Duration of Disease, Neuropathic Symptoms, and Plantar Sensitivity in Patients With Diabetes With and Without Previous Plantar U

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Author(s): 
Tatiana de A. Bacarin, M.Sc., Dip PT; Paula M. H. Akashi, M.Sc., Dip PT; Prof. Isabel de C. N. Sacco, PhD

Disclosure: This project was supported by FAPESP Grant 2004/09585-2

The loss of protective sensation due to the consequences of the diabetic peripheral neuropathy (DPN) is one major risk factor for ulceration in diabetic feet.1–5 The prevalence of DPN is highly correlated to the duration of the diabetes, aging, and metabolic control.6 Approximately 20% of patients with diabetes will develop clinically significant DPN within 10 years of onset,7 and this frequency can increase to 50% after 10 or 15 years.8 Ulceration and amputation are the most common complications of DPN and are responsible for the majority of hospitalizations among patients with diabetes.9 Furthermore, these amputations cost R$18.2 million (Brazilian Reais) to the Brazilian health system annually, which is equivalent to $8.4 million (US).10

Ulcerated feet have decreased plantar sensitivity.11 Research shows that patients with an ulcer due to diabetes have had a longer duration of diabetes and are older than their nonulcerated counterparts with diabetes.12 In the same study,12 ulcerated feet had higher vibration perception threshold values and poor sensitivity to the monofilament test. The 10-g monofilament is considered a good instrument to assess the loss of protective sensation in all patients with diabetes. The International Consensus on the Diabetic Foot recommends its use.13 It has high reproducibility and specificity,3 and it can predict risk for ulceration and amputation.5,14,15 The motor nerve conduction velocity test can also predict ulceration and mortality in people with diabetes.15 Other authors demonstrated that the induced plantar insensitivity can lead to higher mechanical loads under the foot during gait.16,17 Therefore, the more insensitive a foot becomes, the more predisposed it is to ulceration. Such patients may also present other symptoms such as, numbness, prickling, muscle cramps, and burning sensation, indicating loss of protective sensation.

The new approach of this study is to determine if patients with a history of plantar ulcers due to the DPN have more symptoms, a longer duration of disease, and poorer foot sensitivity. These 3 parameters have not been previously studied together in ulcerated patients with diabetes.

Many health professionals who care for patients with diabetes use tools such as, the Michigan Neuropathy Screening Instrument questionnaire [MNSI-q]),18 to evaluate symptoms and signs of neuropathy. Ordinarily, these forms are effective and easy to apply and can serve as the primary screening indicator for assessment of neuropathy. It can, therefore, be confirmed that symptoms are related to the loss of sensitivity in ulcerated patients— this would be an important indication in the process of diagnosing patients at risk of foot ulceration; otherwise professionals should carry on with electrophysiological tests to confirm this risk.

The purpose of this study was to compare the duration of disease and the prevalence of diabetic neuropathic symptoms. This includes investigating plantar insensitivity and its prevalence by assessing sensitive chronaxie, tactile and thermal sensitivities, among diabetic neuropathic subjects with and without previous history of plantar ulcers.This will determine if ulcerated subjects with diabetic neuropathy have an increased sensory deficit in their feet, which may lead to ulcer formation. In addition, the authors correlated the symptoms of neuropathy with the sensory tests results to determine their relationship. It is hypothesized that the ulcerated group will have decreased plantar sensitivity, longer duration of diabetes, and an increase in neuropathic symptoms.

References: 


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