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Table of Contents
ORIGINAL ARTICLE
Year : 2017  |  Volume : 5  |  Issue : 2  |  Page : 69-76

To study clinical profile of peripheral neuropathy in type 2 diabetes mellitus using nerve conduction velocity


1 Associate Professor, Department of Medicine, SBKS Medical Institute & Research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, Gujarat, India
2 Resident, Department of Medicine, SBKS Medical Institute & Research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, Gujarat, India

Date of Web Publication31-Aug-2018

Correspondence Address:
Amit Shah
Associate Professor, Department of Medicine, SBKS Medical Institute & Research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2347-6486.240249

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  Abstract 


Introduction: Diabetes is one of the leading non communicable disease throughout the world. Due to its chronic nature it causes a number of complications. Diabetic peripheral neuropathy is one of the most dreaded complications of diabetes as it is associated with significant morbidity. Diagnosis of neuropathy is commonly done by NCV which is a gold standard test for it. Other simpler method to detect early loss of protective vibration sensation, to find out feet at risk of future complications is the need of the hour. Hence this study was done to study the symptoms of peripheral neuropathy in type 2 diabetic patients and to correlate these with patient's age, duration of diabetes, glycemic parameters and other microvascular complications.
Methodology: This was a cross sectional study carried out in 40 patients with symptoms of peripheral neuropathy in the Department of General Medicine at Dhiraj General Hospital, Sumandeep Vidyapeeth, Piparia, Vadodara district, Gujarat. All patients were subjected to detailed clinical history, examination of their feet and neuropathy testing by NCV using the RMS NCV/EMG machine using a hand held biothesiometer.
Results: Out of the total of 40 patients, 30 were males and 10 were females. Increasing age of the patients, increasing duration of diabetes, smoking and poor glycemic control were significant risk factors for the development of neuropathy. It was also consistently associated with other microvascular complications like retinopathy and nephropathy. The most frequently encountered symptom of neuropathy in our study was burning feet.
Conclusion: The study concludes that increasing diabetes duration is an independent and strong risk factor and considering the dreaded complications of end stage diabetic foot disease, routine screening of all type 2 diabetic patients should be done in daily practice.

Keywords: Diabetes mellitus, Neuropathy, Risk factors


How to cite this article:
Shah A, Shah D. To study clinical profile of peripheral neuropathy in type 2 diabetes mellitus using nerve conduction velocity. J Integr Health Sci 2017;5:69-76

How to cite this URL:
Shah A, Shah D. To study clinical profile of peripheral neuropathy in type 2 diabetes mellitus using nerve conduction velocity. J Integr Health Sci [serial online] 2017 [cited 2019 Mar 20];5:69-76. Available from: http://www.jihs.in/text.asp?2017/5/2/69/240249




  Introduction Top


Diabetes mellitus (DM) has been defined as a metabolic disorder with hyperglycemia as an essential and common feature and has number of abnormalities in metabolic parameters namely the carbohydrate, protein and fat metabolism which is further explained by either a defect in insulin secretion, insulin action or both.[1] When chronic, the disease causes damage, dysfunction, and failure of various organs, especially the eyes, kidneys, heart and blood vessels.

Prevalence of T2DM is increasing globally and has reached epidemic proportions in many countries[2]. Focus of management of diabetes over the past two decades has also changed from controlling symptoms to also preventing complications.‘Chronic complications of diabetes can be broadly divided into vascular and nonvascular complications. The vascular complications of DM are further divided into microvascular (retinopathy, neuropathy, and nephropathy) and macrovascular (coronary artery disease, peripheral arterial disease, cerebrovascular disease) whereas nonvascular complications include gastroparesis, infections, skin changes etc.‘'

Diabetic neuropathy is defined as peripheral, somatic or autonomic nerve damage attributed solely to diabetes mellitus.[3]

Neuropathy is the most common complication of DM affecting up to 50% of patients with type 1 and type 2 DM [4]. In contrast to Type 1 DM where distal polyneuropathy typically becomes symptomatic after many years of chronic prolonged hypreglycemia, patients with Type 2 DM may present with distal polyneuropathy after many years of poor glycemic control; sometimes neuropathy may be present at the time of diagnosis.

Aim and Objective

  1. To study symptoms of peripheral neuropathy in type 2 diabetic patients.
  2. To study distribution pattern of peripheral neuropathy with respect to age, sex, duration of diabetes and glycemic status.



  Methodology Top


Study Design: Cross sectional study

Sample size: 40 patients

Duration of enrollment: 1.5 years

Study was started after clearance from institutional ethics committee.

Inclusion criteria:

  1. Patients willing to give informed and written consent to participate in the study.
  2. Type 2 Diabetic patients with symptoms indicative of peripheral neuropathy like tingling, burning, numbness, hyperesthesia etc.


Exclusion criteria:

  1. Patients not willing to give consent
  2. Extremes of ages <18 and >80 years
  3. Persons with known neurological disease
  4. Known alcoholics
  5. On sedatives/hypnotics
  6. Anemic (Hb<=11gm%, MCV>92 fl)


Type II DM patients attending the OPD or admitted to DHIRAJ HOSPITAL affiliated to S.B.K.S Medical Institute & Research Centre, Piparia, Waghodia were taken. A detailed history about their diabetes (i.e duration, drugs, complications), age, gender, symptoms of peripheral neuropathy (i.e tingling, numbness, hyperesthesia, burning sensation in limbs) and foot ulceration was taken. All were investigated for CBC, FPG, PPPG, HbA1c, urine routine microscopy, blood urea, serum creatinine and evaluation of fundus for retinopathy. A systemic examination was also done to find any associated comorbid conditions like hypertension, obesity etc. Patient's feet were examined for surrogate markers of diabetic peripheral neuropathy like callus, fissures, trophic changes, dryness, shiny skin etc. and also any past or present ulceration history was sought. Light touch sensation was checked with a cotton cusp applied to both limbs alternatively and asking the patient for the perception of touch. Superficial and deep pain was tested using head end of a pin and sharp end of the pin respectively. Temperature sense was checked using hot and cold water filled test tubes. Joint position was checked using patient's ability to recognize his toe position either in plantar or dorsiflexed position when eyes were closed. All enrolled patients were subjected to neuropathy testing by Nerve Conduction Velocity (NCV). Also presence or absence of neuropathy was assessed with relation to duration of diabetes, glycemic status, age, risk factors like obesity, smoking, microalbuminuria and retinopathy. Sensitivity of foot examination in detection of neuropathy were also checked. Nerve conduction study was performed using Nicolet Viking Quest EDX machine by Natus Neurology.


  Results Top


A total of 40 patients were taken for the study. Mean patients' age in this study was 56.8 ± 9.78 years. Patients' mean weight was 71.87 ± 7.93 kilograms. Mean height of the patients was 158.88 ± 10.47 cm. Mean BMI of the patients was 28.51 ± 2.49 kg/m2. Mean HbA1c was 8.9 ± 1.85 %. Mean FPG was 188.35 ± 43 mg/dl. Mean PPPG was 270.72 ± 63.59 mg/dl. All values are represented at 95% confidence interval.

Out of total 40 patients, 12 were in age group 41-50 years (30%), 15 were in 51-60 year group (37.5%), 10 in 61-70 year group (7.5%) and 3 in 71-80 year age group (7.5%) with maximum patients between 51-60 years.

Three had disease of less than 5 year duration, 23 patients had diabetes since 5 to 10 years and 14 patients had diabetes of more than 10 year duration. Maximum patients (57.5%) had their diabetes since 5 to 10 years. 27 patients out of 40 (67.5%) were smokers. [Table 1] Microalbuminuria was found in 23 (57.5%) patients out of 40 patients. [Table 1] 15 (37.5%) had some form of retinopathy, either nonproliferative or proliferative at the time of their presentation and 25 (62.5%) patients did not have retinopathy. [Table 1] 6 patients out of 40 (15%) had their HbA1c values <7.5 %, 25 patients (62.5%) had their HbA1c between 7.5-10 %, 5 patients (12.5%) had HbA1c between 10-12 % and 4 patients (10%) had HbA1c of >12 %. [Table 1] Out of total 40 patients, 33 (82.5%) had burning feet as their presenting complaint, 11 (27.5%) had hyperaesthesia, 26 (65%) had tingling, 34 (85%) had normal sense of pain and temperature while 6 (15%) had abnormality in perceiving pain and temperature sense. Foot ulcer was found in 2 (5%) of the patients, gait abnormality and weakness was present in 1 (2.5%) of patients each.
Table 1: Distribution of patient

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Twenty patients out of 40 (50%) had normal foot examination while others had abnormalities in foot examination (e.g callus, fissures, trophic changes, charcot foot, ulcers, shiny skin etc.) [Table 1] Abnormality in perception of light touch sense was present in 7 patients (17.5%), superficial pain sense in 4 (10%), deep pain sense in 0 patients, temperature sense in 8 patients (20%) and joint position sense abnormality was present in 4 patients (10%).[Table 1]

Out of the total of 40 patients tested for neuropathy by NCV, 19 (47.5%) had presence of neuropathy and 21 (52.5%) did not have neuropathy of right foot while 21 out of 40 patients (52.5%) had neuropathy of left foot by NCV.[Table 2]
Table 2: Neuropathy by nerve conduction velocity

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Increasing age was associated with increasing incidence of neuropathy and maximum percentage of patients with neuropathy (80%) were in the age group of 61-70 years. While majority of the patients in the study were in the BMI range of 25-29.99, 11 out of 14 patients (78.6%) who were in the BMI group of 30-34.99 had neuropathy. Similarly increasing HbA1c is also consistently associated with neuropathy and maximum percentage of patients having neuropathy (100%) were more at A1c values of >12 [Table 3]. Out of 3 patients who had their diabetes since <5 years, 2 (66.7%) had evidence of neuropathy, 11 out of 23 patients (47.8%) who had their diabetes since 5-10 years had neuropathy while 13 out of 14 patients (92.9%) who had their diabetes since more than 10 years had evidence of neuropathy by NCV (p- 0.021). Out of 27 patients who smoked, 18 (66.7%) had evidence of neuropathy while 8 patients out of 13 (61.5%) who did not smoke had neuropathy. (p- 0.750, RR- 1.083).[Table 3]
Table 3: Comparison of different parameters with neuropathy by NCV

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26 patients out of 40 who had evidence of sensory neuropathy had higher mean FPG levels with a p value of 0.015. Similarly 26 patients with sensory neuropathy had higher PPPG levels than patients with no neuropathy with a p value of 0.038. [Table 4]
Table 4: Comparison of glycemic parameters with presence of neuropathy by NCV

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Out of 26 patients who had neuropathy by NCV, 7 had normal foot examination and 19 patients had some abnormality in foot examination with sensitivity of 73.5% and positive predictive value of 95%. While 13 patients out of 14 who had no neuropathy by NCV, 13 were having normal foot examination with specificity of 92.9% and negative predictive value of 65% and accuracy of 80% (p- 0.377). [Table 5]
Table 5: Foot examination and relation with neuropathy by NCV

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Out of 34 patients who had intact pain and temperature sensation, 20 (58.8%) had neuropathy by NCV and out of 6 patients who had abnormal perception of pain and temperature, all 6 had neuropathy by NCV (p- 0.074, RR- 0.58). [Table 6] Out of 26 patients who had tingling sensation in feet, 20 (76.9%) were found to have neuropathy while only 6 out of 14 patients (42.9%) who had no tingling sensation had neuropathy by NCV (p- 0.043, RR- 1.795). [Table 6]
Table 6: Relation between sensory symptoms and neuropathy by NCV

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Out of 11 patients who had hyperesthesia, all had presence of neuropathy while 15 patients out of 29 (51.7%) who did not have hyperesthesia had evidence of neuropathy (p- 0.004, RR- 1.93). [Table 6] Out of 33 patients who had burning feet, 24 patients (72.7%) had neuropathy while 2 patients out of 7 (28.6%) who did not have burning feet had evidence of neuropathy (p- 0.039, RR- 2.545). [Table 6]

Out of 23 patients who had microalbuminuria, 20 patients (87%) had neuropathy by NCV while 6 out of 17 patients (35.3%) who did not have microalbuminuria had evidence of neuropathy (p- 0.001, RR- 2.464). [Table 7] 14 patients out of 15 (93.9%) who had retinopathy had evidence of neuropathy while 12 out of 25 patients (48%) who did not have retinopathy had neuropathy by NCV (p- 0.004, RR- 1.944) [Table 7].
Table 7: Relation between other microvascular complications and neuropathy

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  Discussion Top


Peripheral neuropathy is one of the most common and chronic microvascular complication of diabetes mellitus [1],[2]. Global impact of untreated neuropathy is increasing and alarming [3]. It is the most common cause of non traumatic lower limb amputations in the world [5]. Our study was aimed at early diagnosis of diabetic peripheral neuropathy by detection of loss of protective sense (LOPS) which converts a diabetic foot into a high risk foot. The study also aimed to recognize common signs and symptoms of peripheral neuropathy for early detection and also correlated results of gold standard Nerve Conduction Study (NCS)

In this study, various other parameters like age, sex, duration of diabetes, history of smoking, glycosylated hemoglobin (GHbA1c), Fasting Plasma Glucose (FPG), Post prandial Plasma Glucose (PPPG), Body Mass Index (BMI), microalbuminuria and retinopathy were also evaluated and their relationship with neuropathy was also checked. With increasing age of the patient incidence of neuropathy increased but it didn’t attain statistical significance (p- 0.532) in our study most probably because the major bulk of the patients in our study was in the age group of 41-60 years. However, a number of studies in the past have established that increasing age is a risk factor for diabetic neuropathy.[6],[7]

One characteristic finding of the study was relationship of neuropathy with other microvascular complications of diabetes like nephropathy and retinopathy. Those patients who had neuropathy were also having microalbuminuria and/or retinopathy. The relationship reached a statistical significance (p- 0.001 and 0.004 respectively) which suggests a common pathophysiology of the microvascular complications and need for evaluating for other complications once it is identified. This finding has been supported and confirmed by a variety of studies in the past.[6],[7],[5]

Patients who had neuropathy were more likely to have some form of abnormality in the foot examination which failed to reach a statistical significance (p- 0.377) but had a higher specificity, positive predictive value and accuracy of 92.9%, 95% and 80 % respectively indicating that foot examination is an integral part of evaluation of peripheral neuropathy and cannot be overlooked.[8]

Another aspect of the study was to look for clinical features of neuropathy. In our study, burning feet was most commonly and consistently associated with neuropathy with a p value of 0.039. Other features of neuropathy like tingling, hyperesthesia were also associated with increased neuropathy incidence with a p value of 0.043 and 0.004 respectively. Loss of pain and temperature sense was also found more consistently in patients with neuropathy however it failed to reach a statistical significance (p- 0.074).[9],[10],[11]


  Conclusion Top


The study concludes that increasing diabetes duration is an independent and strong risk factor and considering the dreaded complications of end stage diabetic foot disease, routine screening of all type 2 diabetic patients should be done in daily practice.



 
  References Top

1.
Longo DL, Fauci as, Kasper DL, Hauser SL, Jameson JL Loscalzo J: Harrisons's Principles of Internal Medicine, 19th edition, pg 2399.   Back to cited text no. 1
    
2.
Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes- estimates for the year 2000 and projections for 2030. Diabetes Care. 2004; 27(3):1047-53.  Back to cited text no. 2
    
3.
Levin and O’Neal‘s The diabetic Foot; 6th edition. 2000; 3(33)  Back to cited text no. 3
    
4.
Dyck PJ, Kratz KM, Karnes JL, et al. The prevalence by staged severity of various types of diabetic neuropathy, retinopathy, and nephropathy in a population-based cohort: the Rochester Diabetic Neuropathy Study. Neurology. 1993;43:817-824  Back to cited text no. 4
    
5.
Longo DL, Fauci as, Kasper DL, Hauser SL, Jameson JL Loscalzo J: Harrisons's Principles of Internal Medicine, 19th edition, pg 2426  Back to cited text no. 5
    
6.
Dipika Bansal et al. Prevalence and risk factors of development of peripheral diabetic neuropathy in type 2 diabetes mellitus in a tertiary care setting. Journal of Diabetes Investigation. 2014 Nov; 5(6): 714-721.  Back to cited text no. 6
    
7.
Franklin GM, Shtterly SM, Cohen JA, Baxter J, Hamman RF : Risk factor for distal symmetric neuropathy in NIDDM. Diabetes Care 1994 ; 17 : 1172-1177.  Back to cited text no. 7
    
8.
Boulton AJM, Armstrong DG, Albert ST, et al. Comprehensive Foot Examination Risk Assessment. Diabetes Care 2008; 31:1679.  Back to cited text no. 8
    
9.
Dyck PJ, Thomas PK. Diabetic Neuropathy ,Second Edition, Philadelphia, W.B. Saunders, 1999.  Back to cited text no. 9
    
10.
Joslin's Diabetes Mellitus, 14th Edition, new Delhi, Lippincott Williams and Wilkins, 2005, Kahn, Weir, King, Jacobson, Moses, Smith.  Back to cited text no. 10
    
11.
Ropper AH, Brown RH. Adams and Victors Principles of Neurology; 8th edition, New York, Mc Graw Hill, 2005.  Back to cited text no. 11
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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