Eficacia de plantillas y zapatos terapéuticos en la reducción de la incidencia de ulceración en pacientes con neuropatía diabética: una revisión sistemática con metaanálisis / Efficacy of insoles and therapeutic shoes in the reduction of the ulceration incidence in diabetic neuropathy patients: A Systematic Review with meta-analysis

Objetivo Investigar el nivel de eficacia de plantillas personalizadas y zapatos terapéuticos en la reducción de la presión plantar y la incidencia de ulceración en presencia de neuropatía diabética. Metodología Las bases de datos PubMed, Scopus, Web of Science, Cinahls, Central Cochrane y Lilacs fueron encuestados en enero de 2020. Se incluyeron ensayos clínicos aleatorizados (ECA) que reportaron pacientes con neuropatía diabética sometidos a intervención con plantillas y calzado terapéutico en comparación con un grupo control. La calidad de las publicaciones se evaluó mediante la escala PEDro y la evidencia mediante la clasificación GRADE. En cuanto al metaanálisis, se realizó la agrupación de datos homogéneos y comparables. Resultados Se incluyeron 11 estudios, lo que resultó en una muestra de 1.443 participantes. Siete artículos presentaron datos suficientes para el metaanálisis. En el corto plazo, el riesgo relativo de protección fue de 0,23 (IC 95%; 0,07; 0,72), mientras que en el largo plazo el riesgo fue de 0,32 (IC 95%; 0,21; 0,48). La escala GRADE señaló baja calidad de evidencia en cuanto a la protección a corto plazo y alta calidad a largo plazo En el análisis cualitativo, seis estudios concluyeron que hubo reducción en la presión plantar del grupo de intervención. Conclusión Se encontró efecto protector del uso de plantillas en el desarrollo de úlceras a corto y largo plazo. (AU)

Objective To investigate the level of efficacy of personalized insoles and therapeutical shoes in plantar pressure and ulceration incidence reduction in the presence of diabetic neuropathy. Methodology The data bases PubMed, Scopus, Web of Science, Cinahls, Central Cochrane and Lilacs were surveyed in January/2020. Randomized clinical trials (RCT) were included that reported diabetic neuropathy patients submitted to intervention with insoles and therapeutical shoes compared to a control group. The quality of the publications was evaluated using the PEDro scale and the evidence by the GRADE classification. Regarding the meta-analysis, the grouping of homogeneous and comparable data was carried out. Results Eleven studies were included, which resulted in a sample containing 1,443 participants. Seven papers presented enough data for the meta-analysis. In the short term, the protection relative risk was 0.23 (IC95% 0.07;0.72), while in the long term, the risk was 0.32 (IC95% 0.21;0.48). The GRADE scale pointed out low evidence quality regarding short-term protection and high quality in the long term. In the qualitative analysis, six studies concluded that there was reduction in the plantar pressure of the intervention group. Conclusion Protective effect of using insoles was found in the development of ulcers in the short and long term. (AU)

Cytokine Levels in Neural Pain in Leprosy.

Pain is a frequent symptom in leprosy patients. It may be predominantly nociceptive, as in neuritis, or neuropathic, due to injury or nerve dysfunction. The differential diagnosis of these two forms of pain is a challenge in clinical practice, especially because it is quite common for a patient to suffer from both types of pain. A better understanding of cytokine profile may serve as a tool in assessing patients and also help to comprehend pathophysiology of leprosy pain. Patients with leprosy and neural pain (n = 22), neuropathic pain (n = 18), neuritis (nociceptive pain) (n = 4), or no pain (n = 17), further to those with diabetic neuropathy and neuropathic pain (n = 17) were recruited at Souza Araujo Out-Patient Unit (Fiocruz, Rio de Janeiro, RJ, Brazil). Serum levels of IL1ß, IL-6, IL-10, IL-17, TNF, CCL-2/MCP-1, IFN-γ, CXCL-10/IP-10, and TGF-ß were evaluated in the different Groups. Impairment in thermal or pain sensitivity was the most frequent clinical finding (95.5%) in leprosy neuropathy patients with and without pain, but less frequent in Diabetic Group (88.2%). Previous reactional episodes have occurred in patients in the leprosy and Pain Group (p = 0.027) more often. Analysis of cytokine levels have demonstrated that the concentrations of IL-1ß, TNF, TGF-ß, and IL-17 in serum samples of patients having leprosy neuropathy in combination with neuropathic or nociceptive pain were higher when compared to the samples of leprosy neuropathy patients without pain. In addition, these cytokine levels were significantly augmented in leprosy patients with neuropathic pain in relation to those with neuropathic pain due to diabetes. IL-1ß levels are an independent variable associated with both types of pain in patients with leprosy neuropathy. IL-6 concentration was increased in both groups with pain. Moreover, CCL-2/MCP-1 and CXCL-10/IP-10 levels were higher in patients with diabetic neuropathy over those with leprosy neuropathy. In brief, IL-1ß is an independent variable related to neuropathic and nociceptive pain in patients with leprosy, and could be an important biomarker for patient follow-up. IL-6 was higher in both groups with pain (leprosy and diabetic patients), and could be a therapeutic target in pain control.

Clinical spectrum and quality of life in patients with chronic polyneuropathy: A cross-sectional study.

Chronic polyneuropathy is a disabling condition of the peripheral nerves, characterized by symmetrical sensory motor symptoms and signs. There is paucity of studies on the etiological spectrum of polyneuropathy and its impact on quality of life (QoL). The present cross-sectional study in a referral based tertiary care center in North India found diabetic neuropathy as the commonest cause (25.5%) amongst 212 patients with chronic polyneuropathy. Idiopathic axonal polyneuropathy was present in 14.2% patients. Leprosy presenting as confluent mononeuritis multiplex constituted 11.3% of the patients. Additionally, it revealed a significantly worse QoL in these patients in all domains measured by short form (SF-36). This is the first study conducted in India to determine the QoL in chronic neuropathy patients. The current study demonstrates the clinical feasibility and applicability of the SF-36 generic health status in patients with polyneuropathies.

Neuropathic ulcers in leprosy treated with intralesional platelet-rich plasma.

Neuropathic ulcers in leprosy represent a therapeutic challenge for clinicians. Chronic ulcers affect patient health, emotional state and quality of life, causing considerable morbidity and mortality in addition to contributing to significant health care costs. The pathogenesis is mainly related to the abnormally increased pressure in areas such as the sole of the foot, secondary to lack of sensation and deformities induced by peripheral sensory-motor neuropathy. Conventional treatment of these wounds can be slow due to their chronic inflammatory state and the senescence of local reparative cells. Platelet-rich plasma (PRP) may restore the healing process, leading to a reparative phase. We present two patients with four neuropathic leprosy ulcers that have responded satisfactory to PRP treatment. PRP therapy has been growing as a viable treatment alternative for chronic ulcers. However, stronger scientific evidence is required to support its potential benefit for use in chronic wounds.

Diabetic neuropathy and foot complications.

Foot ulceration and Charcot neuroarthropathy (CN) are well recognized and documented late sequelae of diabetic peripheral, somatic, and sympathetic autonomic neuropathy. The neuropathic foot, however, does not ulcerate spontaneously: it is a combination of loss of sensation due to neuropathy together with other factors such as foot deformity and external trauma that results in ulceration and indeed CN. The commonest trauma leading to foot ulcers in the neuropathic foot in Western countries is from inappropriate footwear. Much of the management of the insensate foot in diabetes has been learned from leprosy which similarly gives rise to insensitive foot ulceration. No expensive equipment is required to identify the high risk foot and recently developed tests such as the Ipswich Touch Test and the Vibratip have been shown to be useful in identifying the high risk foot. A comprehensive screening program, together with education of high risk patients, should help to reduce the all too high incidence of ulceration in diabetes. More recently another very high risk group has been identified, namely patients on dialysis, who are at extremely high risk of developing foot ulceration; this should be preventable. The most important feature in management of neuropathic foot ulceration is offloading as patients can easily walk on active foot ulcers due to the loss of pain sensation. Infection should be treated aggressively and if there is any evidence of peripheral vascular disease, arteriography and appropriate surgical management is also indicated. CN often presents with a unilateral hot, swollen foot and any patient presenting with these features known to have neuropathy should be treated as a Charcot until this is proven otherwise. Most important in the management of acute CN is offloading, often in a total contact cast.

The pathway to foot ulceration in diabetes.

It should now be possible to achieve a reduction in the incidence of foot ulceration and amputations as knowledge about pathways that result in both these events increases. However, despite the universal use of patient education and the hope of reducing the incidence of ulcers in high-risk patients, there are no appropriately designed large, randomized controlled trials actually confirming that education works. It has been recognized for some years that education as part of a multidisciplinary approach to care of the diabetic foot can help to reduce the incidence of amputations in certain settings. Ultimately, however, a reduction in neuropathic foot problems will only be achieved if we remember that the patients with neuropathic feet have lost their prime warning signal­pain­that ordinarily brings patients to their doctor. Very little training is offered to health care professionals as to how to deal with such patients. Much can be learned about the management of such patients from the treatment of individuals with leprosy: if we are to succeed, we must realize that with loss of pain there is also diminished motivation in the healing of and prevention of injury.

Diabetic foot--what can we learn from leprosy? Legacy of Dr Paul W. Brand.

Leprosy and diabetes, though two very different conditions, may both result in severe loss of sensation in the feet, which are then a great risk of painless injury and ulceration. Seminal observations made by the late Dr Paul W. Brand, a surgeon working with leprosy patients in South India in the mid-20th century, resulted in the subsequent development of treatments to manage insensitive foot ulcers that are today entirely applicable to patients with diabetes. As a consequence of his research, the recognition of the relationship between insensitivity, repetitive pressures and skin breakdown has helped our understanding of the aetiopathogenesis of neuropathic foot lesions in diabetes: the development of the total contact cast and other casting devices to treat such lesions forms the basis of management of diabetic foot lesions with off-loading devices that are widely used in the 21st century in diabetic foot clinics around the world. Moreover, observations by Brand that the foot 'heats up before it breaks down' resulted in more recent research showing that self-skin temperature monitoring might help reduce the incidence of recurrent neuropathic foot ulcers in diabetes. In summary, Brand's understanding of 'the gift of pain' that, when lost, results in the late complications of diabetic neuropathy has guided the prevention, diagnosis and management of diabetic foot problems in the 21st century.

Clinical study of nail changes in leprosy and comparison with nail changes in diabetic patients.

BACKGROUND: Nail changes in leprotic patients are not specific to leprosy, and may be observed in other peripheral neuropathies. Diabetes is one of the diseases that present with nail dystrophy secondary to peripheral neuropathy, vasculopathy, trauma and infections. Therefore, nail changes in diabetic neuropathy are expected to be very similar to that of leprosy. OBJECTIVES: To evaluate the frequency and pattern of nail changes in Egyptian leprotic patients with the different spectrums of the disease, and to compare nail changes in leprosy with those seen in patients with diabetic neuropathy. METHODS: The study included 115 leprosy patients and 60 patients with diabetic peripheral neuropathy. Nail examination was thoroughly carried out and various nail changes were recorded including the location of the involved nails (fingers, toes). RESULTS: Our study detected similar incidence of nail changes in both multibacillary (MB) (86%) and paucibacillary (PB) patients (86%). Flag sign (alternating horizontal bands of whitish and pinkish discoloration of the nail) observed in our study was not reported before. It was more commonly seen in MB patients (21%) than in PB patients (14%). Our results also revealed that the nail changes were more commonly seen in leprosy patients (86%) than in diabetic patients (68%). CONCLUSION: Nail changes in leprosy are multifactorial, and could be related to one or more of the following: neuropathy, endarteritis, trauma, drugs or superimposed infections. Nail changes in leprosy may be used as an additional clue that helps in the diagnosis.

Peripheral neuropathy of the upper extremity: medical comorbidity that confounds common orthopedic pathology.

In the orthopedic patient, the diagnosis of a compression neuropathy may be straightforward. However, various medical comorbidities can obscure this diagnosis. It is paramount for the practicing orthopedic surgeon to have an appreciation for the medical pathology of common axonal neuropathies to properly diagnose, treat, and refer a patient with altered sensation in the upper extremity. The prevalence of diabetes in the United States is 10%, and roughly 20% of diabetic patients have peripheral neuropathy. In addition to diabetes, 32% of heavy alcohol users present with polyneuropathy. With advancements in the treatment of human immunodeficiency virus/acquired immunodeficiency syndrome clinicians may see the long-term effects of the virus manifested as axonal neuropathies and extreme allodynia. In some regions of the world, Hansen's disease usurps diabetes as the most common cause of polyneuropathy. Based on patient demographics and social habits, Lyme disease, multiple sclerosis, and syphilis can all manifest as polyneuropathies. Understanding the common medical causes of neuropathy will aid the orthopedic surgeon in differentiating simple compression neuropathies from diseases mimicking or confounding them.

Stress analysis in three-dimensional foot models of normal and diabetic neuropathy.

In this paper, a three-dimensional two-arch model of the foot is developed, taking foot geometry from X-rays of normal and diabetic subjects, which considered bones, cartilages, ligaments, important muscle forces and foot-sole soft-tissue. The stress analysis is carried out by a finite element technique using NISA software for the foot models simulating quasi-static walking phases of heel-strike, mid-stance and push-off. The analysis shows that the highest stresses occur during the push-off phase in the dorsal central part of the lateral and medial metatarsals and the dorsal junction of the calcaneus and cuboid. The vertical stresses, in the foot-sole soft-tissue at the foot-ground interface, for normal and diabetic neuropathic subjects, are the highest in the push-off phase and were in good agreement with the experimentally measured foot pressures. It is found that the foot-sole vertical stresses (at the foot-ground interface), in diabetic neuropathy, increase considerably in the heel region in the heel-strike phase and in the fore-foot regions in the push-off phase. The high stress concentration areas, in the plantar surfaces indicated above, are of great importance since it is found from clinical reports that in diabetic neuropathic patients these areas of the foot-sole are prone to ulcers. Thus, this investigation could possibly provide information on the areas of high stress concentration of the foot bones in the normal foot giving rise to arthritis when the mechanical strength decreases and possible high stress regions of foot bone giving rise to disintegration of tarsal bones in leprosy, as well as an insight into the factors contributing to plantar ulcers in diabetic neuropathy.

Use of the Semmes-Weinstein 5.07/10 gram monofilament: the long and the short of it.

The Semmes-Weinstein monofilament has been developed for the detection of patients at risk of neuropathic ulceration. In this study we evaluated how the physical characteristics of the monofilaments can impact on their performance. Commercially purchased monofilaments from the Hansen's Disease Center (HDC) and a batch produced 'in-house' (RPAH) were calibrated using a Mettler Balance. To assess the effects of varying lengths on buckling force, the monofilaments were tested repeatedly while the length of the filament was reduced stepwise from 4.1 to 3.1 cm. The correct length of the monofilament to generate a buckling force of 10 g was also determined theoretically by applying the Euler's Buckling Equation. Results showed neither batch of monofilaments buckled at a strength of 10 g (HDC 6.8 g, CI 5.7-7.9, and RPAH 7.2 g, CI 7.1-7.3). In addition HDC showed a wide interfilament variation range, 4.1-10.3 g with CV 29% versus corresponding figures of range 7.1-7.9 g, CV 4.9% for the RPAH monofilaments. As predicted by Euler's Buckling Theory, buckling force can be increased by reducing the length of the filament. These results demonstrate that the physical characteristics of the monofilament are important determinants of buckling force and are not necessarily uniform in commercial filaments. The clinical relevance of variance in buckling force remains to be determined.

Neurotrophins and peripheral neuropathy.

Endogenous nerve growth factor (NGF) levels were studied in patients with nerve trauma, diabetes mellitus and leprosy, the most common causes of human peripheral neuropathy. In diabetics, there was an early length-dependent dysfunction of small-diameter sensory fibres, with depletion of skin NGF and the sensory neuropeptide substance P. The NGF depletion correlated significantly with decreased skin axon-reflex vasodilatation, which is mediated by small sensory fibres at least partly via substance P release. Immunostaining showed depletion of NGF in keratinocytes in diabetic skin. In injured nerves, NGF levels were reduced when compared to intact nerve, except acutely distal to injury; NGF-immunostaining was seen in Schwann cells in distal segments, including neuromas. NGF levels were decreased in leprosy-affected skin and nerve. The role of neurotrophins in the rational treatment of human neuropathies is discussed e.g. loss of nociception and axon-reflex vasodilatation contribute to skin ulceration, a major and serious complication, for which NGF may provide prophylaxis.

Mal perfurante plantar: estudo de 50 casos / Plantar perforating injury: study of 50 cases

Os autores apresentam um trabalho inédito sobre o mal perfurante plantar (MPP). Reuniram-se os dados colhidos da revisäo dos prontuários do serviço de dermatologia dos últimos cinco anos com uma amostra de 50 casos e deu-se a eles um tratamento estatístico. Os autores apresentam os resultados obtidos valorizando a revisäo literária das causas e destacando as principais encontradas na amostra: A neuropatia hansênica, a seguir a alcoólica e em terceiro lugar a diabética.