Painful Diabetic Polyneuropathy Research Articles

Differences in corneal nerve fiber density and fiber length in patients with painful chronic idiopathic axonal polyneuropathy and diabetic polyneuropathy.

Corneal confocal microscopy (CCM) detects small nerve fiber loss and correlates with skin biopsy findings in diabetic neuropathy. In chronic idiopathic axonal polyneuropathy (CIAP) this correlation is unknown. Therefore, we compared CCM and skin biopsy in patients with CIAP to healthy controls, patients with painful diabetic neuropathy (PDN) and diabetics without overt neuropathy (DM). Participants with CIAP and suspected small fiber neuropathy (n = 15), PDN (n = 16), DM (n = 15), and healthy controls (n = 16) underwent skin biopsy and CCM testing. Inter-center intraclass correlation coefficients (ICC) were calculated for CCM parameters. Compared with healthy controls, patients with CIAP and PDN had significantly fewer nerve fibers in the skin (IENFD: 5.7 ± 2.3, 3.0 ± 1.8, 3.9 ± 1.5 fibers/mm, all p < .05). Corneal nerve parameters in CIAP (fiber density 23.8 ± 4.9 no./mm2, branch density 16.0 ± 8.8 no./mm2, fiber length 13.1 ± 2.6 mm/mm2) were not different from healthy controls (24.0 ± 6.8 no./mm2, 22.1 ± 9.7 no./mm2, 13.5 ± 3.5 mm/mm2, all p > .05). In patients with PDN, corneal nerve fiber density (17.8 ± 5.7 no./mm2) and fiber length (10.5 ± 2.7 mm/mm2) were reduced compared with healthy controls (p < .05). CCM results did not correlate with IENFD in CIAP patients. Inter-center ICC was 0.77 for fiber density and 0.87 for fiber length. In contrast to patients with PDN, corneal nerve parameters were not decreased in patients with CIAP and small nerve fiber damage. Therefore, CCM is not a good biomarker for small nerve fiber loss in CIAP patients.

Effectiveness of platelet rich plasma (PRP) treatment and its comparison with pregabalin in painful diabetic polyneuropathy: A randomized controlled clinical trial

Background &amp; objective: The most common consequence of diabetes mellitus (DM) is diabetic peripheral neuropathy (DPN), and it has serious clinical implications that can affect patients' quality of life. There is an urgent need to to discover new methods of treatment, as the medications currently in use for prevention and treatment of DPN are only partially effective and have frequent adverse effects. We aimed to determine and compare the effect of platelet rich plasma (PRP) injection on acupuncture points and pregabalin in painful DPN. Methodology: A randomized controlled trial was conducted at Iffat Anwar Medical Complex. All the clinically diagnosed patients having neuropathic sign and symptoms of DPN, with type 2 DM diagnosed having an HbA1c level greater than 7.5, both genders aged between 40-70 y were enrolled in the study. After the written informed consent, a total of 60 patients were randomly divided into two groups in a 1:1 ratio. Group I received PRP injections on acupuncture points and Group II received 75 mg pregabalin PO twice daily. The PRP injection treatment was given once a month for three months. Follow up of all patients was conducted every month till three months and after one year for final assessment. All the data was entered and analyzed by SPSS 25.0. The difference among pain, SF-36, sleep quality scale among groups was compared by independent sample t test and before and after difference was observed by paired sample t-test. P &lt; 0.05 was considered as significant. Results: The VAS scores were significantly decreased in Group I (from 7.47 ± 1.27 to 3.67 ± 1.09; P &lt; 0.05) as compared to Group II (7.30 ± 1.59 to 5.20 ± 1.58, P &lt; 0.05). The neuropathic symptoms scale also showed significant improvement (Group I: 13.50 ± 50 to 8.50 ± 2.30 vs. Group II: 14.93 ± 2.55 to 9.83 ± 2.17, P &lt; 0.05), as well as the quality of life (Group I: 67.77 to 31.50 ± 9.24 vs. Group II:69.37 ± 11.7to 41.20 ± 12.16, P &lt; 0.05) and sleep quality scale (Group I:49.53 ± 12.4 to 27.30 ± 8.03 vs. Group II: 52.13 ± 10.9to 32.60 ± 7.103, P &lt; 0.05). Conclusion: We conclude that the treatment of diabetic peripheral neuropathy with platelet rich plasma injections at acupuncture points significantly improves the pain scores, quality of sleep and neuropathic symptoms as compared to conventional treatment with 75 mg pregabalin PO twice daily. Abbreviations: DM- Diabetes Mellitus; DPN- Diabetic Polyneuropathy; LANSS- Leeds Assessment of Neuropathic Symptoms and Signs; PRP- Platelet Rich Plasma; QoL- Quality of Life; SQS- Sleep Quality Scale Key words: Acupuncture; Diabetic Poly Neuropathy; Pain; PRP injections; Quality of Life Citation: Anwar S, Hassan MW, Shaukat GR, Tirmzi F, Saeed MU, Aslam M. Effectiveness of platelet rich plasma (PRP) treatment and its comparison with pregabalin in painful diabetic polyneuropathy: A randomized controlled clinical trial. Anaesth. pain intensive care 2024;28(1):44-49; DOI: 10.35975/apic.v28i1.2280 Received: August 07, 2023; Reviewed: August 08, 2923; Accepted: December 21, 2023

The intensity of neuropathic pain and the severity of insomnia in diabetic polyneuropathy

To determine the prevalence of insomnia and the effectiveness of its treatment in patients with a painful form of diabetic polyneuropathy (DPN). Fifty patients with the painful form of DPN were randomly divided into 2 groups: the standard therapy group (ST) and the extended therapy group (ET). In the ST group, a single lesson on sleep hygiene was conducted, in the ET group there were 3-4 face-to-face individual sessions for the treatment of insomnia for two weeks. Both groups were interviewed at the time of hospitalization, after 3 and 6 months. The severity of polyneuropathy and the nature of neuropathic pain were assessed using the Neuropathic Neuropathy Impairment Score in the Lower Limbs (NIS-LL) and the Neuropathy Total Symptom Score - 9 (NTSS-9); the intensity of pain was assessed using a Visual Analog Scale (VAS). Sleep disorders were analyzed using the Pittsburgh Sleep Quality Index (PSQI) and the Insomnia Severity Index (ISI). Sleep disorders of varying severity were observed in 82% of patients in the initial survey. In both groups, improvement in sleep quality was noted during treatment, but significantly better results were in the ET group, the ISI score after 6 months was 7.15±2.08 for the ST group and 3.07±2.49 for the ET group (p<0.0001). In the ST group, there was no significant decrease in the intensity of pain and the severity of polyneuropathy in dynamics. In the ET group, a significant decrease in NTSS-9 and VAS scores was found during the initial survey and after 6 months (p<0.0001). The intensity of pain also significantly decreased in the ET group compared with the ST group (p<0.0001) at the end of follow-up, which indicates the importance of sleep normalization in the treatment of neuropathic pain. Most patients with the painful form of DPN have insomnia. Treatment of insomnia has shown its effectiveness as part of a multimodal approach to the managing of neuropathic pain in DPN and improving the quality of life of patients.

Effectiveness of PRP treatment and its comparison with pregabalin in painful diabetic poly neuropathy (DPN)–A randomized controlled clinical trial

Effectiveness of PRP treatment and its comparison with pregabalin in painful diabetic poly neuropathy (DPN)–A randomized controlled clinical trial

EPH118 Elevated Amputation Rates in Painful Diabetic Polyneuropathy: Insights from a Real-World Large Payer Data Set

EPH118 Elevated Amputation Rates in Painful Diabetic Polyneuropathy: Insights from a Real-World Large Payer Data Set

4. Painful diabetic polyneuropathy.

Pain as a symptom of diabetic polyneuropathy (DPN) significantly lowers quality of life, increases mortality and is the main reason for patients with diabetes to seek medical attention. The number of people suffering from painful diabetic polyneuropathy (PDPN) has increased significantly over the past decades. The literature on the diagnosis and treatment of diabetic polyneuropathy was retrieved and summarized. The etiology of PDPN is complex, with primary damage to peripheral nociceptors and altered spinal and supra-spinal modulation. To achieve better patient outcomes, the mode of diagnosis and treatment of PDPN evolves toward more precise pain-phenotyping and genotyping based on patient-specific characteristics, new diagnostic tools, and prior response to pharmacological treatments. According to the Toronto Diabetic Neuropathy Expert Group, a presumptive diagnosis of "probable PDPN" is sufficient to initiate treatment. Proper control of plasma glucose levels, and prevention of risk factors are essential in the treatment of PDPN. Mechanism-based pharmacological treatment should be initiated as early as possible. If symptomatic pharmacologic treatment fails, spinal cord stimulation (SCS) should be considered. In isolated cases, where symptomatic pharmacologic treatment and SCS are unsuccessful or cannot be used, sympathetic lumbar chain neurolysis and/or radiofrequency ablation (SLCN/SLCRF), dorsal root ganglion stimulation (DRGs) or posterior tibial nerve stimulation (PTNS) may be considered. However, it is recommended that these treatments be applied only in a study setting in a center of expertise. The diagnosis of PDPN evolves toward pheno-and genotyping and treatment should be mechanism-based.

Structural changes in Schwann cells and nerve fibres in type 1 diabetes: relationship with diabetic polyneuropathy

Aims/hypothesisOur aim was to investigate structural changes of cutaneous Schwann cells (SCs), including nociceptive Schwann cells (nSCs) and axons, in individuals with diabetic polyneuropathy. We also aimed to investigate the relationship between these changes and peripheral neuropathic symptoms in type 1 diabetes.MethodsSkin biopsies (3 mm) taken from carefully phenotyped participants with type 1 diabetes without polyneuropathy (T1D, n=25), type 1 diabetes with painless diabetic polyneuropathy (T1DPN, n=30) and type 1 diabetes with painful diabetic polyneuropathy (P-T1DPN, n=27), and from healthy control individuals (n=25) were immunostained with relevant antibodies to visualise SCs and nerve fibres. Stereological methods were used to quantify the expression of cutaneous SCs and nerve fibres.ResultsThere was a difference in the number density of nSCs not abutting to nerve fibres between the groups (p=0.004) but not in the number density of nSCs abutting to nerve fibres, nor in solitary or total subepidermal SC soma number density. The overall dermal SC expression (measured by dermal SC area fraction and subepidermal SC process density) and peripheral nerve fibre expression (measured by intraepidermal nerve fibre density, dermal nerve fibre area fraction and subepidermal nerve fibre density) differed between the groups (all p<0.05): significant differences were seen in participants with T1DPN and P-T1DPN compared with those without diabetic polyneuropathy (healthy control and T1D groups) (all p<0.05). No difference was found between participants in the T1DPN and P-T1DPN group, nor between participants in the T1D and healthy control group (all p>0.05). Correlational analysis showed that cutaneous SC processes and nerve fibres were highly associated, and they were weakly negatively correlated with different neuropathy measures.Conclusions/interpretationCutaneous SC processes and nerves, but not SC soma, are degenerated and interdependent in individuals with diabetic polyneuropathy. However, an increase in structurally damaged nSCs was seen in individuals with diabetic polyneuropathy. Furthermore, dermal SC processes and nerve fibres correlate weakly with clinical measures of neuropathy and may play a partial role in the pathophysiology of diabetic polyneuropathy in type 1 diabetes.Graphical

The association of self-reported symptoms of central sensitization and sleep disturbances in neuropathic pain.

Patients with neuropathic pain (NP) report a higher impairment of quality of life and sleep than patients with chronic pain without neuropathic characteristics. These include somatosensory peculiarities like allodynia, a surrogate marker for central sensitization. This study aimed to investigate the relation between symptoms of central sensitization and sleep disturbances in patients with NP. Within this cross-sectional study, data sets of 3339 patients with chronic NP syndromes (painful diabetic polyneuropathy, n = 543; postherpetic neuralgia, n = 1480) or complex regional pain syndromes (CRPS, n = 1316) were analyzed. Neuropathic pain symptoms were assessed with the painDETECT questionnaire (PD-Q), depression with the Patient Health Questionnaire-9, and sleep impairment with items of the Medical Outcomes Study Sleep Scale in 4 subscales. The association of demographic/clinical data, somatosensory phenotype, depression, and pain intensity with sleep impairment was assessed by unadjusted Spearman correlation analyses and multivariable regression analyses. Sleep impairment was observed in all pain aetiologies although with some significant differences in the single sleep items. The intensity of the individual PD-Q items differed to some extent between the 3 pain entities, whereas the PD-Q sum score was similar. Thermal hyperalgesia and burning assessed by the PD-Q were significantly associated with sleep disturbance, adequacy, and quantity but not with sleep somnolence. Only depression and self-reported allodynia had a significant relation to all 4 sleep elements. Beside depression, allodynia as a surrogate marker hints to a possible impact of central sensitization on the sleep disruption of patients with NP.

Structural Changes of Cutaneous Immune Cells in Patients With Type 1 Diabetes and Their Relationship With Diabetic Polyneuropathy.

Diabetic polyneuropathy (DPN) is a complication of diabetes characterized by pain or lack of peripheral sensation, but the underlying mechanisms are not yet fully understood. Recent evidence showed increased cutaneous macrophage infiltration in patients with type 2 diabetes and painful DPN, and this study aimed to understand whether the same applies to type 1 diabetes. The study included 104 participants: 26 healthy controls and 78 participants with type 1 diabetes (participants without DPN [n = 24], participants with painless DPN [n = 29], and participants with painful DPN [n = 25]). Two immune cells, dermal IBA1+ macrophages and epidermal Langerhans cells (LCs, CD207+), were visualized and quantified using immunohistological labeling and stereological counting methods on skin biopsies from the participants. The IBA1+ macrophage infiltration, LC number density, LC soma cross-sectional area, and LC processes were measured in this study. Significant difference in IBA1+ macrophage expression was seen between the groups (p = 0.003), with lower expression of IBA1 in participants with DPN. No differences in LC morphologies (LC number density, soma cross-sectional area, and process level) were found between the groups (all p > 0.05). In addition, IBA1+ macrophages, but not LCs, correlated with intraepidermal nerve fiber density, Michigan neuropathy symptom inventory, (questionnaire and total score), severity of neuropathy as assessed by the Toronto clinical neuropathy score, and vibration detection threshold in the whole study cohort. This study showed expressional differences of cutaneous IBA1+ macrophages but not LC in participants with type 1 diabetes-induced DPN compared with those in controls. The study suggests that a reduction in macrophages may play a role in the development and progression of autoimmune-induced diabetic neuropathy.

ID: 205108 Long-Term Evaluation of SCS in Patients With Painful Diabetic Peripheral Neuropathy: 8- to 10-Year Prospective Cohort Study

Painful diabetic peripheral neuropathy (PDPN) is defined as ‘pain caused by lesions of the somatosensory system, attributed to diabetes’, and is reported to develop in 10-20% of patients suffering from diabetes mellitus. Conservative pharmacological treatment alone often offers little pain relief and is frequently poorly tolerated. Therefore, better treatment options are a necessity. The first use of spinal cord stimulation (SCS) for PDPN dates from 1996. High-quality studies followed, showing SCS to be up to 8 times more effective in terms of pain relief than best medical treatment at that time. Because most studies only evaluated short-term efficacy of SCS, long-term efficacy remains yet unclear. The aim of this study is to evaluate the long-term effects of spinal cord stimulation (SCS) in patients with painful diabetic polyneuropathy (PDPN).

Machine learning analysis of the UK Biobank reveals prognostic and diagnostic immune biomarkers for polyneuropathy and neuropathic pain in diabetes

AimsWe assessed the health data of 11,047 people with diabetes in the UK Biobank to rank 329 risk factors for diabetic polyneuropathy (DPN) and DPN with chronic neuropathic pain without a priori assumption. MethodsThe Integrated Disease Explanation and Risk Scoring (IDEARS) platform applies machine learning algorithms to multimodal data to determine individual disease risk, and rank risk factor importance using mean SHapley Additive exPlanations (SHAP) score. ResultsIDEARS models showed discriminative performances with AUC > 0.64. Lower socioeconomic status, being overweight, poor overall health, cystatin C, HbA1C, and immune activation marker, C-reactive protein (CRP), predict DPN risk. Neutrophils and monocytes were higher in males and lymphocytes lower in females with diabetes that develop DPN. Neutrophil-to-Lymphocyte Ratio (NLR) was increased and IGF-1 levels decreased in people with type 2 diabetes that later develop DPN. CRP was significantly elevated in those with DPN and chronic neuropathic pain compared to DPN without pain. ConclusionsLifestyle factors and blood biomarkers predict the later development of DPN and may relate to DPN pathomechanisms. Our results are consistent with DPN as a disease involving systemic inflammation. We advocate for the use of these biomarkers clinically to predict future DPN risk and improve early diagnosis.

Use of plasma rich in growth factors for symptoms of diabetic neuropathy.

Painful peripheral polyneuropathy is a common complication of diabetes mellitus (DM) and is a significant source of chronic disability and remains a challenging condition with no available disease-modifying treatment. In the present case report, we describe the treatment of a patient featuring painful diabetic neuropathy with perineural injections of autologous plasma rich in growth factors (PRGF). At one-year post-procedure, the patient exhibited improved scores on the neuropathic pain scale and improvement in the activity level. Plasma rich in growth factors (PRGF) is an autologous product that can be prepared and administered in a physician's office. PRGF can be infiltrated as a liquid, creating a three-dimensional gel scaffold in the body. PRGF releases growth factors involved in nerve healing. PRGF may be established as a potent alternative treatment of painful diabetic polyneuropathy.

Is Cerebrolysin effective in reducing symptoms of Diabetic Peripheral Neuropathy?

Aim This is an investigator initiated observational comparative medical program, to test the efficacy of Cerebrolysin® intake for 1 month versus 2 months, in patients clinically diagnosed with type 2 diabetes mellitus (T2DM) and suffering from peripheral neuropathy. Methods Patients aged ≥ 18 years old, clinically diagnosed with mild or moderate painful diabetic polyneuropathy, received Cerebrolysin® for 1 or 2 months according to investigators’ decision. Demographic data, detailed medical history, and laboratory results were collected at baseline. All enrolled patients were evaluated for Toronto Clinical Scoring System (TCSS), Visual Analogue Scale (VAS) and Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale (LANSS) at baseline and end of the program (1 month/2 month). Results VAS, TCSS, and LANSS were significantly improved for all 136 enrolled patients at the end of their treatment with Cerebrolysin® for 1 or 2 months, regarding gender, duration since diagnosis of T2DM (more than or less than 10 years) and HbA1c ≤ 9% or ˃ 9%, with a very highly statistically significant difference (p-value ˂ 0.001). They were slightly improved more in patients received Cerebrolysin® for 1 month more than for 2 months. There was no statistically significant difference for gender, duration of diagnosis with diabetes mellitus less or more than 10 years, and HbA1c ≤ 9% &amp; ˃ 9% regarding the change of VAS, TCSS, and LANSS as dependent variables, using Linear stepwise regression. While there was noticed improvement in VAS, TCSS, and LANSS with use of Cerebrolysin® for 1 month more than 2 months, Regression Coefficient (B (95% of Confidence interval)) B=0.794 (0.29-1.29), B=1.472 (0.87-2.074), B=2.143 (0.45-3.83) and p-value = 0.002, p-value ˂ 0.001, p-value = 0.13 respectively. There was no adverse event (AE) or serious adverse event (SAE) reported during the program. Conclusion: Cerebrolysin® is considered effective in the management of peripheral neuropathy in patients with T2DM Abbreviations: Adverse Event (AE), Advanced Glycation End products (AGE), Contract Research Organization (CRO), Diabetic Peripheral Neuropathy (DPN), Diacylglycerol (DAG), estimated Glomerular Filtration (eGFR), Fasting Blood Sugar (FBS), Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale (LANSS), Peripheral Vascular Disease (PVD), Pin- Prick Threshold (PPT), Protein Kinase C (PKC), Statistical Analysis Plan (SAP), Serious Adverse Event (SAE), Standard Deviation (SD), Type 1 Diabetes Mellitus (T1DM), Type 2 Diabetes Mellitus (T2DM), Toronto Clinical Scoring System (TCSS), Traumatic Brain Injury (TBI), Visual Analogue Scale (VAS).

Painful diabetic polyneuropathy: modern approaches to diagnosis and treatment

Diabetes mellitus is one of the most common chronic diseases, the incidence of which is steadily increasing. Approximately 1 in 11 adults in the world today has diabetes. Diabetic polyneuropathy is a common complication of diabetes mellitus and leads to a decrease in the quality and life expectancy of patients, increases the risk of disability. The pain form of diabetic polyneuropathy has a particularly negative effect on the quality of life. It includes both acute (Ellenberg’s neuropathy and acute insulin-induced neuropathy) and chronic forms. The article discusses modern ideas about the pathogenesis of pain diabetic polyneuropathy, as well as risk factors, clinical symptoms and diagnostic methods (electroneuromyography, quantitative sensory testing, sudomotor function, skin biopsy, confocal biopsy of the cornea) of the disease. In most patients, the pain form of diabetic polyneuropathy is accompanied by autonomic disorders. Treatment of painful diabetic polyneuropathy is a difficult task, including the correction of risk factors (glycemia level, patient lifestyle), as well as pathogenetic and symptomatic therapy. As symptomatic therapy, adjuvant analgesics are used, namely drugs from the group of anticonvulsants (gabapentin, pregabalin) and antidepressants (duloxetine). The use of alpha-lipoic acid is the basis of pathogenetic therapy. As a universal antioxidant, alpha-lipoic acid is an absolutely safe drug with a proven effect in the treatment of painful diabetic polyneuropathy and can be recommended for use in clinical practice.

Safety and efficacy of duloxetine versus gabapentin in painful diabetic polyneuropathy

To evaluate safety and efficacy of Gabapentin and Duloxetine in patients with painful diabetic neuropathy.This is a prospective randomized double blinded parallel group study done for a period of 12 weeks. Total of 60 patients were enrolled and randomly allocated to two groups with 30 patients each, group A received Duloxetine 30 mg twice daily and group B received Gabapentin 300mg twice daily and followed every 2 weeks. Patients of age 35 to 60 years with painful diabetic peripheral polyneuropathy are included in the study. Primary objective is improvement in pain assessed by NPRS; Secondary objective is improvement in sleep and clinical condition of the patient, assessed by Sleep Interference Score and Clinical Global Impression of Change (CGIC). Assessment was done at beginning and at four, eight and twelve weeks. Data was analysed using SPSS 12.0 version.Numerical pain rating scores and daily sleep interference scores were reduced significantly with course of treatment within both groups (p = &amp;#60;0.05 in both groups), but there was no significant difference observed between two groups at baseline, 4th week, 8th week and 12th week. There is significant reduction in CGIC severity scores with course of treatment within both groups (p = &amp;#60;0.05 in both groups), but there was no significant difference observed between groups at baseline and at end of treatment. Common adverse events seen are nausea, dry mouth, dizziness, somnolence and constipation in both groups. There is high incidence of nausea and dry mouth with Duloxetine when compared to Gabapentin.Monotherapy with either Duloxetine or Gabapentin was equally effective at 12 weeks treatment with minor side effects. In addition, Gabapentin showed fewer side effects. It can be concluded that for preventing side effects, Gabapentin can be used. Further large head to- head comparator and combination trials are required.

Analysis of medications for symptomatic treatment of the painful diabetic polyneuropathy in Ukraine

Analysis of medications for symptomatic treatment of the painful diabetic polyneuropathy in Ukraine

Long-Term Evaluation of Spinal Cord Stimulation in Patients With Painful Diabetic Polyneuropathy: An Eight-to-Ten–Year Prospective Cohort Study

ObjectiveThis study aimed to evaluate the long-term effects of spinal cord stimulation (SCS) in patients with painful diabetic polyneuropathy (PDPN). Materials and MethodsThis prospective cohort study was the eight-to-ten–year follow-up of a previously performed pilot and randomized controlled trial on the effects of SCS in PDPN, initiated by the multidisciplinary pain center of Maastricht University Medical Center+. The study population consisted of a subgroup of patients who still used SCS treatment ≥ eight years after implantation (n = 19). Pain intensity scores (numeric rating scale [NRS]) during the day and night and data on secondary outcomes (ie, quality of life, depression, sleep quality) were reported during yearly follow-up consultations. Long-term efficacy of SCS was analyzed by comparing the most recently obtained data eight to ten years after implantation with those obtained at baseline. ResultsPain intensity, day and night, was significantly (p < 0.01) reduced by 2.3 (NRS 6.6–4.3) and 2.2 (NRS 6.8–4.6) points, respectively, when comparing the long-term data with baseline. Moreover, for > 50% of patients, the pain reduction was > 30%, which is considered clinically meaningful. No differences were found regarding the secondary outcomes. ConclusionThis eight-to-ten–year follow-up study indicates that SCS can remain an effective treatment in the long term to reduce pain intensity in a subcohort of patients with PDPN who still had an SCS device implanted after eight years.

Author Response: Oral and Topical Treatment of Painful Diabetic Polyneuropathy: Practice Guideline Update Summary: Report of the AAN Guideline Subcommittee.

Author Response: Oral and Topical Treatment of Painful Diabetic Polyneuropathy: Practice Guideline Update Summary: Report of the AAN Guideline Subcommittee.

Editors' Note: Oral and Topical Treatment of Painful Diabetic Polyneuropathy: Practice Guideline Update Summary: Report of the AAN Guideline Subcommittee.

Editors' Note: Oral and Topical Treatment of Painful Diabetic Polyneuropathy: Practice Guideline Update Summary: Report of the AAN Guideline Subcommittee.

Reader Response: Oral and Topical Treatment of Painful Diabetic Polyneuropathy: Practice Guideline Update Summary: Report of the AAN Guideline Subcommittee.

Reader Response: Oral and Topical Treatment of Painful Diabetic Polyneuropathy: Practice Guideline Update Summary: Report of the AAN Guideline Subcommittee.