Exploration of small fibers for testing diabetic neuropathies

doi:10.1016/j.jbspin.2004.10.003

Joint Bone Spine

Volume 72, Issue 5, October 2005, Pages 412-415

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Abstract

Introduction. – Electrophysiological exploration of neuropathies is a standard method of investigating the dysfunction of myelinated larger fibers (Aα, Aβ). However, this method cannot test dysfunctions in other fibers. To evaluate the smaller (Aδ) and unmyelinated fiber (C-fibers) lesions a quantitative method has been perfected: the study of the sensory thresholds (quantitative sensory testing: QST). It allows the investigation of the sensory symptoms and is a reproducible, non-invasive and painless method. It is used above all in patients suffering from diabetic neuropathy (‘Diabetes Care 9 (1987) 432’).

Patients and methods. – We used the QST testing in comparison with nerve conduction velocities in 40 Non-Insulin-Dependent Diabetes Mellitus (NIDDM or Type II) patients in their 60s (±10 years). Depending on the duration of their diabetes (dd), we distinguished three groups: dd < 5 years (GI) dd from 5 to 15 years (GII) and dd > 15 years (GIII). All the patients underwent a clinical neurological examination, which enabled us to establish a gravity score comparable to the NDS (Neuropathy Disability Score: ‘Muscle Nerve 10 (1988) 21’).

Results. – Nerve conduction velocities and QST were studied for each group of patients. Electrophysiological alterations were connected to the gravity clinical score and in some asymptomatic patients a higher QST heat threshold could be observed.

Discussion. – These results indicate that QST can detect the early dysfunction of the unmyelinated fibers in this kind of neuropathy. Subclinical detection can reduce severe neurological complications and make possible an early and effective treatment.

Introduction

Peripheral neuropathies are a frequent complication in diabetes mellitus and can induce a dysfunction of the larger fibers (Aα), the thin fibers (Aδ) and the unmyelinated fibers (C-fibers). In some patients suffering from diabetic neuropathies, the smaller fibers may be more severely altered than the larger ones [1], [2], [3]. The exploration of the myelinated fibers (Aα, Aδ) has been easily done for some time through the standard electrophysiological methods. The quantitative evaluation of the unmyelinated fibers has only been validated more recently. Several studies showed a delay in the motor and sensory conduction velocities in diabetic patients [4], [5]. Furthermore, abnormalities of the thermal sensory thresholds are often observed in diabetic patients suffering from peripheral neuropathy [6], [7], such abnormalities may also be detected in asymptomatic patients [8]. The study of the quantitative sensory thresholds (quantitative sensory testing: QST) by a semi-objective, painless, technique has been developed in patients suffering from diabetic neuropathy [9]. An early detection of this dysfunction would reduce severe neurological complications and facilitate an epidemiological follow-up of the incidence of neuropathies in diabetic patients.

Section snippets

Material and method

We studied the reactions of 40 diabetic patients (Type II), 23 men and 17 women, all in their 60s (±10 years) and all having suffered from diabetes for 12 years (±10). All the patients underwent systematic neurological examination resulting in the calculation of a neuropathic severity score based on their clinical symptoms and a neurological examination. Three groups were distinguished based on the duration of the patients’ diabetes (dd). Group I (GI): dd < 5 years. Group II (GII): dd from 5 to

Results of clinical score (Table 1)

The neurological examination showed different clinical scores for each group. The highest score was obtained in group III. It varied between 4 and 12. In group I, nine patients had a score of 0 and were considered as “asymptomatic.

Electrophysiological exploration (Table 2)

The upper limbs: a highly significant difference was observed between GI and GIII concerning the motor conduction velocity of the median nerve and the F latency (i.e., decrease of the conduction velocity and increase of the F latency in GIII). The lower limbs: a

Discussion

In this study, we have observed an alteration of the nerve function affecting large-diameter myelinated fibers and small-diameter, thinly myelinated or unmyelinated fibers. The heat sensitivity threshold is increased in diabetic patients as suggested by some authors [1], [2], [6], [8], [11].

The major result of our study indicated that thermal sensitivity is altered in asymptomatic patients. This result is significant because the method used to study thermal sensibility (QST) is semi-objective,

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Neuropathic pain is associated with several clinical conditions, including anxiety, depression, sleep disorders, and decreased quality of life; however, less evaluated in prediabetes. This study aims to assess neuropathic pain through validated diagnostic tools in prediabetes.
One hundred and seventy-two patients with prediabetes and 170 controls were included in this cross-sectional study. The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) Pain Scale and Douleur Neuropathique 4 Questions (DN4) were used to evaluate neuropathic pain. The Visual Analog Scale (VAS) was used to estimate pain intensity.
Twenty-three (13.4%) and 12 (7%) patients with prediabetes were diagnosed with neuropathic pain using DN4 and LANSS questionnaires, respectively. Neuropathic pain rates of the patients were higher than controls with two pain scales (p < 0.001). VAS scores were higher in prediabetes group than in controls (p = 0.021). LANSS, DN4, and VAS scores were positively correlated with HbA1c level (r = 0.184, p = 0.016; r = 0.180, p = 0.018; r = 0.188, p = 0.014, respectively). LANNS and DN4 scores were higher in female patients than in males (p < 0.001).
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Neural gliding versus neural tensioning: Effects on heat and cold thresholds, pain thresholds and hand grip strength in asymptomatic individuals
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Gliding has been shown to have a wider hypoalgesic effect than tensioning (Beltran-Alacreu et al., 2015) and both techniques have been shown to have similar effects on hamstring flexibility (Sharma et al., 2016). To our knowledge, no study has compared the effect of neural gliding and neural tensioning on heat and cold thresholds, important indicators of the function of C- and A-delta fibers, which are commonly affected in peripheral neuropathies (Chéliout-Héraut et al., 2005) or on muscle strength, which has a neural component. Therefore, the aim of this study was to compare the effects of neural gliding and neural tensioning targeting the median nerve on heat and cold temperature threshold, heat pain threshold, pressure pain thresholds, and hand grip strength in asymptomatic participants.
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Participants received 4 series of 10 repetitions of either neural gliding (n = 30) or neural tensioning (n = 30) and were assessed for heat and cold temperature threshold, heat pain threshold, pressure pain threshold, and hand grip strength at baseline, immediately after the intervention, and 30 min post-intervention.
A significant main interaction between time and intervention was found for the PPT at the forearm (F(2,55) = 5.98; p = 0.004), favouring the tensioning neural mobilization. No significant differences were found for the other variables.
Four series of 10 repetitions of neural tensioning targeting the median nerve in asymptomatic subjects seem to be enough to induce hypoalgesia and have no negative effects on A-delta and C mediated sensory function and on hand grip strength production.
Neural gliding and neural tensioning differently impact flexibility, heat and pressure pain thresholds in asymptomatic subjects: A randomized, parallel and double-blind study
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In addition to the reduced number of existing studies comparing gliding and tensioning, studied effects are limited to immediate post-intervention effects on the ipsilateral side of mobilization. The study of the impact of neural gliding and tensioning on other variables, such as heat and cold thresholds, which give an indication on the function of small nerve fibers in peripheral neuropathies (Chéliout-Héraut et al., 2005), is also of relevance. This study aimed to compare the effect of neural gliding techniques against neural tensioning techniques of the dominant lower limb on lower limb flexibility, heat and cold thresholds, pressure pain threshold and perceived pain intensity of the mobilized (dominant lower limb) and non-mobilized (non-dominant) lower limb, immediately after the intervention and at 24 h follow up.
To compare the effect of neural gliding and tensioning on hamstring flexibility, nerve function (heat and cold thresholds) and pain sensitivity (pain intensity and pressure pain threshold) of the mobilized and non-mobilized lower limbs at post-intervention and 24 h follow up.
Randomized, parallel and double blinded trial.
Forty-eight asymptomatic participants.
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Main Outcome Measures – Straight leg raising (SLR; in degrees), heat and cold threshold (ºC), pressure pain threshold (PPT; in Kgf) and pain intensity (visual analogue scale), taken at baseline, post-intervention and at 24 h follow up.
There was a significant interaction between time, intervention and limb for SLR (F2,45 = 3.83; p = 0.029). A significant interaction between time and intervention for PPT (F2,45 = 3.59; p = 0.036) and heat threshold (F2,45 = 5.10; p = 0.01). A significant effect of time (F2,45 = 9.42; p < 0.001) and of limb (F1,46 = 4.78; p = 0.035) for pain intensity during SLR, and a significant effect of time (F2,45 = 3.65; p = 0.034) for pain intensity during PPT.
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Original articleExploration of small fibers for testing diabetic neuropathies

Abstract

Introduction

Section snippets

Material and method

Results of clinical score (Table 1)

Electrophysiological exploration (Table 2)

Discussion

J. Neurol. Sci.

Am. J. Med.

Peripheral neuropathy profile in various groups of diabetics

J. Neurol. Neurosurg. Psychiatry

Vibratory and thermal thresholds in diabetics with and without clinical neuropathy

Acta Neurol. Scand.

Small nerve fiber dysfunction in diabetic neuropathy

Muscle Nerve

Peripheral and autonomic nerve function in newly diagnosed diabetes mellitus

Diabetes

Peripheral and autonomic nerve dysfunction in newly diagnosed insulin-dependant diabetes

Transplant. Proc.

Evaluation of thermal and vibration sensation in diabetic neuropathy

Diabetologia

Small- and large-fibre involvement in early diabetic neuropathy: a study with the medial plantar response and sensory thresholds

Diabetes Care

Vibratory and cooling detection thresholds compared with other tests in diagnosing and staging diabetic neuropathy

Diabetes Care

Original article
Exploration of small fibers for testing diabetic neuropathies