Diabetic & Other Metabolic Neuropathies

Characterizing Diabetic Neuropathy In 1995, an estimated 135 million people worldwide had diabetes, of which 25% will develop foot problems related to the disease, i.e., diabetic neuropathy. The World Health Organization (WHO) estimates the number of diabetes will reach 300 million by 2025. Four to five percent of health budgets are spent on diabetes-related illnesses, such as the management of diabetic neuropathy and its consequences. This neuropathy often causes severe pain and can be incapacitating. The medoc TSA-II NeuroSensory Analyzer and the VSA-3000 Vibratory Sensory Analyzer enable quantitative evaluation of the integrity of both small and large-caliber sensory nerve fibers. Nerve Fiber Types Nerves consist of fibers of variable diameter with the thicker fibers having a faster conduction velocity. Three types of fibers are generally recognized in the sensory subclass of nerve fibers: A-beta fibers, the largest fibers, mediate the sensations of touch and mild pressure, as well as the sensation of position of joints and vibration, at a conduction velocity above 30 m/sec. A-delta fibers, smaller than A-beta fibers, mediate the sensation of cold and the first components of the sensation of pain, at a conduction velocity between 2 and 30 m/sec. C fibers, the slowest and smallest, mediate the sensation of warmth and the main component of the sensation of pain, at a conduction velocity less than 2 m/sec. In addition, C fibers subserve most of the autonomic peripheral functions. Testing Nerve Fibers Traditional tests such as EMG and Nerve Conduction Velocity are not able to test the function of the small fibers; yet small-caliber fibers (i.e., A-delta & C-fibers) constitute 70% of the peripheral nerve system, with C and A-delta fibers responsible for pain transmission. Several disease processes, including diabetic neuropathy, afflict the peripheral nerves, typically both small and large fibers, though this can be at different intervals. Several authors have described findings showing that quantitative assessment of thermal sensitivity (small-fiber testing) may be of value in the detection of early diabetic neuropathy, even in patients without symptoms or signs of a clinical neuropathy. Others have argued that vibratory and thermal testing should be a primary screening test for diabetic peripheral neuropathy. Vibratory thresholds (large, A-beta fiber testing) have been described as an effective predictor of the risk of foot ulceration in diabetes. The 1992 Consensus Statement from the San Antonion Conference on Diabetic Neuropathy (as published in NEUROLOGY, 1992; 42:1823-1839) recommended the use of Quantitative Sensory Testing (QST). Uremic Neuropathy Peripheral neuropathy is found in most renal patients. In fact, polyneuropathy is one of the most common consequences of chronic renal failure (Lindblom & Tegner, 1985; Weseley et al, 1989). The majority of these patients are asymptomatic, requiring electrophysiological testing to confirm abnormality. The health of the peripheral nerve is recognized as an important, quantitative serial or longitudinal measure for effectiveness of dialysis. Nielson (1973) described the impairment of vibratory function in these patients. Lindblom & Tegner (1975) and Angus-Leppan & Burke (1992) reported high incidence of vibratory sensory pathology. TSA-II NeuroSensory Analyzer Indicates Neuropathy in the Uremic Patient Abnormal thermal sensory thresholds (i.e., small-fiber impairment), as identified by the TSA-II NeuroSensory Analyzer, have recently been cited as an early indicator or first sign of neuropathy in the uremic patient (Yosipovitch et al, 1995).

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