Balance impairment in diabetic peripheral neuropathy: Where do we stand?

The World Health Organisation estimated that in the year 2000, 150 million people had diabetes mellitus, and it is predicted that this number will rise to 366 million by the year 2030.[1][1] Neuropathy is a common complication of diabetes and is characterised by a progressive loss of peripheral

The management of diabetic peripheral neuropathy (DPN) comprises a multidimensional approach. Along with pharmacological treatment, physiotherapy has gained applaudable popularity in improving the symptoms of DPN. Neuromuscular taping (NMT) is effective in improving motor, sensory, and balance impairments in many neuromuscular and musculoskeletal conditions but no research has conducted to evaluate the effect of NMT on balance, proprioception, pain, and nerve conduction parameters in patients with DPN. To evaluate the effectiveness of NMT on balance, proprioception, pain, and nerve conduction parameters in patients with DPN. 50 DPN patients aged 40-60 years, scored ≥ 2/13 on physical appearance and ≥ 1/10 on physical examination of Michigan Neuropathy Screening Instrument (MNSI), > 12 on Leeds Assessment of Neuropathic Symptom and Sign (LANSS) scale and < 45 on Berg Balance Scale (BBS) will be included. The experimental group (EG) will receive NMT at the tibialis anterior, tibialis posterior, and peroneus longus muscle and transverse arch of the foot and TENS at the tibial and peroneal nerves (80Hz, 50 Amp, 0.2 ms square pulses, 2 to 3 times sensory threshold) and the control group (CG) will receive sham taping at the ankle joint and TENS with the same parameters as EG. Outcome measures will be taken at baseline, at 4 weeks, and at 8 weeks of intervention, respectively. The results obtained upon completion of this study may provide a cost-effective non-invasive treatment option to improve the outcomes that will be measured in the present study in patients with DPN. The online version contains supplementary material available at 10.1007/s40200-023-01275-5.

Background: Diabetic peripheral neuropathy, is a common manifestation of peripheral nervous system in diabetes due to elevated glucose level. Symptoms include painful lower limbs, altered sensation, reduce reflexes and weakness of lower limb resulting in impairment in balance and gait. As treatment various interventions are used such as balance training, strength training, aerobic exercise, sensory motor training. Aim of study: This study was to assess the effect of multisensory exercise training on sensation and balance in patients with diabetic neuropathy. Methodology: This study was conducted in various OPDs and diabetic center of Surat. 10 diabetic neuropathic patients were randomly assigned in to 2 groups; 5 patients were allocated in group A (conventional &amp; multisensory training) and 5 patients were allocated in group B (conventional therapy). Patients in both groups were treated for 3 days per week for 4 weeks. Conventional physiotherapy was given for 3 days in a week at home for 4 weeks. Sensation and balance were assessed by using Semmes-Weinstein Monofilaments and berg balance scale respectively. Data were recorded at baseline and after 4 weeks of training. Result: The result showed there was no significant difference in effect of multisensory exercise on sensation and there was significant improvement in balance in patients with diabetic neuropathy. Conclusion: The result of study indicate that 4 weeks of multisensory exercise program was improving balance in patients with diabetic neuropathy as compare to conventional therapy. Key words: Multisensory exercise, Sensation, Balance, Diabetic neuropathy

Objective: To compare the effect of Amitriptyline and Pregabalin in treatment of painful diabetic neuropathy. Material and Methods: The design of this study was Randomized Controlled Trial study design. This study was conducted in the Department of Medicine in, Holy Family Hospital, Rawalpindi and the duration of this study was Six months after the approval of synopsis i.e from 1st November 2019 to 1st May 2020. Approval from ethical committee of the hospital was taken. Written informed consent was taken from patients. Consent form is attached with this. Patients were randomly allocated into two groups by lottery method. The dose of Pregabalin was used as 50mg thrice daily for a period of six weeks and label as group-A and group B received amitriptyline as 25mg once daily before bedtime for a period of six weeks as prescribed by a senior consultant who was blind to object of the study. At the start and end of treatment pain was marked by patients on Visual Analogue Scale (VAS) and numerical score. It was noted on the Performa. Results: Total 100 patients were included according to the inclusion criteria of the study. The dose of Pregabalin was given in patients in group-A and group-B received amitriptyline. Mean age (years) in the study was 55.87+6.43 whereas there were 55 (55.0) male and 45 (45.0) female patients who were included in the study according to the inclusion criteria. In our study, frequency and percentage of effect (pain relief) among Pregabalin and Amitriptyline in treatment of painful diabetic neuropathy was 27 (54.0) and 11 (22.0) respectively which was statistically significant (p-value 0.001). Practical Implication: In this study Pregabalin is more responsible for pain relief than Amitriptyline in treatment of painful diabetic neuropathy. Further studies at multiple studies must be conduct in future for determining the efficacy of amitriptyline and Pregabalin in diabetic neuropathy in order to formulate guidelines for management of diabetic peripheral neuropathy. Conclusion: The study concluded that Pregabalin is more responsible for pain relief than Amitriptyline in treatment of painful diabetic neuropathy. Further studies at multiple studies must be conduct in future for determining the efficacy of Pregabalin and amitriptyline in diabetic neuropathy in order to formulate guidelines for management of diabetic peripheral neuropathy. Keywords: Amitriptyline, Pregabalin, Neuropathy, Pain Relief, Diabetic Sensorimotor Polyneuropathy, Prevalence.

Characteristics of the gait initiation phase in older adults with diabetic peripheral neuropathy compared to control older adults

Introduction: The management of Diabetic Peripheral Neuropathy (DPN) consists of multidirectional interventions. Physiotherapy, in addition to the pharmacological approach, has achieved appreciable popularity in ameliorating the symptoms of DPN. Lagos Neuropathy Protocol (LNP), Proprioceptive Neuromuscular Facilitation (PNF), and Neuromuscular Taping (NMT), have shown remarkable improvements in sensorimotor impairments in various neuromuscular and musculoskeletal disorders but no research has been established to compare the effectiveness of LNP, PNF and NMT on sensorimotor functions in individuals with DPN. Need for this study: This study may provide the comparative significant differences between the LNP, PNF and NMT interventions among DPN patients. Aim: To compare the effectiveness of LNP, PNF and NMT on sensorimotor functions in patients with DPN. Materials and Methods: Sixty DPN subjects 60-75 years of age both male and female will be divided into 3 groups, scoring ≥2/13 on physical appearance and ≥1/10 on physical examination of the Michigan Neuropathy Screening Instrument (MNSI), &lt;45 on Berg Balance Scale (BBS) and &gt;12 on Leeds Assessment of Neuropathic Symptom and Sign (LANSS) scale will be included in the study. All three groups (LNP, PNF, and NMT) will receive an intervention for 3 days/week for 10 weeks respectively. Outcome measures will be assessed at baseline and post-intervention, respectively.

Objectives: Diabetic peripheral neuropathy (DPN) is a chronic complication of diabetes mellitus (DM) with symptoms like intense pain and impaired quality of life. This condition has no treatment; instead, the pain is managed with various antidepressants, including duloxetine. The aim of this study is to analyze the evidence on the efficacy of duloxetine in the management of DPN. Methods: A systematic search in different databases was conducted using the keywords "diabetic neuropathy", "duloxetine therapy", "neuropathic pain", and "Diabetes Mellitus". Finally, eight studies were included in this meta-analysis. Results: All articles comparing duloxetine at different doses vs. a placebo reported significant differences in favor of duloxetine on pain scales like 24 h Average Pain Severity (standardized mean difference [SMD] = -1.06, confidence interval [CI] = -1.09 to -1.03, and p < 0.00001) and BPI Severity (SMD = -0.70, CI = -0.72 to -0.68, and p < 0.00001), among others. A total of 75% of the meta-analyses of studies comparing duloxetine at different doses showed a tendency in favor of the 120 mg/d dose. There were significant differences in favor of duloxetine when compared to routine care on the Euro Quality of Life (SMD = -0.04, CI = -0.04 to -0.03, and p < 0.00001) and SF-36 Survey (SMD = -5.86, CI = -6.28 to -5.44, and p < 0.00001) scales. There were no significant differences on the visual analog scale (VAS) when comparing duloxetine and gabapentin. Conclusions: Duloxetine appears to be effective in the management of DPN in different pain, symptom improvement, and quality of life scales.

Guidelines on the out-patient management of diabetic peripheral neuropathy have been developed from an international consensus meeting attended by diabetologists, neurologists, primary care physicians, podiatrists and diabetes specialist nurses. A copy of the full document follows this summary (Appendix 1). The document arose out of suggestions from Neurodiab, a subgroup of the European Association for the Study of Diabetes, that there was a need for guidelines developed by consensus, for the outpatient management of patients with diabetic neuropathy. An international consensus group was created, chaired by two of the authors. A pilot working party met in 1995, followed by a full working party of 39 experts, neurologists and diabetes physicians (Appendix 2). This compiled a draft guideline document which was circulated to a number of international bodies. After consultation with its members, the final guidelines were approved by Neurodiab (chairman F.A. Gries) towards the end of 1997.

Background: Diabetic peripheral neuropathy often demonstrates impairments in balance and thus anincreased risk for falls. This affects the both static balance and dynamic balance, but static balance is moreaffected. Balance training is considered to be a very important tool for prevention of falls in older population.It has been shown to produce improvements in different aspects of balance.Objective: To find out the effect of task-oriented exercises on improving the balance and minimizing therisk of fall in patients with diabetic neuropathy- a comparative study.Methodology: 18 patients meeting the inclusion and exclusion criteria were allocated into 2 groups. GroupA (n=8) received conventional Physiotherapy &amp; Group B (n=10) received task-oriented exercises along withconventional Physiotherapy.Result: Result of this study showed that there is significant difference in pre and post values for both FFABQand BBS scales except for BBS the scores of group A no significant changes. On comparison between GroupA and Group B, the group B showed more improvement in FFABQ and BBS score than group A.Conclusion: This study concluded that the Task-oriented exercises with Conventional Physiotherapy weremore effective in improving balance and reducing the fear of fall than with only conventional physiotherapyin diabetic neuropathy patients after 3 weeks of duration.

Background: Diabetes Mellitus type 2 causes multiple complications like peripheral neuropathy, retinopathy and vestibulopathy. Diabetic neuropathy was one of the very common and long-term complications of DM which worsen throughout time. Postural variability and balance illness were mutual findings in DN due to lessened proprioception. Objective: The objective was to determine the frequency of elderly patients with diabetes type II having risk of Fall and impaired Balance. Methods: It was a cross sectional study. The Sample size was 133 participants surveyed through convenient sampling technique. Total time from May to October 2021 was utilized for study. Berg Balance Scale was used to determine the risk of fall in older adults having diabetes mellitus type 2. Participants were appearing for assessment for once. Data was analyzed on SPS S version 25. Results: The result showed that 76.7% patients were independent in their daily life activities. The results of our study were that total 23.3% patients were at the risk of fall. The means and standard deviation of total score of Berg Balance Scale was found to be 44.49±10.48. Conclusion: Based on findings of study it was concluded about one fourth of patients were at risk of fall and impaired balance. The adverse effects associated with diabetes mellitus like retinopathy, vestibulopathy and diabetic neuropathy may contribute to worsening balance and fall risk. Keywords: Vestibulopathy, Berg Balance Scale, Diabetic Neuropathy, Balance Impairment, Retinopathy

Diabetic neuropathy is one of the most common complications of diabetes. The synthetic drugs available in the market have side effects and limitations for diabetic patients, the vast majority of whom are in the upper age group. In this regard, based on Persian medicinal sources, Nigella sativa (N. sativa) has proved to have beneficial effects on neuropathic pain and neurological disorders. In this study, the effect of N. sativa is investigated topically in patients with diabetic neuropathy. This study was performed as a double-blind clinical trial on 120 neuropathic patients. The patients were divided into three groups. The first group received a topical N. sativa product as an ointment, the second group was given a topical placebo, and the third received 300mg gabapentin capsules. The blindness was done in first and second groups. Diabetic neuropathy was assessed before the study using the Michigan Neuropathy Screening Instrument (MNSI). In addition, neuropathy symptoms were evaluated after the trial using the MNSI questionnaire. The data were elicited from the patients' answers to a number of questions in the Michigan questionnaire. There were statistically significant differences between the group that received the topical N. sativa product and the other two groups in terms of legs and feet numbness (p value = 0.001), burning pain in feet or legs (p value = 0.001), muscle cramps in feet or legs (p value = 0.001), prickling fleeing in feet or legs (p value = 0.001), hurting of the skin when the bed covers touch it (p value = 0.005), aggravated symptoms at night (p value = 0.001) and hurting feelings in the legs when walking (p value = 0.032). However, the three studied groups were not statistically different in distinguishing hot water from cold water. According to the results of this study, the topical use of N. sativa, compared to the current drugs, has acceptable improving effects on diabetic neuropathic patients.

To examine the proportion of diabetic peripheral neuropathy (DPN) patients receiving pharmacologic DPN treatments and specifically to identify the rates and factors associated with opioid use and first-line opioid use. A 10% sample of IMS-LifeLink claims data from 1998 through 2008 was used. The study population consisted of diabetic patients who met DPN criteria using a validated DPN algorithm. Multivariable logistic regression controlling for demographics, comorbidities, and other clinical characteristics was used to identify factors associated with any DPN pharmacologic treatment, any opioid use, and first-line opioid treatment. Sensitivity analyses were conducted to explore variations in exclusion criteria as well as opioid use definitions. A total of 666 DPN patients met inclusion criteria and pharmacologic treatment was received by 288 patients (43.24%) and of those, 154 (53.47%) had DPN-related opioid use and 96 (33.33%) received opioid as first-line treatment. Persons with diabetic complications were more likely to use opioids (odds ratio=4.53; 95% confidence interval, 1.09-18.92). Food and Drug Administration-approved DPN agents duloxetine 1.04% (n=3) and pregabalin 5.56% (n=16) had much lower rates of use. DPN-related drug use and DPN-related opioid usage increased as we used less restrictive samples in sensitivity analyses. Opioids were the most frequently prescribed first-line agents for DPN. More than 50% of DPN patients remained untreated with pharmacologic agents 1 year after a DPN diagnosis.

AIMThe study aimed to investigate the possible relationship between diabetic peripheral neuropathy (DPN) and the development of depressive symptoms in patients with type 2 diabetes mellitus (T2D).METHODSA comparative non-experimental study was conducted. Ninety-five T2D individuals aged 65 years and more were recruited. The sample was divided into two groups: 50 participants with T2D and without DPN and 45 participants with T2D and DPN. The Patient Health Questionnaire 9 (PHQ-9) was used to collect information about low mood and depression symptoms in the subjects recruited.RESULTSParticipants with DPN recorded higher scores on PHQ-9 than those with T2D only. The mean PHQ-9 score for the DPN group (6.09) was significantly higher than that for the T2D only group (2.24) (p < 0.001). Participants with DPN were more likely to have mild to moderate or moderately severe low mood and depression symptoms than T2D only participants who exhibited minimal to no low mood and depressive symptoms.CONCLUSIONSThe association between DPN and depression is confirmed by this study, with significant depressive symptoms found in patients with neuropathy when compared to diabetes patients with no neurological complications. It is therefore important that discomfort and emotional problems caused by DPN should be taken seriously and addressed closely in the management of DPN in order to prevent depression. Also, a change in screening practices to identify patients with diabetes and depressive symptoms is required.

Elderly patients with diabetes and peripheral neuropathy are more likely to experience falls. However, the information available on how such falls can be prevented is scarce. We investigated the effects of whole-body vibration (WBV) combined with a balance exercise program on balance, muscle strength, and glycosylated hemoglobin (HbA1c) in elderly patients with diabetic peripheral neuropathy. Fifty-five elderly patients with diabetic neuropathy were randomly assigned to WBV with balance exercise group, balance exercise (BE) group, and control group. The WBV and BE groups performed the balance exercise program for 60 min per day, 2 times per week, for 6 weeks. Further, the WBV group performed WBV training (up to 3 × 3 min, 3 times per week, for 6 weeks). The control group did not participate in any training. The main outcome measures were assessed at baseline and after 6 weeks of training; namely, we assessed the postural sway and one leg stance (OLS) for static balance; Berg balance scale (BBS), timed up-and-go (TUG) test, and functional reach test (FRT) for dynamic balance; five-times-sit-to-stand (FTSTS) test for muscle strength; and HbA1c for predicting the progression of diabetes. Significant improvements were noted in the static balance, dynamic balance, muscle strength, and HbA1c in the WBV group, compared to the BE and control groups (P < 0.05). Thus, in combination with the balance exercise program, the short-term WBV therapy is beneficial in improving balance, muscle strength and HbA1c, in elderly patients with diabetic neuropathy who are at high risk for suffering falls.

Background: Diabetic peripheral neuropathy (DPN) impacts approximately 50% of individuals with Type 2 diabetes mellitus (T2DM), leading to severe complications such as foot ulcers and amputations. Notably, visceral adiposity is increasingly recognized as a pivotal factor in augmenting the risk of DPN. We aim to evaluate the correlation between obesity-related body composition, particularly visceral fat, and DPN to facilitate early identification of high-risk patients with T2DM. Methods: This cross-sectional analysis encompassed 113 T2DM patients from the Department of Endocrinology and Metabolism at the Second Affiliated Hospital of Fujian Medical University, conducted between September 2020 and January 2021. Patients were categorized into two cohorts: those with DPN (DPN group) and those without (NDPN group). We utilized bioelectrical impedance analysis (BIA) to determine body measurements, such as weight and visceral fat area, in addition to collecting clinical and biochemical data. Logistic regression was employed to analyze the data. Results: The study uncovered a statistically significant difference in the visceral fat area between the DPN and NDPN groups (p = 0.048). Through multivariate logistic regression analysis, the visceral fat area was identified as an independent risk factor for DPN among T2DM patients (OR 1.027; 95% CI 1.004-1.051, p = 0.022). Other significant risk factors included the duration of diabetes and the presence of diabetic retinopathy. Conclusion: The visceral fat area serves as an independent risk factor for DPN in individuals with T2DM. Implementing measures to assess and manage visceral obesity could be vital in the prevention and management of DPN. This underscores the value of technologies such as BIA in clinical and community settings for early intervention.