Diabetes-related Peripheral Neuropathy Research Articles

Getting Ready for Foot Care Certification: Implementing Off-loading Interventions to Prevent or Manage Injury.

Preparation for WOCNCB foot care certification requires a thorough understanding of calluses, including causes, complications, and treatment. In 82% of clients who develop a foot ulcer, the initial cause is callus formation.1 Callus formation is related to pressure and plantar shear stress during the push-off phase of walking.1 In clients with diabetes-related peripheral neuropathy, force or pressure can further contribute to diabetic foot ulcerations.2 In addition to pressure and stress from walking, causes of callus formation with a client who has diabetic neuropathy may include bone deformity, limited joint mobility, and ill-fitting shoes.3 The risk for developing a diabetic foot ulcer (DFU) is higher in patients who have Charcot's foot. Understanding that callus formation will likely lead to ulcer formation is paramount, with 40% of individuals who heal developing another ulcer within 12 months and 60% within 3 years.4 Diabetic foot ulcer infection is another complication that may occur, and prevention of systemic infection is crucial. Standing, walking, or any other activity that may compress tissue must be managed, as it can exacerbate a localized infection and lead to a more widespread or systemic infection.2 An off-loading device is the primary intervention to protect this tissue. When selecting any off-loading device in the setting of active infection, clinicians should consider a removable option to allow for frequent visual inspection. Determining the cause of force (shearing, compressive, frictional, tensile) is essential in the prevention and management of foot ulcers. Shearing force occurs when tissue is moving in 2 or more different directions.2 Tissue that is squeezed between 2 or more opposing loads experiences compressive force.2 A force that moves over a surface while maintaining contact is frictional force.2 Tensile force occurs when tissue is stretched by 2 or more opposing forces.2 Fundamental principles of management of pressure ulcers or injuries include off-loading to reduce the excessive or sustained forces to injury-prone areas.2 The location of the ulcer in the rear, mid-, or forefoot can impact the effectiveness of off-loading interventions and should be considered by the CFCN when determining best long-term treatment options. Toe ulcers are more difficult to treat and can be related to small shoe toe box and require proper shoe sizing or removal of the area causing friction. Therapeutic footwear has been shown to reduce the risk of initial and recurring ulcerations. Therapeutic rocker sole shoes have been associated with avoiding future complications because of their high toe box, wide heel, and specialty laces.5 Off-loading of plantar wounds is essential in managing DFUs, as delayed wound healing has been identified in up to 94% of plantar foot ulcers.5 Crutches, rolling walkers, and wheelchairs are simple and effective methods for off-loading areas of potential ulcers but may not always be practical. A removable cast walker (RCW) is commonly used for the management of DFUs due to time and skill constraints of the clinician with application.6 Total contact casts are the gold standard treatment of mid- and forefoot lesions as they reduce stride length and redistribute plantar forces.5 They are also associated with higher ulcer healing rates compared to the RCW.7 Off-loading recommendations from the International Working Group on the Diabetic Foot Guidelines note a nonremovable knee-high off-loading device as the first choice of off-loading treatment. This is followed by a removable knee-high device and then a removable ankle-high off-loading device as second- and third-choice off-loading treatments.8 If patient presentation prevents use of these options, properly fitted footwear combined with felted foam can be considered as a fourth choice. For patients with metatarsal head and digital ulcers, surgical off-loading interventions should be considered by referral to a surgeon.9 WOCNCB-certified foot care nurses (CFCN) play a critical role in the prevention and treatment of DFUs through their role in holistic patient management of calluses and off-loading. Nurses preparing for WOCNCB foot care certification should be mindful of psychological factors that impact quality of life along with adherence to treatment plans when determining the best off-loading option. Clients with a DFU may experience ulcer-specific emotional distress combined with required use of off-loading devices that may limit healing or impact preventive foot self-care.6 CFCN PRACTICE QUESTIONS 1. A CFCN has undergone additional education and training in conservative sharp wound debridement (CSWD) and is approved to provide this service by the state nurse practice act and the practice facility. A patient presents with a painful neuropathic ulcer on the left plantar midfoot. What patient response to wound debridement could indicate the nurse has gone beyond CSWD? Bleeding Pain Debriding exposed structures All of the above Cognitive level: Analysis Exam content outline location: 020305 ANSWER: D Rationale: Conservative sharp wound debridement is a key intervention in chronic wound care and entails the removal of loose, devascularized tissue, callus, or hyperkeratotic tissue using a scalpel, scissors, or curette.1 Surgical sharp debridement is a more aggressive means of tissue removal that often involves removing viable and nonviable tissues.2 Core differences between CSWD and surgical or sharp wound debridement include the principle that CSWD is not intended to cause pain, bleeding, or the debridement of exposed structures such as bone, tendon, vascular structures, or ligaments, making all above-listed answer options the correct answer.2 2. A middle-aged client with a history of diabetic neuropathy is being followed for a newly healed DFU on the left plantar surface. Which of the following off-loading methods is the best option for the CFCN to select for preventing further callus formation? Using rocker sole footwear Using a rolling walker Reinforcing gait training Maintaining bed rest until ulcer healing Cognitive level: Application Exam content outline location: 020503 ANSWER: A Rationale: Therapeutic footwear offers protection in reducing the risk for re-ulceration. Shoes with a rocker sole can reduce plantar pressure and will decrease DFU recurrence.1 Rocker sole footwear may specifically improve push-off motion to prevent callus formation because such footwear increases the motion of the lower limbs.2 The use of a rolling walker is easy but not practical. While gait training will be beneficial for balance, this will not provide adequate off-loading to prevent further callus formation. Mobility should be encouraged for those who are ambulatory; staying in bed until the ulcer is healed is not appropriate. 3. A CFCN is providing in-home routine foot care for an elderly ambulatory client. The client complains of increased pain in the lateral aspect of the fifth metatarsal joint. Upon assessment, the CFCN notes an area of erythema. Which action should the CFCN should take next? Suggest an RCW Complete pressure mapping study Assess the client's footwear Provide cushion to the noted area Cognitive level: Application Exam content outline location: 020507 ANSWER: C Rationale: The friction is likely caused by an incorrectly sized toe box.1 The best approach would be to obtain shoes that have a larger shoe box or with permission remove the area of friction.1 As the client does not have a current ulcer, an RCW would not be the first line of treatment. Pressure mapping can provide helpful information focusing on plantar pressure distribution, gait, and postural imbalance conditions for diagnosing a lower-limb problem.2 Adding additional cushion may increase friction or shear to the area. However, the shoe should be assessed first.

Preventing diabetes-related foot ulcers through early detection of peripheral neuropathy.

Peripheral neuropathy, peripheral arterial disease and diabetes-related foot ulcers are the most important risk factors for future amputation. Up to 50% of people with diabetes have distal symmetrical polyneuropathy as a complication of diabetes. Distal symmetrical polyneuropathy results in loss of protective sensation in the feet, increasing the risk of diabetes-related foot ulceration. The aim of this article is to provide structured guidance for detecting diabetes-related peripheral neuropathy, appropriate referral based on risk assessment and prevention of diabetes‑related foot ulceration. As a result of the often-asymptomatic nature of diabetes-related peripheral neuropathy, general practice is an ideal location for screening all adults with diabetes for loss of protective sensation. Loss of protective sensation in a person with diabetes indicates an at-risk foot. Increased frequency of foot examination, education in self-care, appropriate footwear and referral to podiatry for non‑ulcerative foot problems can reduce the development of diabetes-related footulcers.

Effect of peer support on adults with diabetes-related peripheral neuropathy

ObjectiveTo explore the effect of peer support on exercise self-efficacy, physical activity level, and neuropathic symptoms in patients with diabetes-related peripheral neuropathy (DPN). MethodsA total of 60 adults with DPN were assigned to groups. Patients in the control group received routine education (RE), while patients in the intervention group received peer support (PS) combined with routine diabetes education. Data were collected at baseline and after intervention (12 weeks). ResultsAt 12 weeks, better outcomes were found in the PS group compared to the RE group for the following aspects: exercise self-efficacy, steps, total physical activity, fasting blood glucose and 2-hour postprandial blood glucose. Decreases in scores on Toronto Clinical Scoring System occurred between baseline and post-intervention in both groups. ConclusionPeer support is an effective way to improve exercise self-efficacy, number of steps, and general physical activity and to reduce blood glucose for patients with DPN. But the effects of peer support on neuropathic symptoms is are obvious. Further research is needed. Practice implicationsAs a low-cost, effective education approach, peer support strategies should be integrated into our healthcare system to meet the minimum needs of patients with DPN.

Associations between diabetes-related foot disease, diabetes, and age-related complications in older patients.

To examine the relationship of diabetes-related foot disease (DFD) with diabetes and age-related complications in older patients with diabetes mellitus (DM). We examined 562 outpatients with diabetes, aged ≥ 65years, for DFD. The variables collected in this study were demographics, DM-related complications, treatment method, and age-related complications. Differences in the complications were compared between patients with and without DFD. Logistic regression analysis was used to determine the associations of DFD with DM and age-related complications. A total of 246 patients (43.8%) had DFD. Logistic regression analysis identified low grip strength [Odds ratio (OR): 1.83, 95% confidence interval (CI) 1.21-2.76), hypertension (OR: 1.81, 95% CI 1.09-3.00), and diabetes-related peripheral neuropathy (DPN) (OR: 1.92, 95% CI 1.24-2.98) to be significantly associated with DFD. Patients with DPN and hypertension had a higher risk of DFD than patients with DPN or hypertension alone. Individuals with DPN and low grip strength (OR: 1.74, 95% CI 1.09-2.81) were at a lower risk than those with low grip strength alone. Hypertension, DPN, and low grip strength were significantly associated with DFD in older patients with DM, with the risk of DFD being higher in patients with both DPN and hypertension. When considering DFD in older patients with DM, low grip strength should be considered equally important as a DM-related complication.

Non-invasive assessment of vibration perception and protective sensation in people with diabetes mellitus: inter- and intra-rater reliability

BackgroundTesting of protective sensation and vibration perception are two of the most commonly used non-invasive methods of screening for diabetes-related peripheral neuropathy (DPN). However, there is limited research investigating the reliability of these tests in people with diabetes. The aim of this study was to determine the inter- and intra-rater reliability of methods used to test vibration perception and protective sensation in a community-based population of adults with type 2 diabetes.MethodsThree podiatrists with varying clinical experience tested four- and 10-site, 10 g monofilament and vibration perception threshold (VPT). In a separate cohort, the reliability of a graduated tuning fork as well as two methods of conventional tuning fork (on/off method and dampening method) was undertaken by a new graduate podiatrist and podiatrist with one-year’s clinical experience. The intra- (Cohen’s К) and inter-rater (Cohen’s or Fleiss’ К) reliability of each test was determined.ResultsFifty participants (66% male, 100% type 2, 32% with DPN) underwent monofilament and neurothesiometer testing with 44 returning for the retest. Twenty-four participants (63% male, 100% type 2, 4% with DPN) underwent tuning fork testing and returned for retest. All tests demonstrated acceptable inter-rater reliability ranging from moderate (10-site monofilament, К: 0.54, CI: 0.38–0.70, p = 0.02) to substantial (graduated tuning fork, К: 0.68, CI: 0.41–0.95, p < 0.01). The 10-site monofilament (К: 0.44–0.77) outperformed the 4-site test (К: 0.34–0.67) and the dampened tuning fork method (К: 0.41–0.49) showed lower intra-rater reliability compared to both conventional (К: 0.52–0.57) and graduated methods (К: 0.50–0.57).ConclusionWe support the current recommendations of using more than one test to screen and monitor progression of DPN. Four- and 10-site 10 g monofilament testing have similarly acceptable levels of reliability and the neurothesiometer is the most reliable method of assessing vibration perception function. Use of a graduated tuning fork was slightly more reliable than other methods of tuning fork application however all had substantial reliability. Years of clinical experience only marginally affected test reliability overall and due to subjective nature of the tests we suggest that testing should be performed regularly and repetitively.

Moderate-to-Vigorous-Intensity Physical Activity Observed in People With Diabetes-Related Foot Ulcers Over a One-Week Period.

Regular moderate-to-vigorous-intensity physical activity results in health benefits in people with diabetes. No study has observed the moderate-to-vigorous-intensity physical activity typically performed by people with diabetes-related foot ulcers (DFU) in their everyday free-living environments. We observed the bouts, and accumulated time, spent doing moderate-to-vigorous-intensity physical activity in cases with DFU compared with diabetes-related peripheral neuropathy (DPN) and diabetes (DM) controls over a one-week period. This was a secondary analysis of a cross-sectional case-control study. Participants wore a multisensor device for >5 days (>22 hours per day). Primary outcomes included the number, duration (minutes) and intensity (metabolic equivalent tasks [METs]) of bouts of moderate-to-vigorous-intensity physical activity (defined as at least >3 METs for >10 consecutive minutes). Secondary outcomes included the total accumulated times spent doing moderate-to-vigorous-intensity physical activity (>3 METs) and doing sedentary-intensity activity (<1.5 METs). DFU subgroups with minor amputations and nonremovable offloading devices were also analyzed. Overall, 15 DM, 23 DPN, and 27 DFU participants were included. All groups recorded similar low median daily numbers (0.33, 0.29, 0.25 numbers, respectively), duration (15, 17, 14 minutes), and intensity of daily bouts of moderate-to-vigorous-intensity physical activity (4.1, 4.3, 3.9 METs) (all, P > .1). Median accumulated daily time spent doing moderate-to-vigorous-intensity physical activity was also similar (40, 37, 36 minutes; P > .8). Those with DFU had more mean accumulated daily time spent doing sedentary-intensity activity (796 minutes) compared to DPN (720 minutes; P < .05), but not compared to DM (728 minutes; P < .08). DFU subgroups with minor amputations had more median accumulated daily time spent doing moderate-to-vigorous-intensity physical activity (66, 28 minutes; P < .05) and less mean time doing sedentary-intensity activity (745, 837; P < .05) than those without amputations. People with DFU performed similar low numbers of daily bouts of moderate-to-vigorous-intensity physical activity to controls, but spend more time doing sedentary-intensity activities. Interventions that gradually increase the moderate-to-vigorous-intensity physical activity in people with DFU should be investigated.

Acupuncture for the treatment of lower limb diabetic peripheral neuropathy: a systematic review

To examine evidence for acupuncture interventions in the management of diabetes-related peripheral neuropathy (DPN) symptoms. Five electronic databases were searched up to June 2017 for studies that included participants with symptoms of DPN, used an acupuncture intervention, and reported before-and-after DPN-related outcome measures. Two reviewers independently performed the data extraction. The level of homogeneity was assessed, and studies were appraised using the Cochrane Risk of Bias tool, the STRICTA guidelines for acupuncture reporting and the NICMAN scale for acupuncture quality. Ten studies with 432 participants were included: three randomised controlled trials (RCTs), two pilot RCTs, three uncontrolled clinical trials, one quasi-RCT and one prospective case series. Improvements in DPN pain symptoms were reported by all studies. Heterogeneity of outcome measures prevented a meta-analysis. Variations were found in needle retention time and point selection, as well as total number and frequency of treatments. Common acupuncture point selections were ST36 and SP6. Half of the studies used local point selection. Studies conducted outside China had better acupuncture reporting and quality according to the STRICTA checklist and NICMAN scales, respectively. Risk of bias was high or unclear in the majority of studies for all domains except attrition bias. Acupuncture for DPN appears to improve symptoms. However, the application of acupuncture varies greatly, and the quality of included studies was generally low. Available studies have varying methodologies and different outcome measures. Further, suitably powered studies using appropriate DPN outcome measures are required.

Identifying early signs of peripheral neuropathy among patients with diabetes mellitus

This article aims to help nurse practitioners develop a best practice algorithm to identify the early signs of peripheral neuropathy (PNP) among individuals living with diabetes mellitus. This literature review also seeks to determine if there are better clinical testing methods than the Semmes-Weinstein monofilament examination to detect diabetes-related PNP.

A Novel Plantar Stimulation Technology for Improving Protective Sensation and Postural Control in Patients with Diabetic Peripheral Neuropathy: A Double-Blinded, Randomized Study

Background: Many diabetes-related peripheral neuropathy (DPN) patients also experience postural instability. Objective: This study examined the effect of electrical stimulation therapy on DPN patients' postural control as well as recovery of plantar sensation. Methods: 54 patients with mild to moderate DPN were enrolled into this study evaluating treatment of DPN with electrical stimulation provided via aqueous solution. The subjects were randomized into either sham or active stimulation. Treatments were administered 5 times per week for 6 weeks. Changes in neuropathy severity were assessed via Semmes-Weinstein monofilament tests and vibration perception threshold (VPT) tests. The potential benefit in postural control was assessed in a subsample of 13 subjects by measuring the area of center of mass (COM) sway. Results: The active group saw a significant (p < 0.05) improvement in VPT at treatment week 6 in comparison to the sham group. The difference did not remain significant at follow-up visits. There were no significant differences between groups for the Semmes-Weinstein monofilament test. However, time was a significant main effect, with both groups improving over the course of the study. The area of COM sway was significantly reduced on average by 36% at treatment week 2 compared to the baseline. Although at treatment week 6 an additional 7% reduction in COM sway was observed compared to treatment week 2, the improvement from treatment week 2 to treatment week 6 was not significant (p > 0.6). Interestingly, no significant difference was observed in the sham group during the study (p > 0.7). Conclusion: This randomized pilot study provides preliminary data on the potential of electrical stimulation via aqueous solution to improve protective sensation and postural stability in DPN patients.

Gait characteristics of people with diabetes-related peripheral neuropathy, with and without a history of ulceration

Biomechanical alterations in diabetes are believed to contribute to plantar neuropathic ulceration. This exploratory study documents clinical measures of flexibility and strength, alongside three-dimensional biomechanical gait data of the lower limb, in 10 patients with a history of neuropathic ulceration (DNU; n=10). Comparative data is presented from age and gender matched groups with; diabetes peripheral neuropathy and no ulcer history (DWN; n=10), diabetes and no peripheral neuropathy (DNN; n=10) and a non-diabetes reference group (NOND; n=10). Biomechanical data were collected at a comfortable walking speed with a Vicon motion analysis system. Clinical measures showed a non-significant trend toward decreased static range of motion at the ankle and first metatarsophalangeal joints, with worsening neuropathy status. Of the diabetes groups, knee and ankle strength was significantly lower in those with an ulcer history (p=0.01–0.03), with the exception of knee extension. In the DNU group, walking speed was on average 0.17ms slower compared to NOND (p=0.04). The DNU group demonstrated a lower range of motion than NOND at the: hips (frontal plane, by 25%: p=0.03); hips and knees (transverse plane, 31%: p=0.01 and 32%: p<0.01); ankles (sagittal plane, 22%: p<0.01) and first metatarsophalangeal joints (sagittal plane, 32%: p=0.01), with less foot rotation (24%: p=0.04). Kinetic alterations in DNU included lower: ankle maximum power (21%: p=0.03) and vertical ground reaction force 2nd peak (6%: p<0.01). The study findings identified gait alterations in people with clinically severe peripheral neuropathy and related plantar foot ulcer history. Further research is needed to explore potential casual pathways.

Strength and Balance Training for Adults With Peripheral Neuropathy and High Risk of Fall: Current Evidence and Implications for Future Research

To evaluate the evidence for strength- and balance-training programs in patients at high risk for falls, discuss how results of existing studies might guide clinical practice, and discuss directions for additional research. A search of PubMed and CINAHL® databases was conducted in June 2011 using the terms strength, balance training, falls, elderly, and neuropathy. Only clinical trials conducted using specific strength- or balance-training exercises that included community-dwelling adults and examined falls, fall risk, balance, and/or strength as outcome measures were included in this review. One matched case-control study and two randomized, controlled studies evaluating strength and balance training in patients with diabetes-related peripheral neuropathy were identified. Eleven studies evaluating strength and balance programs in community-dwelling adults at high risk for falls were identified. The findings from the reviewed studies provide substantial evidence to support the use of strength and balance training for older adults at risk for falls, and detail early evidence to support strength and balance training for individuals with peripheral neuropathy. The evidence demonstrates that strength and balance training is safe and effective at reducing falls and improving lower extremity strength and balance in adults aged 50 years and older at high risk for falls, including patients with diabetic peripheral neuropathy. Future studies should evaluate the effects of strength and balance training in patients with cancer, particularly individuals with chemotherapy-induced peripheral neuropathy.

Reduction of peak plantar pressure in people with diabetes‐related peripheral neuropathy: an evaluation of the DH Pressure Relief Shoe™

BackgroundOffloading plantar pressure is a key strategy for the prevention or healing of neuropathic plantar ulcers in diabetes. Non-removable walking casts, such as total contact casts, are currently considered the gold-standard for offloading this type of wound. However, alternative methods for offloading that are more cost effective and easier to use are continually being sought. The aim of this study was to evaluate the capacity of the DH Pressure Relief Shoe™ to offload high pressure areas under the neuropathic foot in diabetes.MethodsA within-subjects, repeated measures design was used. Sixteen participants with diabetic peripheral neuropathy were recruited and three footwear conditions were evaluated in a randomised order: a canvas shoe (the control), the participants’ own standard shoe, and the DH Pressure Relief Shoe™. The primary outcome was peak plantar pressure, measured using the pedar-X® mobile in-shoe system between the three conditions.ResultsData analysis was conducted on 14 out of the 16 participants because two participants could not complete data collection. The mean peak pressure values in kPa (±SD) for each condition were: control shoe 315.9 (±140.7), participants’ standard shoe 273.0 (±127.1) and DH Pressure Relief Shoe™ 155.4 (±89.9). There was a statistically significant difference in peak plantar pressure between the DH Pressure Relief Shoe™ compared to both the control shoe (p = 0.002) and participants’ standard shoe (p = 0.001). The DH Pressure Relief Shoe™ decreased plantar pressures by 51% compared to the control shoe and by 43% compared to participants’ standard shoe. Importantly, for a couple of study participants, the DH Pressure Relief Shoe™ appeared unsuitable for day-to-day wearing.ConclusionsThe DH Pressure Relief Shoe™ reduced plantar pressures more than the other two shoe conditions. The DH Pressure Relief Shoe™ may be a useful alternative to current offloading modalities used in clinical management of diabetic foot ulceration. However, clinical trials are needed to test their effectiveness for ulcer healing and to ensure they are useable and safe for patients in everyday activities.