various organs including neurological systems. The symptoms caused by heavy metal pollution (including As) are often nonspecific. Therefore, in order to recognize patients experiencing health problems caused by As, a multifaceted approach is needed, including not only clinicians, but also specialists from multiple fields.
Topics: Age Factors; Animals; Arsenic; Arsenic Poisoning; Dose-Response Relationship, Drug; Environmental Pollutants; Environmental Pollution; Humans; Metabolic Networks and Pathways; Neurotoxicity Syndromes; Organ Specificity; Oxidative Stress
PubMed: 31336801
DOI: 10.3390/ijms20143418