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Hansen TM, Croosu SS, Røikjer J, Mørch CD, Ejskjaer N, Frøkjær JB. Neuropathic phenotypes of type 1 diabetes are related to different signatures of magnetic resonance spectroscopy-assessed brain metabolites. Clin Neurophysiol 2024; 166:11-19. [PMID: 39084155 DOI: 10.1016/j.clinph.2024.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/30/2023] [Accepted: 06/15/2024] [Indexed: 08/02/2024]
Abstract
OBJECTIVES The study aimed to investigate brain metabolites in type 1 diabetes and the associations with disease characteristics. We explored the metabolic profiles predicting different neuropathic phenotypes using multiple linear regression analyses. METHODS We compared brain metabolites in 55 adults with type 1 diabetes (including painful diabetic peripheral neuropathy (DPN), painless DPN, without DPN) with 20 healthy controls. Proton magnetic resonance spectroscopy measurements (N-acetylaspartate (NAA), glutamate (glu), myo-inositol (mI), and glycerophosphocholine (GPC) were obtained in ratios to creatine (cre)) from the parietal region, anterior cingulate cortex and thalamus. RESULTS The overall diabetes group revealed decreased parietal NAA/cre compared to healthy controls (1.41 ± 0.12 vs. 1.55 ± 0.13,p < 0.001) and increased mI/cre (parietal: 0.62 ± 0.08 vs. 0.57 ± 0.07,p = 0.025, cingulate: 0.65 ± 0.08 vs. 0.60 ± 0.08,p = 0.033). Reduced NAA/cre was associated with more severe DPN (all p ≤ 0.04) whereas increased mI/cre was associated with higher hemoglobin A1c (HbA1c) (p = 0.02). Diabetes was predicted from decreased parietal NAA/cre, increased parietal ml/cre, and decreased thalamic glu/cre. DPN was predicted from decreased parietal NAA/cre and increased GPC/cre. Painful DPN was predicted from increased parietal GPC/cre and thalamic glu/cre. CONCLUSIONS Specific metabolic brain profiles were linked to the different phenotypes of diabetes, DPN and painful DPN. SIGNIFICANCE Assessment of metabolic profiles could be relevant for detailed understanding of central neuropathy in diabetes.
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Affiliation(s)
- Tine M Hansen
- Department of Radiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark; Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
| | - Suganthiya S Croosu
- Department of Radiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark; Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark; Steno Diabetes Center North Denmark, Aalborg University Hospital, Mølleparkvej 4, 9000 Aalborg, Denmark
| | - Johan Røikjer
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Mølleparkvej 4, 9000 Aalborg, Denmark; Integrative Neuroscience, Aalborg University, Selma Lagerlöfs Vej 249, 9260 Gistrup, Denmark
| | - Carsten D Mørch
- Integrative Neuroscience, Aalborg University, Selma Lagerlöfs Vej 249, 9260 Gistrup, Denmark; Center for Neuroplasticity and Pain (CNAP), SMI, Department of Health Science and Technology, Aalborg University, Selma Lagerlöfs Vej 249, 9260 Gistrup, Denmark
| | - Niels Ejskjaer
- Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark; Steno Diabetes Center North Denmark, Aalborg University Hospital, Mølleparkvej 4, 9000 Aalborg, Denmark; Department of Endocrinology, Aalborg University Hospital, Mølleparkvej 4, 9000 Aalborg, Denmark
| | - Jens B Frøkjær
- Department of Radiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark; Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
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Nanivadekar AC, Bose R, Petersen BA, Okorokova EV, Sarma D, Madonna TJ, Barra B, Farooqui J, Dalrymple AN, Levy I, Helm ER, Miele VJ, Boninger ML, Capogrosso M, Bensmaia SJ, Weber DJ, Fisher LE. Restoration of sensory feedback from the foot and reduction of phantom limb pain via closed-loop spinal cord stimulation. Nat Biomed Eng 2024; 8:992-1003. [PMID: 38097809 PMCID: PMC11404213 DOI: 10.1038/s41551-023-01153-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/27/2023] [Indexed: 12/30/2023]
Abstract
Restoring somatosensory feedback in individuals with lower-limb amputations would reduce the risk of falls and alleviate phantom limb pain. Here we show, in three individuals with transtibial amputation (one traumatic and two owing to diabetic peripheral neuropathy), that sensations from the missing foot, with control over their location and intensity, can be evoked via lateral lumbosacral spinal cord stimulation with commercially available electrodes and by modulating the intensity of stimulation in real time on the basis of signals from a wireless pressure-sensitive shoe insole. The restored somatosensation via closed-loop stimulation improved balance control (with a 19-point improvement in the composite score of the Sensory Organization Test in one individual) and gait stability (with a 5-point improvement in the Functional Gait Assessment in one individual). And over the implantation period of the stimulation leads, the three individuals experienced a clinically meaningful decrease in phantom limb pain (with an average reduction of nearly 70% on a visual analogue scale). Our findings support the further clinical assessment of lower-limb neuroprostheses providing somatosensory feedback.
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Affiliation(s)
- Ameya C Nanivadekar
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
- Center for the Neural Basis of Cognition, Pittsburgh, PA, USA
| | - Rohit Bose
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
- Center for the Neural Basis of Cognition, Pittsburgh, PA, USA
| | - Bailey A Petersen
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
- Center for the Neural Basis of Cognition, Pittsburgh, PA, USA
| | - Elizaveta V Okorokova
- Department of Organismal Biology and Anatomy, University of Chicago, Chicago, IL, USA
| | - Devapratim Sarma
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Mechanical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Tyler J Madonna
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
| | - Beatrice Barra
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neuroscience and Movement Science, University of Fribourg, Fribourg, Switzerland
| | - Juhi Farooqui
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, USA
- Center for the Neural Basis of Cognition, Pittsburgh, PA, USA
| | - Ashley N Dalrymple
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Mechanical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, USA
| | - Isaiah Levy
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
| | - Eric R Helm
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
| | - Vincent J Miele
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael L Boninger
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
- Center for the Neural Basis of Cognition, Pittsburgh, PA, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marco Capogrosso
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
- Center for the Neural Basis of Cognition, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sliman J Bensmaia
- Department of Organismal Biology and Anatomy, University of Chicago, Chicago, IL, USA
| | - Douglas J Weber
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Mechanical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Lee E Fisher
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA.
- Center for the Neural Basis of Cognition, Pittsburgh, PA, USA.
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA.
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3
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Wei XY, Wang X, Shi GX, Tu JF, Yang JW, Ren MM, Liu JL, Lee CK, Zhou H, Wang ZY, Liu CZ. Acupuncture Modulation of Chronic Neuropathic Pain and Its Association With Brain Functional Properties. THE JOURNAL OF PAIN 2024:104645. [PMID: 39089662 DOI: 10.1016/j.jpain.2024.104645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 06/22/2024] [Accepted: 07/24/2024] [Indexed: 08/04/2024]
Abstract
Chronic neuropathic pain has been one of the prominent causes of disability, and acupuncture has shown promise in treatment. The present study aimed to characterize acupuncture modulation of chronic neuropathic pain and explore the related functional brain changes. Sixty chronic sciatica patients were divided into acupuncture- or sham acupuncture groups and received 10 sessions of treatment during 4 weeks. The visual analog scale for leg pain, oswestry disability index (ODI), and resting-state functional magnetic resonance images were assessed at baseline and after treatment. Then, fractional amplitudes of low-frequency fluctuations (fALFF) and support vector regression analyses were performed. Compared with sham acupuncture, acupuncture significantly improved symptoms, including visual analog scale for leg pain and ODI. In addition, acupuncture exhibited increased fALFF of the right superior parietal lobule (SPL) and right postcentral gyrus. Furthermore, the actual 4-week ODI values were positively correlated with the support vector regression-predicted values based on the right SPL fALFF and baseline clinical measurements. These results indicate that the spontaneous neural activity of the right SPL and right postcentral gyrus may be involved in the modulation of acupuncture in chronic neuropathic pain. In addition, the spontaneous neural activity of the right SPL might be used as the predictor of response to acupuncture therapy. PERSPECTIVE: This clinical neuroimaging study elucidated the neural basis of acupuncture in chronic sciatica. Neurological indicators and clinical measurements could be used as potential predictors of acupuncture response. This study combines neuroimaging and artificial intelligence techniques to highlight the potential of acupuncture for the treatment of chronic neuropathic pain. TRIAL REGISTRATION NUMBER: Chinese Clinical Trial Registry, ChiCTR2100044585, http://www.chictr.org.cn.
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Affiliation(s)
- Xiao-Ya Wei
- School of Acupuncture-Moxibustion and Tuina, International Acupuncture and Moxibustion Innovation Institute, Beijing University of Chinese Medicine, Beijing, China
| | - Xu Wang
- School of Life Sciences, Beijing University of Chinese Medicine, Beijing, China
| | - Guang-Xia Shi
- School of Acupuncture-Moxibustion and Tuina, International Acupuncture and Moxibustion Innovation Institute, Beijing University of Chinese Medicine, Beijing, China
| | - Jian-Feng Tu
- School of Acupuncture-Moxibustion and Tuina, International Acupuncture and Moxibustion Innovation Institute, Beijing University of Chinese Medicine, Beijing, China
| | - Jing-Wen Yang
- School of Acupuncture-Moxibustion and Tuina, International Acupuncture and Moxibustion Innovation Institute, Beijing University of Chinese Medicine, Beijing, China
| | - Meng-Meng Ren
- Department of Radiology, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
| | - Jun-Lian Liu
- Department of Radiology, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
| | - Chih-Kai Lee
- School of Acupuncture-Moxibustion and Tuina, International Acupuncture and Moxibustion Innovation Institute, Beijing University of Chinese Medicine, Beijing, China
| | - Hang Zhou
- School of Acupuncture-Moxibustion and Tuina, International Acupuncture and Moxibustion Innovation Institute, Beijing University of Chinese Medicine, Beijing, China
| | - Ze-Yi Wang
- School of Acupuncture-Moxibustion and Tuina, International Acupuncture and Moxibustion Innovation Institute, Beijing University of Chinese Medicine, Beijing, China
| | - Cun-Zhi Liu
- School of Acupuncture-Moxibustion and Tuina, International Acupuncture and Moxibustion Innovation Institute, Beijing University of Chinese Medicine, Beijing, China.
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Liu Y, Wu D, Zheng H, Ni Y, Zhu L, Jiang Y, Dai J, Sun Q, Zhao Y, Zhang Q, Yang Y, Liu R. Serum Spexin Level Is Negatively Associated With Peripheral Neuropathy and Sensory Pain in Type 2 Diabetes. J Diabetes Res 2024; 2024:4538199. [PMID: 38919263 PMCID: PMC11199070 DOI: 10.1155/2024/4538199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/17/2024] [Accepted: 04/20/2024] [Indexed: 06/27/2024] Open
Abstract
Background: Spexin is a novel peptide hormone and has shown antinociceptive effects in experimental mice. This study is aimed at evaluating the association of serum spexin level with diabetic peripheral neuropathy (DPN) and related pain in a Chinese population. Methods: We enrolled 167 type 2 diabetes mellitus (T2DM) including 56 patients without DPN (non-DPN), 67 painless DPN, and 44 painful DPN. Serum spexin was measured using ELISA. Logistic regression models were performed to analyze the independent effects of spexin on prevalence of DPN and painful DPN. In streptozotocin (STZ)-induced diabetic mice, mechanical pain threshold was measured using electronic von Frey aesthesiometer. Human peripheral blood mononuclear cells (PBMCs) were isolated and further stimulated with lipopolysaccharide without or with spexin. The gene expression was assayed by qPCR. Results: Compared with non-DPN, serum spexin level decreased in painless DPN and further decreased in painful DPN. The odds of DPN was associated with low spexin level in T2DM, which was similar by age, sex, BMI, and diabetes duration, but attenuated in smokers. The odds of having pain was associated with decreased spexin level in DPN, which was similar by age, sex, smoking status, and diabetes duration, but attenuated in normal weight. Furthermore, we observed that mechanical pain threshold increased in spexin-treated diabetic mice. We also found that lipopolysaccharide treatment increased the mRNA level of TNF-α, IL-6, and MCP-1 in human PBMCs, while spexin treatment prevented this increase. Conclusions: These results suggested that spexin might serve as a protective factor for diabetes against neuropathology and pain-related pathogenesis.
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Affiliation(s)
- Ying Liu
- Department of Endocrinology and MetabolismHuashan HospitalFudan University, Shanghai 200040, China
- Institute of Endocrinology and DiabetesFudan University, Shanghai 200040, China
| | - Di Wu
- Department of Endocrinology and MetabolismHuashan HospitalFudan University, Shanghai 200040, China
- Institute of Endocrinology and DiabetesFudan University, Shanghai 200040, China
| | - Hangping Zheng
- Department of Endocrinology and MetabolismHuashan HospitalFudan University, Shanghai 200040, China
- Institute of Endocrinology and DiabetesFudan University, Shanghai 200040, China
| | - Yunzhi Ni
- Department of Endocrinology and MetabolismHuashan HospitalFudan University, Shanghai 200040, China
- Institute of Endocrinology and DiabetesFudan University, Shanghai 200040, China
| | - Lu Zhu
- Institute of Endocrinology and DiabetesFudan University, Shanghai 200040, China
| | - Yaojing Jiang
- Department of Endocrinology and MetabolismHuashan HospitalFudan University, Shanghai 200040, China
- Institute of Endocrinology and DiabetesFudan University, Shanghai 200040, China
| | - Jiarong Dai
- Department of Endocrinology and MetabolismHuashan HospitalFudan University, Shanghai 200040, China
- Institute of Endocrinology and DiabetesFudan University, Shanghai 200040, China
| | - Quanya Sun
- Department of Endocrinology and MetabolismHuashan HospitalFudan University, Shanghai 200040, China
- Institute of Endocrinology and DiabetesFudan University, Shanghai 200040, China
| | - Ying Zhao
- Department of Endocrinology and MetabolismHuashan HospitalFudan University, Shanghai 200040, China
- Institute of Endocrinology and DiabetesFudan University, Shanghai 200040, China
| | - Qi Zhang
- Department of Endocrinology and MetabolismHuashan HospitalFudan University, Shanghai 200040, China
- Institute of Endocrinology and DiabetesFudan University, Shanghai 200040, China
| | - Yehong Yang
- Department of Endocrinology and MetabolismHuashan HospitalFudan University, Shanghai 200040, China
- Institute of Endocrinology and DiabetesFudan University, Shanghai 200040, China
| | - Rui Liu
- Department of Endocrinology and MetabolismHuashan HospitalFudan University, Shanghai 200040, China
- Institute of Endocrinology and DiabetesFudan University, Shanghai 200040, China
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5
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Huang Y, Zhang X, Cheng M, Yang Z, Liu W, Ai K, Tang M, Zhang X, Lei X, Zhang D. Altered cortical thickness-based structural covariance networks in type 2 diabetes mellitus. Front Neurosci 2024; 18:1327061. [PMID: 38332862 PMCID: PMC10851426 DOI: 10.3389/fnins.2024.1327061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 01/11/2024] [Indexed: 02/10/2024] Open
Abstract
Cognitive impairment is a common complication of type 2 diabetes mellitus (T2DM), and early cognitive dysfunction may be associated with abnormal changes in the cerebral cortex. This retrospective study aimed to investigate the cortical thickness-based structural topological network changes in T2DM patients without mild cognitive impairment (MCI). Fifty-six T2DM patients and 59 healthy controls underwent neuropsychological assessments and sagittal 3-dimensional T1-weighted structural magnetic resonance imaging. Then, we combined cortical thickness-based assessments with graph theoretical analysis to explore the abnormalities in structural covariance networks in T2DM patients. Correlation analyses were performed to investigate the relationship between the altered topological parameters and cognitive/clinical variables. T2DM patients exhibited significantly lower clustering coefficient (C) and local efficiency (Elocal) values and showed nodal property disorders in the occipital cortical, inferior temporal, and inferior frontal regions, the precuneus, and the precentral and insular gyri. Moreover, the structural topological network changes in multiple nodes were correlated with the findings of neuropsychological tests in T2DM patients. Thus, while T2DM patients without MCI showed a relatively normal global network, the local topological organization of the structural network was disordered. Moreover, the impaired ventral visual pathway may be involved in the neural mechanism of visual cognitive impairment in T2DM patients. This study enriched the characteristics of gray matter structure changes in early cognitive dysfunction in T2DM patients.
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Affiliation(s)
- Yang Huang
- Department of MRI, Shaanxi Provincial People’s Hospital, Xi’an, China
| | - Xin Zhang
- Department of MRI, Shaanxi Provincial People’s Hospital, Xi’an, China
| | - Miao Cheng
- Department of MRI, Shaanxi Provincial People’s Hospital, Xi’an, China
| | - Zhen Yang
- Department of MRI, Shaanxi Provincial People’s Hospital, Xi’an, China
| | - Wanting Liu
- Department of MRI, Shaanxi Provincial People’s Hospital, Xi’an, China
| | - Kai Ai
- Department of Clinical and Technical Support, Philips Healthcare, Xi’an, China
| | - Min Tang
- Department of MRI, Shaanxi Provincial People’s Hospital, Xi’an, China
| | - Xiaoling Zhang
- Department of MRI, Shaanxi Provincial People’s Hospital, Xi’an, China
| | - Xiaoyan Lei
- Department of MRI, Shaanxi Provincial People’s Hospital, Xi’an, China
| | - Dongsheng Zhang
- Department of MRI, Shaanxi Provincial People’s Hospital, Xi’an, China
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Marsili F, Potgieter P, Birkill CF. Adaptive Autonomic and Neuroplastic Control in Diabetic Neuropathy: A Narrative Review. Curr Diabetes Rev 2024; 20:38-54. [PMID: 38018186 DOI: 10.2174/0115733998253213231031050044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 08/31/2023] [Accepted: 09/28/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Type 2 diabetes mellitus (T2DM) is a worldwide socioeconomic burden, and is accompanied by a variety of metabolic disorders, as well as nerve dysfunction referred to as diabetic neuropathy (DN). Despite a tremendous body of research, the pathogenesis of DN remains largely elusive. Currently, two schools of thought exist regarding the pathogenesis of diabetic neuropathy: a) mitochondrial-induced toxicity, and b) microvascular damage. Both mechanisms signify DN as an intractable disease and, as a consequence, therapeutic approaches treat symptoms with limited efficacy and risk of side effects. OBJECTIVE Here, we propose that the human body exclusively employs mechanisms of adaptation to protect itself during an adverse event. For this purpose, two control systems are defined, namely the autonomic and the neural control systems. The autonomic control system responds via inflammatory and immune responses, while the neural control system regulates neural signaling, via plastic adaptation. Both systems are proposed to regulate a network of temporal and causative connections which unravel the complex nature of diabetic complications. RESULTS A significant result of this approach infers that both systems make DN reversible, thus opening the door to novel therapeutic applications.
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Affiliation(s)
| | - Paul Potgieter
- Research Department, Algiamed Technologies, Burnaby, Canada
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Destrebecq V, Rovai A, Trotta N, Comet C, Naeije G. Proprioceptive and tactile processing in individuals with Friedreich ataxia: an fMRI study. Front Neurol 2023; 14:1224345. [PMID: 37808498 PMCID: PMC10556689 DOI: 10.3389/fneur.2023.1224345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 09/01/2023] [Indexed: 10/10/2023] Open
Abstract
Objective Friedreich ataxia (FA) neuropathology affects dorsal root ganglia, posterior columns in the spinal cord, the spinocerebellar tracts, and cerebellar dentate nuclei. The impact of the somatosensory system on ataxic symptoms remains debated. This study aims to better evaluate the contribution of somatosensory processing to ataxia clinical severity by simultaneously investigating passive movement and tactile pneumatic stimulation in individuals with FA. Methods Twenty patients with FA and 20 healthy participants were included. All subjects underwent two 6 min block-design functional magnetic resonance imaging (fMRI) paradigms consisting of twelve 30 s alternating blocks (10 brain volumes per block, 120 brain volumes per paradigm) of a tactile oddball paradigm and a passive movement paradigm. Spearman rank correlation tests were used for correlations between BOLD levels and ataxia severity. Results The passive movement paradigm led to the lower activation of primary (cSI) and secondary somatosensory cortices (cSII) in FA compared with healthy subjects (respectively 1.1 ± 0.78 vs. 0.61 ± 1.02, p = 0.04, and 0.69 ± 0.5 vs. 0.3 ± 0.41, p = 0.005). In the tactile paradigm, there was no significant difference between cSI and cSII activation levels in healthy controls and FA (respectively 0.88 ± 0.73 vs. 1.14 ± 0.99, p = 0.33, and 0.54 ± 0.37 vs. 0.55 ± 0.54, p = 0.93). Correlation analysis showed a significant correlation between cSI activation levels in the tactile paradigm and the clinical severity (R = 0.481, p = 0.032). Interpretation Our study captured the difference between tactile and proprioceptive impairments in FA using somatosensory fMRI paradigms. The lack of correlation between the proprioceptive paradigm and ataxia clinical parameters supports a low contribution of afferent ataxia to FA clinical severity.
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Affiliation(s)
- Virginie Destrebecq
- Laboratoire de Neuroanatomie et de Neuroimagerie translationnelles (LNT), UNI – ULB Neuroscience Institute, Université libre de Bruxelles (ULB), Brussels, Belgium
- Department of Neurology, CUB Hôpital Erasme, Université libre de Bruxelles (ULB), Brussels, Belgium
| | - Antonin Rovai
- Laboratoire de Neuroanatomie et de Neuroimagerie translationnelles (LNT), UNI – ULB Neuroscience Institute, Université libre de Bruxelles (ULB), Brussels, Belgium
| | - Nicola Trotta
- Laboratoire de Neuroanatomie et de Neuroimagerie translationnelles (LNT), UNI – ULB Neuroscience Institute, Université libre de Bruxelles (ULB), Brussels, Belgium
| | - Camille Comet
- Department of Neurology, CUB Hôpital Erasme, Université libre de Bruxelles (ULB), Brussels, Belgium
| | - Gilles Naeije
- Laboratoire de Neuroanatomie et de Neuroimagerie translationnelles (LNT), UNI – ULB Neuroscience Institute, Université libre de Bruxelles (ULB), Brussels, Belgium
- Department of Neurology, CUB Hôpital Erasme, Université libre de Bruxelles (ULB), Brussels, Belgium
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8
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Eid SA, Rumora AE, Beirowski B, Bennett DL, Hur J, Savelieff MG, Feldman EL. New perspectives in diabetic neuropathy. Neuron 2023; 111:2623-2641. [PMID: 37263266 PMCID: PMC10525009 DOI: 10.1016/j.neuron.2023.05.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 04/20/2023] [Accepted: 05/03/2023] [Indexed: 06/03/2023]
Abstract
Diabetes prevalence continues to climb with the aging population. Type 2 diabetes (T2D), which constitutes most cases, is metabolically acquired. Diabetic peripheral neuropathy (DPN), the most common microvascular complication, is length-dependent damage to peripheral nerves. DPN pathogenesis is complex, but, at its core, it can be viewed as a state of impaired metabolism and bioenergetics failure operating against the backdrop of long peripheral nerve axons supported by glia. This unique peripheral nerve anatomy and the injury consequent to T2D underpins the distal-to-proximal symptomatology of DPN. Earlier work focused on the impact of hyperglycemia on nerve damage and bioenergetics failure, but recent evidence additionally implicates contributions from obesity and dyslipidemia. This review will cover peripheral nerve anatomy, bioenergetics, and glia-axon interactions, building the framework for understanding how hyperglycemia and dyslipidemia induce bioenergetics failure in DPN. DPN and painful DPN still lack disease-modifying therapies, and research on novel mechanism-based approaches is also covered.
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Affiliation(s)
- Stephanie A Eid
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA; NeuroNetwork for Emerging Therapies, University of Michigan, Ann Arbor, MI 48109, USA
| | - Amy E Rumora
- Department of Neurology, Columbia University, New York, NY 10032, USA
| | - Bogdan Beirowski
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; Neuroscience Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - David L Bennett
- Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford OX3 9DU, UK
| | - Junguk Hur
- Department of Biomedical Sciences, University of North Dakota, Grand Forks, ND 58202, USA
| | - Masha G Savelieff
- Department of Biomedical Sciences, University of North Dakota, Grand Forks, ND 58202, USA
| | - Eva L Feldman
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA; NeuroNetwork for Emerging Therapies, University of Michigan, Ann Arbor, MI 48109, USA.
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Aurucci GV, Preatoni G, Damiani A, Raspopovic S. Brain-Computer Interface to Deliver Individualized Multisensory Intervention for Neuropathic Pain. Neurotherapeutics 2023; 20:1316-1329. [PMID: 37407726 PMCID: PMC10480109 DOI: 10.1007/s13311-023-01396-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 07/07/2023] Open
Abstract
To unravel the complexity of the neuropathic pain experience, researchers have tried to identify reliable pain signatures (biomarkers) using electroencephalography (EEG) and skin conductance (SC). Nevertheless, their use as a clinical aid to design personalized therapies remains scarce and patients are prescribed with common and inefficient painkillers. To address this need, novel non-pharmacological interventions, such as transcutaneous electrical nerve stimulation (TENS) to activate peripheral pain relief via neuromodulation and virtual reality (VR) to modulate patients' attention, have emerged. However, all present treatments suffer from the inherent bias of the patient's self-reported pain intensity, depending on their predisposition and tolerance, together with unspecific, pre-defined scheduling of sessions which does not consider the timing of pain episodes onset. Here, we show a Brain-Computer Interface (BCI) detecting in real-time neurophysiological signatures of neuropathic pain from EEG combined with SC and accordingly triggering a multisensory intervention combining TENS and VR. After validating that the multisensory intervention effectively decreased experimentally induced pain, the BCI was tested with thirteen healthy subjects by electrically inducing pain and showed 82% recall in decoding pain in real time. Such constructed BCI was then validated with eight neuropathic patients reaching 75% online pain precision, and consequently releasing the intervention inducing a significant decrease (50% NPSI score) in neuropathic patients' pain perception. Our results demonstrate the feasibility of real-time pain detection from objective neurophysiological signals, and the effectiveness of a triggered combination of VR and TENS to decrease neuropathic pain. This paves the way towards personalized, data-driven pain therapies using fully portable technologies.
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Affiliation(s)
- Giuseppe Valerio Aurucci
- Laboratory for Neuroengineering, Department of Health Science and Technology, Institute for Robotics and Intelligent Systems, ETH Zürich, 8092, Zurich, Switzerland
| | - Greta Preatoni
- Laboratory for Neuroengineering, Department of Health Science and Technology, Institute for Robotics and Intelligent Systems, ETH Zürich, 8092, Zurich, Switzerland
| | - Arianna Damiani
- Laboratory for Neuroengineering, Department of Health Science and Technology, Institute for Robotics and Intelligent Systems, ETH Zürich, 8092, Zurich, Switzerland
| | - Stanisa Raspopovic
- Laboratory for Neuroengineering, Department of Health Science and Technology, Institute for Robotics and Intelligent Systems, ETH Zürich, 8092, Zurich, Switzerland.
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10
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Zang Y, Jiang D, Zhuang X, Chen S. Changes in the central nervous system in diabetic neuropathy. Heliyon 2023; 9:e18368. [PMID: 37609411 PMCID: PMC10440454 DOI: 10.1016/j.heliyon.2023.e18368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 07/11/2023] [Accepted: 07/14/2023] [Indexed: 08/24/2023] Open
Abstract
One of the most common chronic complications arising from diabetes is diabetic peripheral neuropathy. Depending on research statistics, approximately half of the people who have diabetes will suffer from diabetic peripheral neuropathy over time, which manifests as abnormal sensations in the distal extremities, and about 25%-50% of these patients have symptoms of neuralgia, called painful diabetic neuropathy. These patients often exhibit adverse emotional conditions, like anxiety or depression, which can reduce their quality of life. The pathogenesis of diabetic peripheral neuropathy is complex, and although persistent hyperglycemia plays a central role in the development of diabetic peripheral neuropathy, strict glycemic control does not eliminate the risk of diabetic peripheral neuropathy. This suggests the need to understand the role of the central nervous system in the development of diabetic peripheral neuropathy to modulate treatment regimens accordingly. Magnetic resonance imaging not only allows for the noninvasive detection of structural and functional alterations in the central nervous system, but also provides insight into the processing of abnormal information such as pain by the central nervous system, and most importantly, contributes to the development of more effective pain relief protocols. Therefore, this article will focus on the mechanisms and related imaging evidence of central alterations in diabetic peripheral neuropathy, especially in painful diabetic neuropathy.
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Affiliation(s)
- Yarui Zang
- Department of Endocrinology and Metabolism, The Second Hospital of Shandong University, 247 Beiyuan Street, 250033, Jinan, Shandong, China
| | - Dongqing Jiang
- Department of Endocrinology and Metabolism, The Second Hospital of Shandong University, 247 Beiyuan Street, 250033, Jinan, Shandong, China
| | - Xianghua Zhuang
- Department of Endocrinology and Metabolism, The Second Hospital of Shandong University, 247 Beiyuan Street, 250033, Jinan, Shandong, China
| | - Shihong Chen
- Department of Endocrinology and Metabolism, The Second Hospital of Shandong University, 247 Beiyuan Street, 250033, Jinan, Shandong, China
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11
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Preston FG, Riley DR, Azmi S, Alam U. Painful Diabetic Peripheral Neuropathy: Practical Guidance and Challenges for Clinical Management. Diabetes Metab Syndr Obes 2023; 16:1595-1612. [PMID: 37288250 PMCID: PMC10243347 DOI: 10.2147/dmso.s370050] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/16/2023] [Indexed: 06/09/2023] Open
Abstract
Painful diabetic peripheral neuropathy (PDPN) is present in nearly a quarter of people with diabetes. It is estimated to affect over 100 million people worldwide. PDPN is associated with impaired daily functioning, depression, sleep disturbance, financial instability, and a decreased quality of life. Despite its high prevalence and significant health burden, it remains an underdiagnosed and undertreated condition. PDPN is a complex pain phenomenon with the experience of pain associated with and exacerbated by poor sleep and low mood. A holistic approach to patient-centred care alongside the pharmacological therapy is required to maximise benefit. A key treatment challenge is managing patient expectation, as a good outcome from treatment is defined as a reduction in pain of 30-50%, with a complete pain-free outcome being rare. The future for the treatment of PDPN holds promise, despite a 20-year void in the licensing of new analgesic agents for neuropathic pain. There are over 50 new molecular entities reaching clinical development and several demonstrating benefit in early-stage clinical trials. We review the current approaches to its diagnosis, the tools, and questionnaires available to clinicians, international guidance on PDPN management, and existing pharmacological and non-pharmacological treatment options. We synthesise evidence and the guidance from the American Association of Clinical Endocrinology, American Academy of Neurology, American Diabetes Association, Diabetes Canada, German Diabetes Association, and the International Diabetes Federation into a practical guide to the treatment of PDPN and highlight the need for future research into mechanistic-based treatments in order to prioritise the development of personalised medicine.
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Affiliation(s)
- Frank G Preston
- Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool, Liverpool, UK
| | - David R Riley
- Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool, Liverpool, UK
| | - Shazli Azmi
- Institute of Cardiovascular Science, University of Manchester and Manchester Diabetes Centre, Manchester Foundation Trust, Manchester, UK
| | - Uazman Alam
- Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
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12
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Gandhi R, Selvarajah D, Sloan G, Greig M, Wilkinson ID, Shaw PJ, Griffiths P, Tesfaye S. Preservation of thalamic neuronal function may be a prerequisite for pain perception in diabetic neuropathy: A magnetic resonance spectroscopy study. FRONTIERS IN PAIN RESEARCH (LAUSANNE, SWITZERLAND) 2023; 3:1086887. [PMID: 36688084 PMCID: PMC9852821 DOI: 10.3389/fpain.2022.1086887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/24/2022] [Indexed: 01/09/2023]
Abstract
Introduction In this study, we used proton Magnetic Resonance Spectroscopy (1H-MRS) to determine the neuronal function in the thalamus and primary somatosensory (S1) cortex in different subgroups of DPN, including subclinical- and painful-DPN. Method One-hundred and ten people with type 1 diabetes [20 without DPN (no-DPN); 30 with subclinical-DPN; 30 with painful-DPN; and 30 with painless-DPN] and 20 healthy volunteers, all of whom were right-handed men, were recruited and underwent detailed clinical and neurophysiological assessments. Participants underwent Magnetic Resonance Imaging at 1.5 Tesla with two 1H-MRS spectra obtained from 8 ml cubic volume voxels: one placed within left thalamus to encompass the ventro-posterior lateral sub-nucleus and another within the S1 cortex. Results In the thalamus, participants with painless-DPN had a significantly lower NAA:Cr ratio [1.55 + 0.22 (mean ± SD)] compared to all other groups [HV (1.80 ± 0.23), no-DPN (1.85 ± 0.20), sub-clinical DPN (1.79 ± 0.23), painful-DPN (1.75 ± 0.19), ANOVA p < 0.001]. There were no significant group differences in S1 cortical neurometabolites. Conclusion In this largest cerebral MRS study in DPN, thalamic neuronal dysfunction was found in advanced painless-DPN with preservation of function in subclinical- and painful-DPN. Furthermore, there was a preservation of neuronal function within the S1 cortex in all subgroups of DPN. Therefore, there may be a proximo-distal gradient to central nervous system alterations in painless-DPN, with thalamic neuronal dysfunction occurring only in established DPN. Moreover, these results further highlight the manifestation of cerebral alterations between painful- and painless-DPN whereby preservation of thalamic function may be a prerequisite for neuropathic pain in DPN.
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Affiliation(s)
- Rajiv Gandhi
- Diabetes Research Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Dinesh Selvarajah
- Department of Oncology and Human Metabolism, University of Sheffield, Sheffield, United Kingdom
| | - Gordon Sloan
- Diabetes Research Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom,Department of Oncology and Human Metabolism, University of Sheffield, Sheffield, United Kingdom
| | - Marni Greig
- Diabetes Research Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Iain D. Wilkinson
- Academic Unit of Radiology, University of Sheffield, Sheffield, United Kingdom
| | - Pamela J. Shaw
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, United Kingdom
| | - Paul Griffiths
- Academic Unit of Radiology, University of Sheffield, Sheffield, United Kingdom
| | - Solomon Tesfaye
- Diabetes Research Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom,Correspondence: Solomon Tesfaye
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13
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Croosu SS, Røikjer J, Mørch CD, Ejskjaer N, Frøkjær JB, Hansen TM. Alterations in Functional Connectivity of Thalamus and Primary Somatosensory Cortex in Painful and Painless Diabetic Peripheral Neuropathy. Diabetes Care 2023; 46:173-182. [PMID: 36469731 DOI: 10.2337/dc22-0587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 10/13/2022] [Indexed: 12/07/2022]
Abstract
OBJECTIVE In this study we aimed to investigate the functional connectivity of brain regions involved in sensory processing in diabetes with and without painful and painless diabetic peripheral neuropathy (DPN) and the association with peripheral nerve function and pain intensity. RESEARCH DESIGN AND METHODS In this cross-sectional study we used resting-state functional MRI (fMRI) to investigate functional brain connectivity of 19 individuals with type 1 diabetes and painful DPN, 19 with type 1 diabetes and painless DPN, 18 with type 1 diabetes without DPN, and 20 healthy control subjects. Seed-based connectivity analyses were performed for thalamus, postcentral gyrus, and insula, and the connectivity z scores were correlated with peripheral nerve function measurements and pain scores. RESULTS Overall, compared with those with painful DPN and healthy control subjects, subjects with type 1 diabetes without DPN showed hyperconnectivity between thalamus and motor areas and between postcentral gyrus and motor areas (all P ≤ 0.029). Poorer peripheral nerve functions and higher pain scores were associated with lower connectivity of the thalamus and postcentral gyrus (all P ≤ 0.043). No connectivity differences were found in insula (all P ≥ 0.071). CONCLUSIONS Higher functional connectivity of thalamus and postcentral gyrus appeared only in diabetes without neuropathic complications. Thalamic/postcentral gyral connectivity measures demonstrated an association with peripheral nerve functions. Based on thalamic connectivity, it was possible to group the phenotypes of type 1 diabetes with painful/painless DPN and type 1 diabetes without DPN. The results of the current study support that fMRI can be used for phenotyping, and with validation, it may contribute to early detection and prevention of neuropathic complications.
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Affiliation(s)
- Suganthiya S Croosu
- Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Johan Røikjer
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
- Center for Neuroplasticity and Pain, SMI, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Carsten D Mørch
- Center for Neuroplasticity and Pain, SMI, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Niels Ejskjaer
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Jens B Frøkjær
- Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Tine M Hansen
- Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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14
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Chao CC, Hsieh PC, Janice Lin CH, Huang SL, Hsieh ST, Chiang MC. Limbic Connectivity Underlies Pain Treatment Response in Small-Fiber Neuropathy. Ann Neurol 2022; 93:655-667. [PMID: 36511844 DOI: 10.1002/ana.26577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/16/2022] [Accepted: 11/28/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Small-fiber neuropathy (SFN) is characterized by neuropathic pain due to degeneration of small-diameter nerves in the skin. Given that brain reorganization occurs following chronic neuropathic pain, this study investigated the structural and functional basis of pain-related brain changes after skin nerve degeneration. METHODS Diffusion-weighted and resting-state functional MRI data were acquired from 53 pathologically confirmed SFN patients, and the structural and functional connectivity of the pain-related network was assessed using network-based statistic (NBS) analysis. RESULTS Compared with age- and sex-matched controls, the SFN patients exhibited a robust and global reduction of functional connectivity, mainly across the limbic and somatosensory systems. Furthermore, lower functional connectivity was associated with skin nerve degeneration measured by reduced intraepidermal nerve fiber density and better therapeutic response to anti-neuralgia medications, particularly for the connectivity between the insula and the limbic areas including the anterior and middle cingulate cortices. Similar to the patterns of functional connectivity changes, the structural connectivity was robustly reduced among the limbic and somatosensory areas, and the cognition-integration areas including the inferior parietal lobule. There was shared reduction of structural and functional connectivity among the limbic, somatosensory, striatal, and cognition-integration systems: (1) between the middle cingulate cortex and inferior parietal lobule and (2) between the thalamus and putamen. These observations indicate the structural basis underlying altered functional connectivity in SFN. INTERPRETATION Our findings provide imaging evidence linking structural and functional brain dysconnectivity to sensory deafferentation caused by peripheral nerve degeneration and therapeutic responses for neuropathic pain in SFN. ANN NEUROL 2022.
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Affiliation(s)
- Chi-Chao Chao
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Paul-Chen Hsieh
- Department of Dermatology, National Taiwan University Hospital, Taipei, Taiwan.,Department of Dermatology, NTU BioMedical Park Hospital, Hsinchu, Taiwan
| | - Chien-Ho Janice Lin
- Department of Physical Therapy and Assistive Technology, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Yeong-An Orthopedic and Physical Therapy Clinic, Taipei, Taiwan
| | - Shin-Leh Huang
- Department of Biomedical Engineering, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Neurology, Fu Jen Catholic University Hospital, New Taipei City, Taiwan
| | - Sung-Tsang Hsieh
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan.,Department of Anatomy and Cell Biology, National Taiwan University College of Medicine, Taipei, Taiwan.,Center of Precision Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ming-Chang Chiang
- Department of Biomedical Engineering, National Yang Ming Chiao Tung University, Taipei, Taiwan
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15
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Timtim SH, Simmons AN, Hays C, Strigo I, Sorg S, Ellis R, Keltner JR. HIV peripheral neuropathy-related degeneration of white matter tracts to sensorimotor cortex. J Neurovirol 2022; 28:505-513. [PMID: 36207560 PMCID: PMC9797459 DOI: 10.1007/s13365-022-01051-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 01/02/2022] [Accepted: 01/11/2022] [Indexed: 01/13/2023]
Abstract
Human immunodeficiency virus-associated distal sensory polyneuropathy (HIV-DSP) affects up to 50% of people with HIV and is associated with depression, unemployment, and generally worsened quality of life. Previous work on the cortical mechanism of HIV neuropathy found decreased gray matter volume in the bilateral midbrain, thalamus, and posterior cingulate cortex, but structural connectivity in this context remains under-studied. Here we examine alterations in white matter microstructure using diffusion imaging, hypothesizing that cortical white matter degeneration would be observed in continuation of the peripheral white matter atrophy previously observed in HIV-DSP. Male HIV seropositive patients (n = 57) experiencing varying degrees of HIV neuropathy underwent single-shell diffusion tensor imaging with 51 sampling directions. The scans were pooled using tractography and connectometry to create a quantitative map of white matter tract integrity, measured in generalized fractional anisotropy (GFA). The relationship between GFA and neuropathy severity was evaluated with linear regression. Correction for multiple comparisons was done using false discovery rate (FDR), a statistical method commonly used in genomics and imaging to minimize false positives when thousands of individual comparisons are made. Neuropathy severity was associated with decreased GFA along thalamocortical radiations leading along the lateral thalamus to sensorimotor cortex, with r = -0.405 (p < 0.001; FDR), as well as with the superior bilateral cingulum (r = -0.346 (p < 0.05; FDR)). Among a population of HIV neuropathy patients, greater neuropathy severity was correlated with lower white matter integrity running from midbrain to somatosensory cortex. This suggests ascending deafferentation extending from damaged peripheral nerves further downstream than seen previously, into the axons of third-order neurons. There is also evidence of cingulum degeneration, implying some more complex mechanism beyond the ascending atrophy observed here.
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Affiliation(s)
- Sara H Timtim
- UCSD, University of California San Diego School of Medicine, San Diego, CA, USA.
| | - Alan N Simmons
- UCSD, University of California San Diego School of Medicine, San Diego, CA, USA
| | - Chelsea Hays
- UCSD, University of California San Diego School of Medicine, San Diego, CA, USA
| | - Irina Strigo
- UCSF, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Scott Sorg
- UCSD, University of California San Diego School of Medicine, San Diego, CA, USA
| | - Ronald Ellis
- UCSD, University of California San Diego School of Medicine, San Diego, CA, USA
| | - John R Keltner
- UCSD, University of California San Diego School of Medicine, San Diego, CA, USA
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16
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Zhao LM, Chen X, Zhang YM, Qu ML, Selvarajah D, Tesfaye S, Yang FX, Ou CY, Liao WH, Wu J. Changed cerebral function and morphology serve as neuroimaging evidence for subclinical type 2 diabetic polyneuropathy. Front Endocrinol (Lausanne) 2022; 13:1069437. [PMID: 36506054 PMCID: PMC9729333 DOI: 10.3389/fendo.2022.1069437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 11/08/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Central and peripheral nervous systems are all involved in type 2 diabetic polyneuropathy mechanisms, but such subclinical changes and associations remain unknown. This study aims to explore subclinical changes of the central and peripheral and unveil their association. Methods A total of 55 type-2 diabetes patients consisting of symptomatic (n = 23), subclinical (n = 12), and no polyneuropathy (n = 20) were enrolled in this study. Cerebral morphology, function, peripheral electrophysiology, and clinical information were collected and assessed using ANOVA and post-hoc analysis. Gaussian random field correction was used for multiple comparison corrections. Pearson/Spearman correlation analysis was used to evaluate the association of the cerebral with the peripheral. Results When comparing the subclinical group with no polyneuropathy groups, no statistical differences were shown in peripheral evaluations except amplitudes of tibial nerves. At the same time, functional connectivity from the orbitofrontal to bilateral postcentral and middle temporal cortex increased significantly. Gray matter volume of orbitofrontal and its functional connectivity show a transient elevation in the subclinical group compared with the symptomatic group. Besides, gray matter volume in the orbitofrontal cortex negatively correlated with the Neuropathy Symptom Score (r = -0.5871, p < 0.001), Neuropathy Disability Score (r = -0.3682, p = 0.009), and Douleur Neuropathique en 4 questions (r = -0.4403, p = 0.003), and also found correlated positively with bilateral peroneal amplitude (r > 0.4, p < 0.05) and conduction velocities of the right sensory sural nerve(r = 0.3181, p = 0.03). Similarly, functional connectivity from the orbitofrontal to the postcentral cortex was positively associated with cold detection threshold (r = 0.3842, p = 0.03) and negatively associated with Neuropathy Symptom Score (r = -0.3460, p = 0.01). Discussion Function and morphology of brain changes in subclinical type 2 diabetic polyneuropathy might serve as an earlier biomarker. Novel insights from subclinical stage to investigate the mechanism of type 2 diabetic polyneuropathy are warranted.
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Affiliation(s)
- Lin-Mei Zhao
- Department of Endocrinology, Xiangya Hospital, Central South University, Changsha, China
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, China
- Department of Radiology and Radiological Sciences, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Xin Chen
- Department of Endocrinology, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Hunan Engineering Research Center for Obesity and its Metabolic Complications, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - You-Ming Zhang
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, China
| | - Min-Li Qu
- Department of Endocrinology, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Hunan Engineering Research Center for Obesity and its Metabolic Complications, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Dinesh Selvarajah
- Diabetes Research Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Solomon Tesfaye
- Diabetes Research Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Fang-Xue Yang
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, China
| | - Chu-Ying Ou
- Department of Endocrinology, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Hunan Engineering Research Center for Obesity and its Metabolic Complications, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Wei-Hua Liao
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, China
- National Engineering Research Center of Personalized Diagnostic and Therapeutic Technology, Xiangya Hospital, Central South University, Changsha, China
| | - Jing Wu
- Department of Endocrinology, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Hunan Engineering Research Center for Obesity and its Metabolic Complications, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Engineering Research Center of Personalized Diagnostic and Therapeutic Technology, Xiangya Hospital, Central South University, Changsha, China
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17
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Abstract
Distal symmetric diabetic peripheral polyneuropathy (DPN) is the most common form of neuropathy in the world, affecting 30 to 50% of diabetic individuals and resulting in significant morbidity and socioeconomic costs. This review summarizes updates in the diagnosis and management of DPN. Recently updated clinical criteria facilitate bedside diagnosis, and a number of new technologies are being explored for diagnostic confirmation in specific settings and for use as surrogate measures in clinical trials. Evolving literature indicates that distinct but overlapping mechanisms underlie neuropathy in type 1 versus type 2 diabetes, and there is a growing focus on the role of metabolic factors in the development and progression of DPN. Exercise-based lifestyle interventions have shown therapeutic promise. A variety of potential disease-modifying and symptomatic therapies are in development. Innovations in clinical trial design include the incorporation of detailed pain phenotyping and biomarkers for central sensitization.
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Affiliation(s)
- Qihua Fan
- Department of Neurology, Division of Neuromuscular Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - A Gordon Smith
- Department of Neurology, Division of Neuromuscular Medicine, Virginia Commonwealth University, Richmond, VA, USA
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18
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Elafros MA, Andersen H, Bennett DL, Savelieff MG, Viswanathan V, Callaghan BC, Feldman EL. Towards prevention of diabetic peripheral neuropathy: clinical presentation, pathogenesis, and new treatments. Lancet Neurol 2022; 21:922-936. [PMID: 36115364 PMCID: PMC10112836 DOI: 10.1016/s1474-4422(22)00188-0] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/15/2022] [Accepted: 04/29/2022] [Indexed: 12/24/2022]
Abstract
Diabetic peripheral neuropathy (DPN) occurs in up to half of individuals with type 1 or type 2 diabetes. DPN results from the distal-to-proximal loss of peripheral nerve function, leading to physical disability and sometimes pain, with the consequent lowering of quality of life. Early diagnosis improves clinical outcomes, but many patients still develop neuropathy. Hyperglycaemia is a risk factor and glycaemic control prevents DPN development in type 1 diabetes. However, glycaemic control has modest or no benefit in individuals with type 2 diabetes, probably because they usually have comorbidities. Among them, the metabolic syndrome is a major risk factor for DPN. The pathophysiology of DPN is complex, but mechanisms converge on a unifying theme of bioenergetic failure in the peripheral nerves due to their unique anatomy. Current clinical management focuses on controlling diabetes, the metabolic syndrome, and pain, but remains suboptimal for most patients. Thus, research is ongoing to improve early diagnosis and prognosis, to identify molecular mechanisms that could lead to therapeutic targets, and to investigate lifestyle interventions to improve clinical outcomes.
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Affiliation(s)
| | - Henning Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - David L Bennett
- Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, UK
| | | | - Vijay Viswanathan
- MV Hospital for Diabetes and Prof M Viswanathan Diabetes Research Centre, Royapuram, Chennai, India
| | | | - Eva L Feldman
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA.
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19
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Muthulingam JA, Brock C, Hansen TM, Drewes AM, Brock B, Frøkjær JB. Disrupted white matter integrity in the brain of type 1 diabetes is associated with peripheral neuropathy and abnormal brain metabolites. J Diabetes Complications 2022; 36:108267. [PMID: 35905510 DOI: 10.1016/j.jdiacomp.2022.108267] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 05/23/2022] [Accepted: 07/13/2022] [Indexed: 11/30/2022]
Abstract
AIMS We aimed to quantify microstructural white matter abnormalities using magnetic resonance imaging and examine their associations with 1) brain metabolite and volumes and 2) clinical diabetes-specific characteristics and complications in adults with type 1 diabetes mellitus (T1DM) and distal symmetric peripheral neuropathy (DSPN). METHODS Diffusion tensor images (DTI) obtained from 46 adults with T1DM and DSPN and 28 healthy controls were analyzed using tract-based spatial statistics and were then associated with 1) brain metabolites and volumes and 2) diabetes-specific clinical characteristics (incl. HbA1c, diabetes duration, level of retinopathy, nerve conduction assessment). RESULTS Adults with T1DM and DSPN had reduced whole-brain FA skeleton (P = 0.018), most prominently in the inferior longitudinal fasciculus and retrolenticular internal capsule (P < 0.001). Reduced fractional anisotropy (FA) was associated with lower parietal N-acetylaspartate/creatine metabolite ratio (r = 0.399, P = 0.006), brain volumes (P ≤ 0.002), diabetes duration (r = -0.495, P < 0.001) and sural nerve amplitude (r = 0.296, P = 0.046). Additionally, FA was reduced in the subgroup with concomitant proliferative retinopathy compared to non-proliferative retinopathy (P = 0.03). No association was observed between FA and HbA1c. CONCLUSIONS This hypothesis-generating study provided that altered white matter microstructural abnormalities in T1DM with DSPN were associated with reduced metabolites central for neuronal communications and diabetes complications, indicating that peripheral neuropathic complications are often accompanied by central neuropathy.
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Affiliation(s)
| | - Christina Brock
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Tine Maria Hansen
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Centre for Pancreatic Diseases, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Birgitte Brock
- Steno Diabetes Center Copenhagen, Niels Steensens Vej 2, 2820 Gentofte, Denmark
| | - Jens Brøndum Frøkjær
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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20
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Smith S, Normahani P, Lane T, Hohenschurz-Schmidt D, Oliver N, Davies AH. Pathogenesis of Distal Symmetrical Polyneuropathy in Diabetes. LIFE (BASEL, SWITZERLAND) 2022; 12:life12071074. [PMID: 35888162 PMCID: PMC9319251 DOI: 10.3390/life12071074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/11/2022] [Accepted: 07/13/2022] [Indexed: 12/13/2022]
Abstract
Distal symmetrical polyneuropathy (DSPN) is a serious complication of diabetes associated with significant disability and mortality. Although more than 50% of people with diabetes develop DSPN, its pathogenesis is still relatively unknown. This lack of understanding has limited the development of novel disease-modifying therapies and left the reasons for failed therapies uncertain, which is critical given that current management strategies often fail to achieve long-term efficacy. In this article, the pathogenesis of DSPN is reviewed, covering pathogenic changes in the peripheral nervous system, microvasculature and central nervous system (CNS). Furthermore, the successes and limitations of current therapies are discussed, and potential therapeutic targets are proposed. Recent findings on its pathogenesis have called the definition of DSPN into question and transformed the disease model, paving the way for new research prospects.
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Affiliation(s)
- Sasha Smith
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London W6 8RF, UK; (S.S.); (P.N.); (T.L.)
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London W6 8RF, UK
| | - Pasha Normahani
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London W6 8RF, UK; (S.S.); (P.N.); (T.L.)
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London W6 8RF, UK
| | - Tristan Lane
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London W6 8RF, UK; (S.S.); (P.N.); (T.L.)
- Department of Vascular Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - David Hohenschurz-Schmidt
- Pain Research Group, Department of Surgery and Cancer, Imperial College London, London SW10 9NH, UK;
| | - Nick Oliver
- Section of Metabolic Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W2 1PG, UK;
- Division of Medicine and Integrated Care, Imperial College Healthcare NHS Trust, London W2 1NY, UK
| | - Alun Huw Davies
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London W6 8RF, UK; (S.S.); (P.N.); (T.L.)
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London W6 8RF, UK
- Correspondence:
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21
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Croosu SS, Hansen TM, Røikjer J, Mørch CD, Ejskjaer N, Frøkjær JB. Gray Matter Brain Alterations in Type 1 Diabetes - Findings Based on Detailed Phenotyping of Neuropathy Status. Exp Clin Endocrinol Diabetes 2022; 130:730-739. [PMID: 35668671 DOI: 10.1055/a-1835-1877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS This study investigated brain structure in patients of type 1 diabetes with diabetic peripheral neuropathy (DPN) and type 1 diabetes with neuropathic pain and the associations to clinical, peripheral, and cognitive measurements. METHODS Sixty individuals with type 1 diabetes and 20 healthy controls were included in the study. Nineteen individuals with type 1 diabetes and neuropathic pain, 19 with type 1 diabetes and DPN, 18 with type 1 diabetes without DPN, and 20 healthy controls were included in the brain analyses. We utilized structural brain magnetic resonance imaging to investigate total and regional gray matter volume. RESULTS Significant lower gray matter volume was found in type 1 diabetes with neuropathic pain and in type 1 diabetes without DPN compared to healthy controls (p=0.024 and p=0.019, respectively). Lower insula volume was observed in all three diabetes groups (all p≤0.050). Thalamus and hippocampus volume was lower in type 1 diabetes with neuropathic pain, cerebellum volume was lower in type 1 diabetes with DPN, and somatosensory cortex volume was lower in type 1 diabetes without DPN (all p≤0.018). Attenuated memory was associated with lower gray matter volume in type 1 diabetes with DPN. No associations were found between gray matter volume and clinical/peripheral measurements. CONCLUSION We demonstrated lower gray matter volume in individuals with type 1 diabetes regardless of the presence of DPN and neuropathic pain. Hence, central gray matter alteration was not associated with peripheral alterations.
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Affiliation(s)
- Suganthiya S Croosu
- Department of Radiology, Aalborg University Hospital, Hobrovej Aalborg, Denmark.,Steno Diabetes Center North Denmark, Aalborg University Hospital, Mølleparkvej Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Søndre Skovvej Aalborg, Denmark
| | - Tine M Hansen
- Department of Radiology, Aalborg University Hospital, Hobrovej Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Søndre Skovvej Aalborg, Denmark
| | - Johan Røikjer
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Mølleparkvej Aalborg, Denmark.,Center for Neuroplasticity and Pain (CNAP), SMI, Department of Health Science and Technology, Aalborg University, Fredrik Bajers Vej Aalborg, Denmark
| | - Carsten D Mørch
- Center for Neuroplasticity and Pain (CNAP), SMI, Department of Health Science and Technology, Aalborg University, Fredrik Bajers Vej Aalborg, Denmark
| | - Niels Ejskjaer
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Mølleparkvej Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Søndre Skovvej Aalborg, Denmark.,Department of Endocrinology, Aalborg University Hospital, Mølleparkvej Aalborg, Denmark
| | - Jens B Frøkjær
- Department of Radiology, Aalborg University Hospital, Hobrovej Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Søndre Skovvej Aalborg, Denmark
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22
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Diaz MM, Caylor J, Strigo I, Lerman I, Henry B, Lopez E, Wallace MS, Ellis RJ, Simmons AN, Keltner JR. Toward Composite Pain Biomarkers of Neuropathic Pain-Focus on Peripheral Neuropathic Pain. FRONTIERS IN PAIN RESEARCH 2022; 3:869215. [PMID: 35634449 PMCID: PMC9130475 DOI: 10.3389/fpain.2022.869215] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/21/2022] [Indexed: 01/09/2023] Open
Abstract
Chronic pain affects ~10-20% of the U.S. population with an estimated annual cost of $600 billion, the most significant economic cost of any disease to-date. Neuropathic pain is a type of chronic pain that is particularly difficult to manage and leads to significant disability and poor quality of life. Pain biomarkers offer the possibility to develop objective pain-related indicators that may help diagnose, treat, and improve the understanding of neuropathic pain pathophysiology. We review neuropathic pain mechanisms related to opiates, inflammation, and endocannabinoids with the objective of identifying composite biomarkers of neuropathic pain. In the literature, pain biomarkers typically are divided into physiological non-imaging pain biomarkers and brain imaging pain biomarkers. We review both types of biomarker types with the goal of identifying composite pain biomarkers that may improve recognition and treatment of neuropathic pain.
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Affiliation(s)
- Monica M. Diaz
- Department of Neurology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States
| | - Jacob Caylor
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, United States
| | - Irina Strigo
- Department of Psychiatry, San Francisco Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
| | - Imanuel Lerman
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, United States
| | - Brook Henry
- Department of Psychiatry, University of California, San Diego, San Diego, CA, United States
| | - Eduardo Lopez
- Department of Psychiatry, San Francisco Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, United States
| | - Mark S. Wallace
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, United States
| | - Ronald J. Ellis
- Department of Neurosciences, University of California, San Diego, San Diego, CA, United States
| | - Alan N. Simmons
- Department of Psychiatry, San Diego & Center of Excellence in Stress and Mental Health, Veteran Affairs Health Care System, University of California, San Diego, San Diego, CA, United States
| | - John R. Keltner
- Department of Psychiatry, San Diego & San Diego VA Medical Center, University of California, San Diego, San Diego, CA, United States
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23
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Chitneni A, Rupp A, Ghorayeb J, Abd-Elsayed A. Early Detection of Diabetic Peripheral Neuropathy by fMRI: An Evidence-Based Review. Brain Sci 2022; 12:brainsci12050557. [PMID: 35624944 PMCID: PMC9139132 DOI: 10.3390/brainsci12050557] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 04/24/2022] [Accepted: 04/26/2022] [Indexed: 01/13/2023] Open
Abstract
With the significant rise in the prevalence of diabetes worldwide, diabetic peripheral neuropathy (DPN) remains the most common complication among type 1 and 2 diabetics. The adverse sequelae of DPN, which include neuropathic pain, diabetic foot ulcers and lower-limb amputations, significantly impact quality of life and are major contributors to the biopsychosocial and economic burden of diabetes at the individual, societal and health system levels. Because DPN is often diagnosed in the late stages of disease progression by electromyography (EMG), and neuropathic pain as a result of DPN is difficult to treat, the need for earlier detection is crucial to better ascertain and manage the condition. Among the various modalities available to aid in the early detection of DPN, functional magnetic resonance imaging (fMRI) has emerged as a practical tool in DPN imaging due to its noninvasive radiation-free nature and its ability to relate real-time functional changes reflecting the local oxygen consumption of regions of the CNS due to external stimuli. This review aims to summarize the current body of knowledge regarding the utility of fMRI in detecting DPN by observing central nervous system (CNS) activity changes among individuals with DPN when compared to controls. The evidence to date points toward a tendency for increased activity in various central neuroanatomical structures that can be detected by fMRI and positively correlates with diabetic neuropathic pain.
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Affiliation(s)
- Ahish Chitneni
- Department of Rehabilitation and Regenerative Medicine, NewYork-Presbyterian Hospital—Columbia and Cornell, New York, NY 10065, USA
- Correspondence: (A.C.); (A.A.-E.); Tel.: +1-608-263-6039 (A.A.-E.)
| | - Adam Rupp
- Department of Physical Medicine and Rehabilitation, University of Kansas Health System, Kansas City, MO 66160, USA;
| | - Joe Ghorayeb
- Department of Physical Medicine and Rehabilitation, University of Medicine & Health Sciences, New York, NY 10001, USA;
| | - Alaa Abd-Elsayed
- Department of Anesthesia, Division of Pain Medicine, School of Medicine & Public Health, University of Wisconsin, Madison, WI 53726, USA
- Correspondence: (A.C.); (A.A.-E.); Tel.: +1-608-263-6039 (A.A.-E.)
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24
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Königs V, Pierre S, Schicht M, Welss J, Hahnefeld L, Rimola V, Lütjen-Drecoll E, Geisslinger G, Scholich K. GPR40 Activation Abolishes Diabetes-Induced Painful Neuropathy by Suppressing VEGF-A Expression. Diabetes 2022; 71:774-787. [PMID: 35061031 DOI: 10.2337/db21-0711] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 01/11/2022] [Indexed: 11/13/2022]
Abstract
G-protein-coupled receptor 40 (GPR40) is a promising target to support glucose-induced insulin release in patients with type 2 diabetes. We studied the role of GPR40 in the regulation of blood-nerve barrier integrity and its involvement in diabetes-induced neuropathies. Because GPR40 modulates insulin release, we used the streptozotocin model for type 1 diabetes, in which GPR40 functions can be investigated independently of its effects on insulin release. Diabetic wild-type mice exhibited increased vascular endothelial permeability and showed epineural microlesions in sciatic nerves, which were also observed in naïve GPR40-/- mice. Fittingly, expression of vascular endothelial growth factor-A (VEGF-A), an inducer of vascular permeability, was increased in diabetic wild-type and naïve GPR40-/- mice. GPR40 antagonists increased VEGF-A expression in murine and human endothelial cells as well as permeability of transendothelial barriers. In contrast, GPR40 agonists suppressed VEGF-A release and mRNA expression. The VEGF receptor inhibitor axitinib prevented diabetes-induced hypersensitivities and reduced endothelial and epineural permeability. Importantly, the GPR40 agonist GW9508 reverted established diabetes-induced hypersensitivity, an effect that was blocked by VEGF-A administration. Thus, GPR40 activation suppresses VEGF-A expression, thereby reducing diabetes-induced blood-nerve barrier permeability and reverting diabetes-induced hypersensitivities.
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Affiliation(s)
- Vanessa Königs
- Fraunhofer Institute for Translational Medicine and Pharmacology, Frankfurt am Main, Germany
- Fraunhofer Cluster of Excellence for Immune-Mediated Diseases, Frankfurt am Main, Germany
| | - Sandra Pierre
- Institute of Clinical Pharmacology, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Martin Schicht
- Institute of Functional and Clinical Anatomy, Friedrich Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Jessica Welss
- Institute of Functional and Clinical Anatomy, Friedrich Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Lisa Hahnefeld
- Fraunhofer Institute for Translational Medicine and Pharmacology, Frankfurt am Main, Germany
- Fraunhofer Cluster of Excellence for Immune-Mediated Diseases, Frankfurt am Main, Germany
- Institute of Clinical Pharmacology, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Vittoria Rimola
- Institute of Clinical Pharmacology, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Elke Lütjen-Drecoll
- Institute of Functional and Clinical Anatomy, Friedrich Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Gerd Geisslinger
- Fraunhofer Institute for Translational Medicine and Pharmacology, Frankfurt am Main, Germany
- Fraunhofer Cluster of Excellence for Immune-Mediated Diseases, Frankfurt am Main, Germany
- Institute of Clinical Pharmacology, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Klaus Scholich
- Fraunhofer Institute for Translational Medicine and Pharmacology, Frankfurt am Main, Germany
- Fraunhofer Cluster of Excellence for Immune-Mediated Diseases, Frankfurt am Main, Germany
- Institute of Clinical Pharmacology, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Germany
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25
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Croosu SS, Hansen TM, Brock B, Mohr Drewes A, Brock C, Frøkjær JB. Altered functional connectivity between brain structures in adults with type 1 diabetes and polyneuropathy. Brain Res 2022; 1784:147882. [DOI: 10.1016/j.brainres.2022.147882] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 01/17/2022] [Accepted: 03/09/2022] [Indexed: 12/13/2022]
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26
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Chao CC, Tseng MT, Hsieh PC, Lin CHJ, Huang SL, Hsieh ST, Chiang MC. Brain Mechanisms of Pain and Dysautonomia in Diabetic Neuropathy: Connectivity Changes in Thalamus and Hypothalamus. J Clin Endocrinol Metab 2022; 107:e1167-e1180. [PMID: 34665863 DOI: 10.1210/clinem/dgab754] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT About one-third of diabetic patients suffer from neuropathic pain, which is poorly responsive to analgesic therapy and associated with greater autonomic dysfunction. Previous research on diabetic neuropathy mainly links pain and autonomic dysfunction to peripheral nerve degeneration resulting from systemic metabolic disturbances, but maladaptive plasticity in the central pain and autonomic systems following peripheral nerve injury has been relatively ignored. OBJECTIVE This study aimed to investigate how the brain is affected in painful diabetic neuropathy (PDN), in terms of altered structural connectivity (SC) of the thalamus and hypothalamus that are key regions modulating nociceptive and autonomic responses. METHODS We recruited 25 PDN and 13 painless (PLDN) diabetic neuropathy patients, and 27 healthy adults as controls. The SC of the thalamus and hypothalamus with limbic regions mediating nociceptive and autonomic responses was assessed using diffusion tractography. RESULTS The PDN patients had significantly lower thalamic and hypothalamic SC of the right amygdala compared with the PLDN and control groups. In addition, lower thalamic SC of the insula was associated with more severe peripheral nerve degeneration, and lower hypothalamic SC of the anterior cingulate cortex was associated with greater autonomic dysfunction manifested by decreased heart rate variability. CONCLUSION Our findings indicate that alterations in brain structural connectivity could be a form of maladaptive plasticity after peripheral nerve injury, and also demonstrate a pathophysiological association between disconnection of the limbic circuitry and pain and autonomic dysfunction in diabetes.
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Affiliation(s)
- Chi-Chao Chao
- Department of Neurology, National Taiwan University Hospital, Taipei 10002, Taiwan
| | - Ming-Tsung Tseng
- Graduate Institute of Brain and Mind Sciences, National Taiwan University College of Medicine, Taipei 10617, Taiwan
| | - Paul-Chen Hsieh
- Department of Dermatology, National Taiwan University Hospital, Taipei 10002, Taiwan
| | - Chien-Ho Janice Lin
- Department of Physical Therapy and Assistive Technology, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Yeong-An Orthopedic and Physical Therapy Clinic, Taipei 11155, Taiwan
| | - Shin-Leh Huang
- Department of Biomedical Engineering, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Department of Neurology, Fu Jen Catholic University Hospital, New Taipei City 24352, Taiwan
| | - Sung-Tsang Hsieh
- Department of Neurology, National Taiwan University Hospital, Taipei 10002, Taiwan
- Department of Anatomy and Cell Biology, National Taiwan University College of Medicine, Taipei 10617, Taiwan
- Center of Precision Medicine, National Taiwan University College of Medicine, Taipei 10617, Taiwan
| | - Ming-Chang Chiang
- Department of Biomedical Engineering, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
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27
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Ising E, Ekman L, Elding Larsson H, Dahlin LB. Vibrotactile sense might improve over time in paediatric subjects with type 1 diabetes-A mid-term follow-up using multifrequency vibrometry. Acta Paediatr 2022; 111:411-417. [PMID: 34564903 DOI: 10.1111/apa.16124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/20/2021] [Accepted: 09/23/2021] [Indexed: 12/26/2022]
Abstract
AIM Impaired vibrotactile sense, mirroring diabetic peripheral neuropathy, is present among children and adolescents with type 1 diabetes. This study aims to re-examine the vibrotactile sense of paediatric type 1 diabetes subjects in order to evaluate any alterations in the vibrotactile sense over time. METHODS A VibroSense Meter I device was used to determine the vibrotactile perception thresholds (VPTs) for seven frequencies from the pulp of index and little fingers and for five frequencies from metatarsal heads one and five on the sole of the foot, of 37 children and adolescents with type 1 diabetes, previously examined in a larger cohort. Subjects were followed up after a median time of 30 months. Z-scores of VPTs were calculated using previously collected normative data. RESULTS Vibrotactile perception thresholds improved over time at low frequencies (especially 16 Hz) on the foot, while not being statistically significant different on the rest of the frequencies, either on hand or foot. VPTs were not correlated with HbA1c. CONCLUSION A mid-term follow-up of vibrotactile sense in paediatric subjects with type 1 diabetes shows a conceivable normalization of previously impaired vibrotactile sense on some frequencies on the foot, indicating that vibrotactile sense might fluctuate over time.
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Affiliation(s)
- Erik Ising
- Department of Clinical Sciences ‐ Paediatric Endocrinology Lund University Malmö Sweden
- Department of Emergency and Internal Medicine Skåne University Hospital Malmö Sweden
| | - Linnéa Ekman
- Department of Translational Medicine ‐ Hand Surgery Lund University Malmö Sweden
| | - Helena Elding Larsson
- Department of Clinical Sciences ‐ Paediatric Endocrinology Lund University Malmö Sweden
- Department of Paediatrics Skåne University Hospital Malmö Sweden
| | - Lars B. Dahlin
- Department of Translational Medicine ‐ Hand Surgery Lund University Malmö Sweden
- Department of Hand Surgery Skåne University Hospital Malmö Sweden
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28
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Abstract
Diabetic painless and painful peripheral neuropathy remains the most frequent complication of diabetes mellitus, but the pathophysiology remains undescribed, there are no robust clinical endpoints and no efficient treatment exists. This hampers good clinical practice, fruitful clinical research and successful pharmacological trials, necessary for the development of early detection, prevention and treatment. This chapter supplies an update on background and treatment of diabetic peripheral neuropathy. Goals and perspectives for future clinical and scientific approaches are also described.
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Affiliation(s)
- Johan Røikjer
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
- Faculty of Health Science and Technology, Aalborg University, Aalborg, Denmark
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Niels Ejskjaer
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark.
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark.
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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29
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Fan Q, Gordon Smith A. Recent updates in the treatment of diabetic polyneuropathy. Fac Rev 2022. [PMID: 36311537 DOI: 10.1270/r/11-30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023] Open
Abstract
Distal symmetric diabetic peripheral polyneuropathy (DPN) is the most common form of neuropathy in the world, affecting 30 to 50% of diabetic individuals and resulting in significant morbidity and socioeconomic costs. This review summarizes updates in the diagnosis and management of DPN. Recently updated clinical criteria facilitate bedside diagnosis, and a number of new technologies are being explored for diagnostic confirmation in specific settings and for use as surrogate measures in clinical trials. Evolving literature indicates that distinct but overlapping mechanisms underlie neuropathy in type 1 versus type 2 diabetes, and there is a growing focus on the role of metabolic factors in the development and progression of DPN. Exercise-based lifestyle interventions have shown therapeutic promise. A variety of potential disease-modifying and symptomatic therapies are in development. Innovations in clinical trial design include the incorporation of detailed pain phenotyping and biomarkers for central sensitization.
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Affiliation(s)
- Qihua Fan
- Department of Neurology, Division of Neuromuscular Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - A Gordon Smith
- Department of Neurology, Division of Neuromuscular Medicine, Virginia Commonwealth University, Richmond, VA, USA
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30
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Sloan G, Alam U, Selvarajah D, Tesfaye S. The Treatment of Painful Diabetic Neuropathy. Curr Diabetes Rev 2022; 18:e070721194556. [PMID: 34238163 DOI: 10.2174/1573399817666210707112413] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/18/2021] [Accepted: 03/08/2021] [Indexed: 11/22/2022]
Abstract
Painful diabetic peripheral neuropathy (painful-DPN) is a highly prevalent and disabling condition, affecting up to one-third of patients with diabetes. This condition can have a profound impact resulting in a poor quality of life, disruption of employment, impaired sleep, and poor mental health with an excess of depression and anxiety. The management of painful-DPN poses a great challenge. Unfortunately, currently there are no Food and Drug Administration (USA) approved disease-modifying treatments for diabetic peripheral neuropathy (DPN) as trials of putative pathogenetic treatments have failed at phase 3 clinical trial stage. Therefore, the focus of managing painful- DPN other than improving glycaemic control and cardiovascular risk factor modification is treating symptoms. The recommended treatments based on expert international consensus for painful- DPN have remained essentially unchanged for the last decade. Both the serotonin re-uptake inhibitor (SNRI) duloxetine and α2δ ligand pregabalin have the most robust evidence for treating painful-DPN. The weak opioids (e.g. tapentadol and tramadol, both of which have an SNRI effect), tricyclic antidepressants such as amitriptyline and α2δ ligand gabapentin are also widely recommended and prescribed agents. Opioids (except tramadol and tapentadol), should be prescribed with caution in view of the lack of definitive data surrounding efficacy, concerns surrounding addiction and adverse events. Recently, emerging therapies have gained local licenses, including the α2δ ligand mirogabalin (Japan) and the high dose 8% capsaicin patch (FDA and Europe). The management of refractory painful-DPN is difficult; specialist pain services may offer off-label therapies (e.g. botulinum toxin, intravenous lidocaine and spinal cord stimulation), although there is limited clinical trial evidence supporting their use. Additionally, despite combination therapy being commonly used clinically, there is little evidence supporting this practise. There is a need for further clinical trials to assess novel therapeutic agents, optimal combination therapy and existing agents to determine which are the most effective for the treatment of painful-DPN. This article reviews the evidence for the treatment of painful-DPN, including emerging treatment strategies such as novel compounds and stratification of patients according to individual characteristics (e.g. pain phenotype, neuroimaging and genotype) to improve treatment responses.
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Affiliation(s)
- Gordon Sloan
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
| | - Uazman Alam
- Department of Cardiovascular and Metabolic Medicine and the Pain Research Institute, Institute of Life Course and Medical Sciences, University of Liverpool, and Liverpool University Hospital, NHS Foundation Trust, Liverpool, UK
- Division of Diabetes, Endocrinology and Gastroenterology, Institute of Human Development, University of Manchester, Manchester, UK
| | - Dinesh Selvarajah
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
- Department of Oncology and Human Metabolism, University of Sheffield, Sheffield, UK
| | - Solomon Tesfaye
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
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Reduced gray matter brain volume and cortical thickness in adults with type 1 diabetes and neuropathy. Neurosci Res 2021; 176:66-72. [PMID: 34656646 DOI: 10.1016/j.neures.2021.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 09/11/2021] [Accepted: 10/10/2021] [Indexed: 01/13/2023]
Abstract
In this study we investigated brain morphology in adults with diabetic neuropathy. We aimed to characterize gray matter volume (GMV) and cortical thickness, and to explore associations between whole brain morphology and clinical characteristics. 46 adults with type 1 diabetes and distal symmetric peripheral neuropathy (DSPN) and 28 healthy controls underwent magnetic resonance imaging scans. GMV and cortical thickness were estimated using voxel-/surface-based morphometry. Associations between total GMV and clinical characteristics were explored. Adults with DSPN had reduced total GMV compared with controls (627.4 ± 4.1 mL vs. 642.5 ± 5.2 mL, P = 0.026). GMV loss was more pronounced for participants with painful neuropathy compared with controls (619.1±8.9 mL vs. 642.4±5.2 mL, P = 0.026) and for those with proliferative vs. non-proliferative retinopathy (609.9 ± 6.8 mL vs. 636.0 ± 4.7 mL, P = 0.003). Characteristics such as severity of neuropathy and decreased parietal N-acetylaspartate/creatine metabolite concentration seem to be related to GMV loss in this cohort. Regional GMV loss was confined to bilateral thalamus/putamen/caudate, occipital and precentral regions, and decreased cortical thickness was identified in frontal areas. Since the observed total GMV loss influenced with clinical characteristics, brain imaging could be useful for supplementary characterization of diabetic neuropathy. The regional brain changes could suggest that some areas are more vulnerable in this cohort.
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Kalteniece A, Ferdousi M, Azmi S, Khan SU, Worthington A, Marshall A, Faber CG, Lauria G, Boulton AJM, Soran H, Malik RA. Corneal nerve loss is related to the severity of painful diabetic neuropathy. Eur J Neurol 2021; 29:286-294. [PMID: 34570924 PMCID: PMC9292015 DOI: 10.1111/ene.15129] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/26/2021] [Indexed: 12/17/2022]
Abstract
Background and purpose Previously it has been shown that patients with painful diabetic neuropathy (PDN) have greater corneal nerve loss compared to patients with painless diabetic neuropathy. This study investigated if the severity of corneal nerve loss was related to the severity of PDN. Methods Participants with diabetic neuropathy (n = 118) and healthy controls (n = 38) underwent clinical and neurological evaluation, quantitative sensory testing, nerve conduction testing and corneal confocal microscopy and were categorized into those with no (n = 43), mild (n = 34) and moderate‐to‐severe (n = 41) neuropathic pain. Results Corneal nerve fibre density (p = 0.003), corneal nerve fibre length (p < 0.0001) and cold perception threshold (p < 0.0001) were lower and warm perception threshold was higher (p = 0.002) in patients with more severe pain, but there was no significant difference in the neuropathy disability score (p = 0.5), vibration perception threshold (p = 0.5), sural nerve conduction velocity (p = 0.3) and amplitude (p = 0.7), corneal nerve branch density (p = 0.06) and deep breathing heart rate variability (p = 0.08) between patients with differing severity of PDN. The visual analogue scale correlated significantly with corneal nerve fibre density (r = −0.3, p = 0.0002), corneal nerve branch density (r = −0.3, p = 0.001) and corneal nerve fibre length (r = −0.4, p < 0.0001). Receiver operating curve analysis showed that corneal nerve fibre density had an area under the curve of 0.78 with a sensitivity of 0.73 and specificity of 0.72 for the diagnosis of PDN. Conclusions Corneal confocal microscopy reveals increasing corneal nerve fibre loss with increasing severity of neuropathic pain and a good diagnostic outcome for identifying patients with PDN.
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Affiliation(s)
- Alise Kalteniece
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, UK
| | - Maryam Ferdousi
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, UK
| | - Shazli Azmi
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, UK
| | - Saif Ullah Khan
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, UK
| | - Anne Worthington
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, UK
| | - Andrew Marshall
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Catharina G Faber
- Department of Neurology, School of Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Giuseppe Lauria
- Neuroalgology Unit and Skin Biopsy, Peripheral Neuropathy and Neuropathic Pain Centre, IRCCS Foundation 'Carlo Besta' Neurological Institute, Milan, Italy
| | - Andrew J M Boulton
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, UK
| | - Handrean Soran
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, UK
| | - Rayaz A Malik
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, UK.,Research Division, Qatar Foundation, Weill Cornell Medicine-Qatar, Education City, Qatar
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Nedergaard RB, Nissen TD, Mørch CD, Meldgaard T, Juhl AH, Jakobsen PE, Karmisholt J, Brock B, Drewes AM, Brock C. Diabetic Neuropathy Influences Control of Spinal Mechanisms. J Clin Neurophysiol 2021; 38:299-305. [PMID: 32501945 DOI: 10.1097/wnp.0000000000000691] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Comprehensive evaluation of the upstream sensory processing in diabetic symmetrical polyneuropathy (DSPN) is sparse. The authors investigated the spinal nociceptive withdrawal reflex and the related elicited somatosensory evoked cortical potentials. They hypothesized that DSPN induces alterations in spinal and supraspinal sensory-motor processing compared with age- and gender-matched healthy controls. METHODS In this study, 48 patients with type 1 diabetes and DSPN were compared with 21 healthy controls. Perception and reflex thresholds were determined and subjects received electrical stimulations on the plantar site of the foot at three stimulation intensities to evoke a nociceptive withdrawal reflex. Electromyogram and EEG were recorded for analysis. RESULTS Patients with DSPN had higher perception (P < 0.001) and reflex (P = 0.012) thresholds. Fewer patients completed the recording session compared with healthy controls (34/48 vs. 21/21; P = 0.004). Diabetic symmetrical polyneuropathy reduced the odds ratio of a successful elicited nociceptive withdrawal reflex (odds ratio = 0.045; P = 0.014). Diabetic symmetrical polyneuropathy changed the evoked potentials (F = 2.86; P = 0.025), and post hoc test revealed reduction of amplitude (-3.72 mV; P = 0.021) and prolonged latencies (15.1 ms; P = 0.013) of the N1 peak. CONCLUSIONS The study revealed that patients with type 1 diabetes and DSPN have significantly changed spinal and supraspinal processing of the somatosensory input. This implies that DSPN induces widespread differences in the central nervous system processing of afferent A-δ and A-β fiber input. These differences in processing may potentially lead to identification of subgroups with different stages of small fiber neuropathy and ultimately differentiated treatments.
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Affiliation(s)
- Rasmus Bach Nedergaard
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Thomas Dahl Nissen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Carsten Dahl Mørch
- Department of Health Science and Technology, Center for Neuroplasticity and Pain, SMI, School of Medicine, Aalborg University, Aalborg, Denmark
| | - Theresa Meldgaard
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Anne H Juhl
- Department of Neurophysiology, Aalborg University Hospital, Aalborg, Denmark
| | - Poul Erik Jakobsen
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Jutland, Region Nordjylland, Denmark ; and
| | - Jesper Karmisholt
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Birgitte Brock
- Steno Diabetes Center Copenhagen, Region Hovedstaden, Gentofte, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Steno Diabetes Center North Jutland, Region Nordjylland, Denmark ; and
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Sloan G, Selvarajah D, Tesfaye S. Pathogenesis, diagnosis and clinical management of diabetic sensorimotor peripheral neuropathy. Nat Rev Endocrinol 2021; 17:400-420. [PMID: 34050323 DOI: 10.1038/s41574-021-00496-z] [Citation(s) in RCA: 158] [Impact Index Per Article: 52.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 02/08/2023]
Abstract
Diabetic sensorimotor peripheral neuropathy (DSPN) is a serious complication of diabetes mellitus and is associated with increased mortality, lower-limb amputations and distressing painful neuropathic symptoms (painful DSPN). Our understanding of the pathophysiology of the disease has largely been derived from animal models, which have identified key potential mechanisms. However, effective therapies in preclinical models have not translated into clinical trials and we have no universally accepted disease-modifying treatments. Moreover, the condition is generally diagnosed late when irreversible nerve damage has already taken place. Innovative point-of-care devices have great potential to enable the early diagnosis of DSPN when the condition might be more amenable to treatment. The management of painful DSPN remains less than optimal; however, studies suggest that a mechanism-based approach might offer an enhanced benefit in certain pain phenotypes. The management of patients with DSPN involves the control of individualized cardiometabolic targets, a multidisciplinary approach aimed at the prevention and management of foot complications, and the timely diagnosis and management of neuropathic pain. Here, we discuss the latest advances in the mechanisms of DSPN and painful DSPN, originating both from the periphery and the central nervous system, as well as the emerging diagnostics and treatments.
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Affiliation(s)
- Gordon Sloan
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Dinesh Selvarajah
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Oncology and Human Metabolism, University of Sheffield, Sheffield, UK
| | - Solomon Tesfaye
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
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Teh K, Wilkinson ID, Heiberg-Gibbons F, Awadh M, Kelsall A, Pallai S, Sloan G, Tesfaye S, Selvarajah D. Somatosensory network functional connectivity differentiates clinical pain phenotypes in diabetic neuropathy. Diabetologia 2021; 64:1412-1421. [PMID: 33768284 PMCID: PMC8099810 DOI: 10.1007/s00125-021-05416-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 01/04/2021] [Indexed: 01/25/2023]
Abstract
AIMS/HYPOTHESIS The aim of this work was to investigate whether different clinical pain phenotypes of diabetic polyneuropathy (DPN) are distinguished by functional connectivity at rest. METHODS This was an observational, cohort study of 43 individuals with painful DPN, divided into irritable (IR, n = 10) and non-irritable (NIR, n = 33) nociceptor phenotypes using the German Research Network of Neuropathic Pain quantitative sensory testing protocol. In-situ brain MRI included 3D T1-weighted anatomical and 6 min resting-state functional MRI scans. Subgroup differences in resting-state functional connectivity in brain regions involved with somatic (thalamus, primary somatosensory cortex, motor cortex) and non-somatic (insular and anterior cingulate cortices) pain processing were examined. Multidimensional reduction of MRI datasets was performed using a machine-learning approach to classify individuals into each clinical pain phenotype. RESULTS Individuals with the IR nociceptor phenotype had significantly greater thalamic-insular cortex (p false discovery rate [FDR] = 0.03) and reduced thalamus-somatosensory cortex functional connectivity (p-FDR = 0.03). We observed a double dissociation such that self-reported neuropathic pain score was more associated with greater thalamus-insular cortex functional connectivity (r = 0.41; p = 0.01) whereas more severe nerve function deficits were more related to lower thalamus-somatosensory cortex functional connectivity (r = -0.35; p = 0.03). Machine-learning group classification performance to identify individuals with the NIR nociceptor phenotype achieved an accuracy of 0.92 (95% CI 0.08) and sensitivity of 90%. CONCLUSIONS/INTERPRETATION This study demonstrates differences in functional connectivity in nociceptive processing brain regions between IR and NIR phenotypes in painful DPN. We also establish proof of concept for the utility of multimodal MRI as a biomarker for painful DPN by using a machine-learning approach to classify individuals into sensory phenotypes.
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Affiliation(s)
- Kevin Teh
- Academic Department of Magnetic Resonance Imaging, University of Sheffield, Sheffield, UK
| | - Iain D Wilkinson
- Academic Department of Magnetic Resonance Imaging, University of Sheffield, Sheffield, UK
| | | | - Mohammed Awadh
- Department of Oncology and Human Metabolism, University of Sheffield, Sheffield, UK
| | - Alan Kelsall
- Diabetes Research Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Shillo Pallai
- Diabetes Research Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Gordon Sloan
- Diabetes Research Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Solomon Tesfaye
- Diabetes Research Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Dinesh Selvarajah
- Department of Oncology and Human Metabolism, University of Sheffield, Sheffield, UK.
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Brain imaging signature of neuropathic pain phenotypes in small-fiber neuropathy: altered thalamic connectome and its associations with skin nerve degeneration. Pain 2021; 162:1387-1399. [PMID: 33239524 DOI: 10.1097/j.pain.0000000000002155] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 11/18/2020] [Indexed: 12/12/2022]
Abstract
ABSTRACT Small-fiber neuropathy (SFN) has been traditionally considered as a pure disorder of the peripheral nervous system, characterized by neuropathic pain and degeneration of small-diameter nerve fibers in the skin. Previous functional magnetic resonance imaging studies revealed abnormal activations of pain networks, but the structural basis underlying such maladaptive functional alterations remains elusive. We applied diffusion tensor imaging to explore the influences of SFN on brain microstructures. Forty-one patients with pathology-proven SFN with reduced skin innervation were recruited. White matter connectivity with the thalamus as the seed was assessed using probabilistic tractography of diffusion tensor imaging. Patients with SFN had reduced thalamic connectivity with the insular cortex and the sensorimotor areas, including the postcentral and precentral gyri. Furthermore, the degree of skin nerve degeneration, measured by intraepidermal nerve fiber density, was associated with the reduction of connectivity between the thalamus and pain-related areas according to different neuropathic pain phenotypes, specifically, the frontal, cingulate, motor, and limbic areas for burning, electrical shocks, tingling, mechanical allodynia, and numbness. Despite altered white matter connectivity, there was no change in white matter integrity assessed with fractional anisotropy. Our findings indicate that alterations in structural connectivity may serve as a biomarker of maladaptive brain plasticity that contributes to neuropathic pain after peripheral nerve degeneration.
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Fang F, Luo Q, Ge RB, Lai MY, Gong YJ, Kang M, Ma MM, Zhang L, Li Y, Wang YF, Peng YD. Decreased Microstructural Integrity of the Central Somatosensory Tracts in Diabetic Peripheral Neuropathy. J Clin Endocrinol Metab 2021; 106:1566-1575. [PMID: 33711158 DOI: 10.1210/clinem/dgab158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Although diabetic peripheral neuropathy (DPN) is predominantly considered a disorder of the peripheral nerves, some evidence for central nervous system involvement has recently emerged. However, whether or to what extent the microstructure of central somatosensory tracts may be injured remains unknown. OBJECTIVE This work aimed to detect the microstructure of central somatosensory tracts in type 2 diabetic patients and to correlate it with the severity of DPN. METHODS A case-control study at a tertiary referral hospital took place with 57 individuals with type 2 diabetes (25 with DPN, 32 without DPN) and 33 nondiabetic controls. The fractional anisotropy (FA) values of 2 major somatosensory tracts (the spinothalamic tract and its thalamocortical [spino-thalamo-cortical, STC] pathway, the medial lemniscus and its thalamocortical [medial lemnisco-thalamo-cortical, MLTC] pathway) were assessed based on diffusion tensor tractography. Regression models were further applied to detect the association of FA values with the severity of DPN in diabetic patients. RESULTS The mean FA values of left STC and left MLTC pathways were significantly lower in patients with DPN than those without DPN and controls. Moreover, FA values of left STC and left MLTC pathways were significantly associated with the severity of DPN (expressed as Toronto Clinical Scoring System values) in patients after adjusting for multiple confounders. CONCLUSION Our findings demonstrated the axonal degeneration of central somatosensory tracts in type 2 diabetic patients with DPN. The parallel disease progression of the intracranial and extracranial somatosensory system merits further attention to the central nerves in diabetic patients with DPN.
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Affiliation(s)
- Fang Fang
- Department of Endocrinology and Metabolism, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Qian Luo
- Department of Radiology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ren-Bin Ge
- Department of Radiology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Meng-Yu Lai
- Department of Endocrinology and Metabolism, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yu-Jia Gong
- Department of Endocrinology and Metabolism, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Mei Kang
- Clinical Research Center, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ming-Ming Ma
- Department of Ophthalmology, National Clinical Research Center for Eye Disease, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Lei Zhang
- Department of Radiology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yao Li
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Yu-Fan Wang
- Department of Endocrinology and Metabolism, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yong-De Peng
- Department of Endocrinology and Metabolism, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
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Marshall A, Alam U, Themistocleous A, Calcutt N, Marshall A. Novel and Emerging Electrophysiological Biomarkers of Diabetic Neuropathy and Painful Diabetic Neuropathy. Clin Ther 2021; 43:1441-1456. [PMID: 33906790 DOI: 10.1016/j.clinthera.2021.03.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 03/26/2021] [Accepted: 03/27/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE Diabetic peripheral neuropathy (DPN) is the most common complication of diabetes. Small and large peripheral nerve fibers can be involved in DPN. Large nerve fiber damage causes paresthesia, sensory loss, and muscle weakness, and small nerve fiber damage is associated with pain, anesthesia, foot ulcer, and autonomic symptoms. Treatments for DPN and painful DPN (pDPN) pose considerable challenges due to the lack of effective therapies. To meet these challenges, there is a major need to develop biomarkers that can reliably diagnose and monitor progression of nerve damage and, for pDPN, facilitate personalized treatment based on underlying pain mechanisms. METHODS This study involved a comprehensive literature review, incorporating article searches in electronic databases (Google Scholar, PubMed, and OVID) and reference lists of relevant articles with the authors' substantial expertise in DPN. This review considered seminal and novel research and summarizes emerging biomarkers of DPN and pDPN that are based on neurophysiological methods. FINDINGS From the evidence gathered from 145 papers, this submission describes emerging clinical neurophysiological methods with potential to act as biomarkers for the diagnosis and monitoring of DPN as well as putative future roles as predictors of response to antineuropathic pain medication in pDPN. Nerve conduction studies only detect large fiber damage and do not capture pathology or dysfunction of small fibers. Because small nerve fiber damage is prominent in DPN, additional biomarkers of small nerve fiber function are needed. Activation of peripheral nociceptor fibers using laser, heat, or targeted electrical stimuli can generate pain-related evoked potentials, which are an objective neurophysiological measure of damage along the small fiber pathways. Assessment of nerve excitability, which provides a surrogate of axonal properties, may detect alterations in function before abnormalities are detected by nerve conduction studies. Microneurography and rate-dependent depression of the Hoffmann-reflex can be used to dissect underlying pain-generating mechanisms arising from the periphery and spinal cord, respectively. Their role in informing mechanistic-based treatment of pDPN as well as facilitating clinical trials design is discussed. IMPLICATIONS The neurophysiological methods discussed, although currently not practical for use in busy outpatient settings, detect small fiber and early large fiber damage in DPN as well as disclosing dominant pain mechanisms in pDPN. They are suited as diagnostic and predictive biomarkers as well as end points in mechanistic clinical trials of DPN and pDPN.
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Affiliation(s)
- Anne Marshall
- Musculoskeletal Biology, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom; Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Uazman Alam
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Andreas Themistocleous
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom; Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nigel Calcutt
- Department of Pathology, University of California, San Diego, La Jolla, California
| | - Andrew Marshall
- Musculoskeletal Biology, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom; Department of Clinical Neurophysiology, The Walton Centre, Liverpool, United Kingdom; Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom.
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Nagpal AS, Leet J, Egan K, Garza R. Diabetic Neuropathy: a Critical, Narrative Review of Published Data from 2019. Curr Pain Headache Rep 2021; 25:15. [PMID: 33630186 DOI: 10.1007/s11916-020-00928-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2020] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW This manuscript is a systematic, narrative review that compiles and describes all data available from 2019 related to epidemiologic, diagnostic, and therapeutic advances in diabetic neuropathy (DN). RECENT FINDINGS Epidemiology of DN is discussed. Diagnostic modalities include predictive models, electrodiagnostics, imaging, and biomarkers. A majority of studies on the treatment of diabetic peripheral neuropathy (DPN) involve pharmacotherapy, but complementary and alternative medicine, exercise, modalities, psychological, interventional, and surgical options are also explored. DN is a highly prevalent and debilitating consequence of diabetes that can present challenges to the clinician as the assessment is largely subjective with different phenotypic presentations among patients. Treatment of DN is largely symptomatic as the pathogenesis of DN is not fully understood and is likely multifactorial. It is evident from the broad range of treatments that too often provide unsatisfactory relief that there is no consensus about a single most effective treatment for DN, and monotherapy rarely proves to be successful.
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Affiliation(s)
- Ameet S Nagpal
- Department of Anesthesiology, Joe R. & Thereza Lozano Long School of Medicine, UT Health San Antonio, San Antonio, TX, USA.
| | - Jennifer Leet
- Department of Rehabilitation Medicine, Joe R. & Theresa Lozano Long School of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - Kaitlyn Egan
- Department of Rehabilitation Medicine, Joe R. & Theresa Lozano Long School of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - Rudy Garza
- Department of Anesthesiology, Joe R. & Thereza Lozano Long School of Medicine, UT Health San Antonio, San Antonio, TX, USA
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Abstract
Neuropathy is a common complication of long-term diabetes that impairs quality of life by producing pain, sensory loss and limb amputation. The presence of neuropathy in both insulin-deficient (type 1) and insulin resistant (type 2) diabetes along with the slowing of progression of neuropathy by improved glycemic control in type 1 diabetes has caused the majority of preclinical and clinical investigations to focus on hyperglycemia as the initiating pathogenic lesion. Studies in animal models of diabetes have identified multiple plausible mechanisms of glucotoxicity to the nervous system including post-translational modification of proteins by glucose and increased glucose metabolism by aldose reductase, glycolysis and other catabolic pathways. However, it is becoming increasingly apparent that factors not necessarily downstream of hyperglycemia can also contribute to the incidence, progression and severity of neuropathy and neuropathic pain. For example, peripheral nerve contains insulin receptors that transduce the neurotrophic and neurosupportive properties of insulin, independent of systemic glucose regulation, while the detection of neuropathy and neuropathic pain in patients with metabolic syndrome and failure of improved glycemic control to protect against neuropathy in cohorts of type 2 diabetic patients has placed a focus on the pathogenic role of dyslipidemia. This review provides an overview of current understanding of potential initiating lesions for diabetic neuropathy and the multiple downstream mechanisms identified in cell and animal models of diabetes that may contribute to the pathogenesis of diabetic neuropathy and neuropathic pain.
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Felicetti G, Thoumie P, Do MC, Schieppati M. Cutaneous and muscular afferents from the foot and sensory fusion processing: Physiology and pathology in neuropathies. J Peripher Nerv Syst 2021; 26:17-34. [PMID: 33426723 DOI: 10.1111/jns.12429] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/30/2020] [Accepted: 12/30/2020] [Indexed: 12/16/2022]
Abstract
The foot-sole cutaneous receptors (section 2), their function in stance control (sway minimisation, exploratory role) (2.1), and the modulation of their effects by gait pattern and intended behaviour (2.2) are reviewed. Experimental manipulations (anaesthesia, temperature) (2.3 and 2.4) have shown that information from foot sole has widespread influence on balance. Foot-sole stimulation (2.5) appears to be a promising approach for rehabilitation. Proprioceptive information (3) has a pre-eminent role in balance and gait. Reflex responses to balance perturbations are produced by both leg and foot muscle stretch (3.1) and show complex interactions with skin input at both spinal and supra-spinal levels (3.2), where sensory feedback is modulated by posture, locomotion and vision. Other muscles, notably of neck and trunk, contribute to kinaesthesia and sense of orientation in space (3.3). The effects of age-related decline of afferent input are variable under different foot-contact and visual conditions (3.4). Muscle force diminishes with age and sarcopenia, affecting intrinsic foot muscles relaying relevant feedback (3.5). In neuropathy (4), reduction in cutaneous sensation accompanies the diminished density of viable receptors (4.1). Loss of foot-sole input goes along with large-fibre dysfunction in intrinsic foot muscles. Diabetic patients have an elevated risk of falling, and vision and vestibular compensation strategies may be inadequate (4.2). From Charcot-Marie-Tooth 1A disease (4.3) we have become aware of the role of spindle group II fibres and of the anatomical feet conditions in balance control. Lastly (5) we touch on the effects of nerve stimulation onto cortical and spinal excitability, which may participate in plasticity processes, and on exercise interventions to reduce the impact of neuropathy.
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Affiliation(s)
- Guido Felicetti
- Istituti Clinici Scientifici Maugeri IRCCS, Unit of Neuromotor Rehabilitation, Institute of Montescano, Pavia, Italy
| | - Philippe Thoumie
- Service de rééducation neuro-orthopédique, Hôpital Rothschild APHP, Université Sorbonne, Paris, France.,Agathe Lab ERL Inserm U-1150, Paris, France
| | - Manh-Cuong Do
- Université Paris-Saclay, CIAMS, Orsay, France.,Université d'Orléans, CIAMS, Orléans, France
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Guo X, Wang S, Chen YC, Wei HL, Zhou GP, Yu YS, Yin X, Wang K, Zhang H. Aberrant Brain Functional Connectivity Strength and Effective Connectivity in Patients with Type 2 Diabetes Mellitus. J Diabetes Res 2021; 2021:5171618. [PMID: 34877358 PMCID: PMC8645376 DOI: 10.1155/2021/5171618] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 11/03/2021] [Indexed: 12/04/2022] Open
Abstract
Alterations of brain functional connectivity in patients with type 2 diabetes mellitus (T2DM) have been reported by resting-state functional magnetic resonance imaging studies, but the underlying precise neuropathological mechanism remains unclear. This study is aimed at investigating the implicit alterations of functional connections in T2DM by integrating functional connectivity strength (FCS) and Granger causality analysis (GCA) and further exploring their associations with clinical characteristics. Sixty T2DM patients and thirty-three sex-, age-, and education-matched healthy controls (HC) were recruited. Global FCS analysis of resting-state functional magnetic resonance imaging was performed to explore seed regions with significant differences between the two groups; then, GCA was applied to detect directional effective connectivity (EC) between the seeds and other brain regions. Correlations of EC with clinical variables were further explored in T2DM patients. Compared with HC, T2DM patients showed lower FCS in the bilateral fusiform gyrus, right superior frontal gyrus (SFG), and right postcentral gyrus, but higher FCS in the right supplementary motor area (SMA). Moreover, altered directional EC was found between the left fusiform gyrus and bilateral lingual gyrus and right medial frontal gyrus (MFG), as well as between the right SFG and bilateral frontal regions. In addition, triglyceride, insulin, and plasma glucose levels were correlated with the abnormal EC of the left fusiform, while disease duration and cognitive function were associated with the abnormal EC of the right SFG in T2DM patients. These results suggest that T2DM patients show aberrant brain function connectivity strength and effective connectivity which is associated with the diabetes-related metabolic characteristics, disease duration, and cognitive function, providing further insights into the complex neural basis of diabetes.
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Affiliation(s)
- Xi Guo
- Department of Radiology, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu Province 211100, China
| | - Su Wang
- Department of Endocrinology, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu Province 211100, China
| | - Yu-Chen Chen
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu Province 210006, China
| | - Heng-Le Wei
- Department of Radiology, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu Province 211100, China
| | - Gang-Ping Zhou
- Department of Radiology, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu Province 211100, China
| | - Yu-Sheng Yu
- Department of Radiology, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu Province 211100, China
| | - Xindao Yin
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu Province 210006, China
| | - Kun Wang
- Department of Endocrinology, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu Province 211100, China
| | - Hong Zhang
- Department of Radiology, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu Province 211100, China
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Ni W, Zhang Z, Zhang B, Zhang W, Cheng H, Miao Y, Chen W, Liu J, Zhu D, Bi Y. Connecting Peripheral to Central Neuropathy: Examination of Nerve Conduction Combined with Olfactory Tests in Patients with Type 2 Diabetes. Diabetes Metab Syndr Obes 2021; 14:3097-3107. [PMID: 34267530 PMCID: PMC8276992 DOI: 10.2147/dmso.s312021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 06/14/2021] [Indexed: 12/11/2022] Open
Abstract
AIM Few studies have investigated the associations between diabetic peripheral neuropathy (DPN) and cognitive decline. Olfactory impairment is related to neurodegenerative diseases and type 2 diabetes mellitus (T2DM); however, the cognitive alterations of patients with DPN and the role of olfactory function in DPN are not known. We explored alterations in cognition with DPN and the associations of neuropathy parameters with cognition and olfaction. METHODS Healthy controls (HCs) and patients with T2DM underwent nerve-conduction tests, detailed cognitive assessment, olfactory-behavior tests, and odor-induced functional magnetic resonance imaging (fMRI). T2DM patients were divided into two groups (non-DPN [NDPN] and DPN). Olfactory brain regions showing different activation between the two groups were selected for functional connectivity (FC) analyses. A structural equation model (SEM) was also generated to demonstrate the association among cognition, olfactory, and neuropathy parameters. RESULTS One hundred individuals (36 HCs, 36 NDPN, and 28 DPN) were matched for age, sex, and educational level. Compared with the NDPN group, the DPN group had significantly lower scores for memory and processing speed, as well as lower olfactory identification and memory scores, decreased activation of the left frontal lobe, and reduced seed-based functional connectivity in the right insula. The nerve conduction velocity in patients with T2DM was associated with cognitive functions. The association between nerve conduction and executive function was mediated by olfactory behavior. CONCLUSION Patients with DPN had worse cognition than the NDPN patients in the domains of memory and processing speed. Cognitive dysfunction could be predicted by olfactory-behavior tests and electrophysiological examination.
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Affiliation(s)
- Wenyu Ni
- Department of Endocrinology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, People’s Republic of China
| | - Zhou Zhang
- Department of Endocrinology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, People’s Republic of China
| | - Bing Zhang
- Department of Radiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, People’s Republic of China
| | - Wen Zhang
- Department of Radiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, People’s Republic of China
| | - Haiyan Cheng
- Department of Endocrinology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, People’s Republic of China
| | - Yingwen Miao
- Department of Endocrinology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, People’s Republic of China
| | - Wei Chen
- Department of Endocrinology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, People’s Republic of China
| | - Jiani Liu
- Department of Radiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, People’s Republic of China
| | - Dalong Zhu
- Department of Endocrinology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, People’s Republic of China
| | - Yan Bi
- Department of Endocrinology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, People’s Republic of China
- Correspondence: Yan Bi Department of Endocrinology, Drum Tower Hospital, Affiliated to Nanjing University Medical School, No. 321, Zhongshan Road, Nanjing, 210008, People’s Republic of ChinaTel +86 25-83304616-61431Fax +86 25-83304616-61431 Email
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44
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Xu X, Xu DS. Prospects for the application of transcranial magnetic stimulation in diabetic neuropathy. Neural Regen Res 2021; 16:955-962. [PMID: 33229735 PMCID: PMC8178790 DOI: 10.4103/1673-5374.297062] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Encouraging results have been reported for the use of transcranial magnetic stimulation-based nerve stimulation in studies of the mechanisms of neurological regulation, nerve injury repair, and nerve localization. However, to date, there are only a few reviews on the use of transcranial magnetic stimulation for diabetic neuropathy. Patients with diabetic neuropathy vary in disease progression and show neuropathy in the early stage of the disease with mild symptoms, making it difficult to screen and identify. In the later stage of the disease, irreversible neurological damage occurs, resulting in treatment difficulties. In this review, we summarize the current state of diabetic neuropathy research and the prospects for the application of transcranial magnetic stimulation in diabetic neuropathy. We review significant studies on the beneficial effects of transcranial magnetic stimulation in diabetic neuropathy treatment, based on the outcomes of its use to treat neurodegeneration, pain, blood flow change, autonomic nervous disorders, vascular endothelial injury, and depression. Collectively, the studies suggest that transcranial magnetic stimulation can produce excitatory/inhibitory stimulation of the cerebral cortex or local areas, promote the remodeling of the nervous system, and that it has good application prospects for the localization of the injury, neuroprotection, and the promotion of nerve regeneration. Therefore, transcranial magnetic stimulation is useful for the screening and early treatment of diabetic neuropathy. Transcranial magnetic stimulation can also alleviate pain symptoms by changing the cortical threshold and inhibiting the conduction of sensory information in the thalamo-spinal pathway, and therefore it has therapeutic potential for the treatment of pain and pain-related depressive symptoms in patients with diabetic neuropathy. Additionally, based on the effect of transcranial magnetic stimulation on local blood flow and its ability to change heart rate and urine protein content, transcranial magnetic stimulation has potential in the treatment of autonomic nerve dysfunction and vascular injury in diabetic neuropathy. Furthermore, oxidative stress and the inflammatory response are involved in the process of diabetic neuropathy, and transcranial magnetic stimulation can reduce oxidative damage. The pathological mechanisms of diabetic neuropathy should be further studied in combination with transcranial magnetic stimulation technology.
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Affiliation(s)
- Xi Xu
- Department of Rehabilitation Medicine, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Dong-Sheng Xu
- Department of Rehabilitation Medicine, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine; School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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45
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Archibald J, MacMillan EL, Graf C, Kozlowski P, Laule C, Kramer JLK. Metabolite activity in the anterior cingulate cortex during a painful stimulus using functional MRS. Sci Rep 2020; 10:19218. [PMID: 33154474 PMCID: PMC7645766 DOI: 10.1038/s41598-020-76263-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 10/14/2020] [Indexed: 02/07/2023] Open
Abstract
To understand neurochemical brain responses to pain, proton magnetic resonance spectroscopy (1H-MRS) is used in humans in vivo to examine various metabolites. Recent MRS investigations have adopted a functional approach, where acquisitions of MRS are performed over time to track task-related changes. Previous studies suggest glutamate is of primary interest, as it may play a role during cortical processing of noxious stimuli. The objective of this study was to examine the metabolic effect (i.e., glutamate) in the anterior cingulate cortex during noxious stimulation using fMRS. The analysis addressed changes in glutamate and glutamate + glutamine (Glx) associated with the onset of pain, and the degree by which fluctuations in metabolites corresponded with continuous pain outcomes. Results suggest healthy participants undergoing tonic noxious stimulation demonstrated increased concentrations of glutamate and Glx at the onset of pain. Subsequent reports of pain were not accompanied by corresponding changes in glutamate of Glx concentrations. An exploratory analysis on sex revealed large effect size changes in glutamate at pain onset in female participants, compared with medium-sized effects in male participants. We propose a role for glutamate in the ACC related to the detection of a noxious stimulus.
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Affiliation(s)
- J Archibald
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, Canada.
- Department of Experimental Medicine, University of British Columbia, Vancouver, Canada.
| | - E L MacMillan
- Department of Radiology, University of British Columbia, Vancouver, Canada
- ImageTech Lab, Simon Fraser University, Surrey, Canada
- Philips Healthcare Canada, Markham, Canada
| | - C Graf
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, Canada
- Department of Physics and Astronomy, University of British Columbia, Vancouver, Canada
| | - P Kozlowski
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, Canada
- Hughill Center, Vancouver, Canada
- Department of Radiology, University of British Columbia, Vancouver, Canada
- UBC MRI Research Centre, University of British Columbia, Vancouver, Canada
| | - C Laule
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, Canada
- Hughill Center, Vancouver, Canada
- Department of Radiology, University of British Columbia, Vancouver, Canada
- Department of Physics and Astronomy, University of British Columbia, Vancouver, Canada
- UBC MRI Research Centre, University of British Columbia, Vancouver, Canada
- Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - J L K Kramer
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Djavad Mowafaghian Center for Brain Health (DMCH), Vancouver, Canada
- Hughill Center, Vancouver, Canada
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46
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Pontillo G, Tozza S, Perillo T, Cocozza S, Dubbioso R, Severi D, Iodice R, Tedeschi E, Elefante A, Brunetti A, Manganelli F, Quarantelli M. Diffuse brain connectivity changes in Charcot-Marie-Tooth type 1a patients: a resting-state functional magnetic resonance imaging study. Eur J Neurol 2020; 28:305-313. [PMID: 32955777 DOI: 10.1111/ene.14540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/09/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Changes of brain structure and function have been described in peripheral neuropathies. The aim of our study was to systematically investigate possible modifications of major large-scale brain networks using resting-state functional magnetic resonance imaging (RS-fMRI) in Charcot-Marie-Tooth disease type 1A (CMT1A) patients. METHODS In this cross-sectional study, 3-T MRI brain scans were acquired of right-handed genetically confirmed CMT1A patients and age- and sex-comparable healthy controls. Patients also underwent clinical and electrophysiological examinations assessing neurological impairment. RS-fMRI data were analysed using a seed-based approach, with 32 different seeds sampling the main hubs of default mode, sensorimotor, visual, salience (SN), dorsal attention, frontoparietal, language and cerebellar networks. Between-group differences in terms of functional connectivity (FC) with the explored seeds were tested voxelwise, correcting for local grey matter density to account for possible structural abnormalities, whilst the relationship between FC modifications and neurological impairment was investigated using robust correlation analyses. RESULTS Eighteen CMT1A patients (34.0 ± 11.4 years; M/F 11/7) were enrolled, along with 20 healthy controls (30.1 ± 10.2 years; M/F 11/9). In the CMT group compared to controls, clusters of increased FC with the visual cortex (P = 0.001), SN (P < 6 × 10-4 ), dorsal attention network (P < 8 × 10-5 ) and language network (P < 7 × 10-4 ) were found, along with a single cluster of reduced FC with the visual cortex in the left lentiform nucleus (P = 10-6 ). A significant correlation emerged between neurophysiological impairment and increased FC with right temporal language areas (r = 0.655, P = 0.006), along with an association between walking ability and increased FC with the left supramarginal gyrus (SN) (r = 0.620, P = 0.006). CONCLUSIONS Our data show evidence of diffuse functional reorganization involving multiple large-scale networks in the CMT1A brain, independent of structural modifications and partially correlating with peripheral nerve damage and functional impairment.
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Affiliation(s)
- G Pontillo
- Department of Advanced Biomedical Sciences, University 'Federico II', Naples, Italy
| | - S Tozza
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University 'Federico II', Naples, Italy
| | - T Perillo
- Department of Advanced Biomedical Sciences, University 'Federico II', Naples, Italy
| | - S Cocozza
- Department of Advanced Biomedical Sciences, University 'Federico II', Naples, Italy
| | - R Dubbioso
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University 'Federico II', Naples, Italy
| | - D Severi
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University 'Federico II', Naples, Italy
| | - R Iodice
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University 'Federico II', Naples, Italy
| | - E Tedeschi
- Department of Advanced Biomedical Sciences, University 'Federico II', Naples, Italy
| | - A Elefante
- Department of Advanced Biomedical Sciences, University 'Federico II', Naples, Italy
| | - A Brunetti
- Department of Advanced Biomedical Sciences, University 'Federico II', Naples, Italy
| | - F Manganelli
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University 'Federico II', Naples, Italy
| | - M Quarantelli
- Institute of Biostructure and Bioimaging, National Research Council, Naples, Italy
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47
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Pei Y, Zhang Y, Zhu Y, Zhao Y, Zhou F, Huang M, Wu L, Gong H. Hyperconnectivity and High Temporal Variability of the Primary Somatosensory Cortex in Low-Back-Related Leg Pain: An fMRI Study of Static and Dynamic Functional Connectivity. J Pain Res 2020; 13:1665-1675. [PMID: 32753942 PMCID: PMC7351631 DOI: 10.2147/jpr.s242807] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 05/23/2020] [Indexed: 01/10/2023] Open
Abstract
Objective To investigate the functional connectivity (FC) and its variability in the primary somatosensory cortex (S1) of patients with low-back-related leg pain (LBLP) in the context of the persistent stimuli of pain and numbness. Patients and Methods We performed functional magnetic resonance imaging on LBLP patients (n = 26) and healthy controls (HCs; n = 34) at rest. We quantified and compared static FC (sFC) using a seed-based analysis strategy, with 6 predefined bilateral paired spherical regions of interest (ROIs) in the S1 cortex. Then, we captured the dynamic FC using sliding window correlation of ROIs in both the LBLP patients and HCs. Furthermore, we performed a correlational analysis between altered static and dynamic FC and clinical measures in LBLP patients. Results Compared with controls, the LBLP patients had 1) significantly increased static FC between the left S1back (the representation of the back in the S1) and right superior and middle frontal gyrus (SFG/MFG), between the left S1chest and right SFG/MFG, between right S1chest and right SFG/MFG, between the left S1face and right MFG, and between the right S1face and right inferior parietal lobule (P < 0.001, Gaussian random field theory correction); 2) increased dynamic FC only between the right S1finger and the left precentral and postcentral gyrus and between the right S1hand and the right precentral and postcentral gyrus (P < 0.01, Gaussian random field theory correction); and 3) a negative correlation between the Barthel index and the increased static FC between the left S1face and right inferior parietal lobule (P = 0.048). Conclusion The present study demonstrated the hyperconnectivity of the S1 cortex to the default mode and executive control network in a spatial pattern and an increase in the tendency for signal variability in the internal network connections of the S1 cortex in patients with LBLP.
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Affiliation(s)
- Yixiu Pei
- Department of Radiology, The First Affiliated Hospital, Nanchang University, Nanchang 330006, People's Republic of China.,Neuroradiology Laboratory, Jiangxi Province Medical Imaging Research Institute, Nanchang 330006, People's Republic of China
| | - Yong Zhang
- Department of Pain Clinic, The First Affiliated Hospital, Nanchang University, Nanchang, Jiangxi Province 330006, People's Republic of China
| | - Yanyan Zhu
- Department of Radiology, The First Affiliated Hospital, Nanchang University, Nanchang 330006, People's Republic of China.,Neuroradiology Laboratory, Jiangxi Province Medical Imaging Research Institute, Nanchang 330006, People's Republic of China
| | - Yanlin Zhao
- Department of Radiology, The First Affiliated Hospital, Nanchang University, Nanchang 330006, People's Republic of China.,Neuroradiology Laboratory, Jiangxi Province Medical Imaging Research Institute, Nanchang 330006, People's Republic of China
| | - Fuqing Zhou
- Department of Radiology, The First Affiliated Hospital, Nanchang University, Nanchang 330006, People's Republic of China.,Neuroradiology Laboratory, Jiangxi Province Medical Imaging Research Institute, Nanchang 330006, People's Republic of China
| | - Muhua Huang
- Department of Radiology, The First Affiliated Hospital, Nanchang University, Nanchang 330006, People's Republic of China.,Neuroradiology Laboratory, Jiangxi Province Medical Imaging Research Institute, Nanchang 330006, People's Republic of China
| | - Lin Wu
- Department of Radiology, The First Affiliated Hospital, Nanchang University, Nanchang 330006, People's Republic of China.,Neuroradiology Laboratory, Jiangxi Province Medical Imaging Research Institute, Nanchang 330006, People's Republic of China
| | - Honghan Gong
- Department of Radiology, The First Affiliated Hospital, Nanchang University, Nanchang 330006, People's Republic of China.,Neuroradiology Laboratory, Jiangxi Province Medical Imaging Research Institute, Nanchang 330006, People's Republic of China
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Sierra-Silvestre E, Somerville M, Bisset L, Coppieters MW. Altered pain processing in patients with type 1 and 2 diabetes: systematic review and meta-analysis of pain detection thresholds and pain modulation mechanisms. BMJ Open Diabetes Res Care 2020; 8:8/1/e001566. [PMID: 32868312 PMCID: PMC7462232 DOI: 10.1136/bmjdrc-2020-001566] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/24/2020] [Accepted: 07/06/2020] [Indexed: 12/15/2022] Open
Abstract
The first signs of diabetic neuropathy typically result from small-diameter nerve fiber dysfunction. This review synthesized the evidence for small-diameter nerve fiber neuropathy measured via quantitative sensory testing (QST) in patients with diabetes with and without painful and non-painful neuropathies. Electronic databases were searched to identify studies in patients with diabetes with at least one QST measure reflecting small-diameter nerve fiber function (thermal or electrical pain detection threshold, contact heat-evoked potentials, temporal summation or conditioned pain modulation). Four groups were compared: patients with diabetes (1) without neuropathy, (2) with non-painful diabetic neuropathy, (3) with painful diabetic neuropathy and (4) healthy individuals. Recommended methods were used for article identification, selection, risk of bias assessment, data extraction and analysis. For the meta-analyses, data were pooled using random-effect models. Twenty-seven studies with 2422 participants met selection criteria; 18 studies were included in the meta-analysis. Patients with diabetes without symptoms of neuropathy already showed loss of nerve function for heat (standardized mean difference (SMD): 0.52, p<0.001), cold (SMD: -0.71, p=0.01) and electrical pain thresholds (SMD: 1.26, p=0.01). Patients with non-painful neuropathy had greater loss of function in heat pain threshold (SMD: 0.75, p=0.01) and electrical stimuli (SMD: 0.55, p=0.03) compared with patients with diabetes without neuropathy. Patients with painful diabetic neuropathy exhibited a greater loss of function in heat pain threshold (SMD: 0.55, p=0.005) compared with patients with non-painful diabetic neuropathy. Small-diameter nerve fiber function deteriorates progressively in patients with diabetes. Because the dysfunction is already present before symptoms occur, early detection is possible, which may assist in prevention and effective management of diabetic neuropathy.
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Affiliation(s)
- Eva Sierra-Silvestre
- School of Allied Health Sciences, Griffith University, Gold Coast, Queensland, Australia
- Faculty of Human Movement Sciences, Free University Amsterdam, Amsterdam, The Netherlands
| | - Mari Somerville
- School of Allied Health Sciences, Griffith University, Gold Coast, Queensland, Australia
| | - Leanne Bisset
- School of Allied Health Sciences, Griffith University, Gold Coast, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Nathan, Queensland, Australia
| | - Michel W Coppieters
- Menzies Health Institute Queensland, Griffith University, Nathan, Queensland, Australia
- Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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49
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Wilkinson ID, Teh K, Heiberg-Gibbons F, Awadh M, Kelsall A, Shillo P, Sloan G, Tesfaye S, Selvarajah D. Determinants of Treatment Response in Painful Diabetic Peripheral Neuropathy: A Combined Deep Sensory Phenotyping and Multimodal Brain MRI Study. Diabetes 2020; 69:1804-1814. [PMID: 32471808 DOI: 10.2337/db20-0029] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 05/26/2020] [Indexed: 11/13/2022]
Abstract
Painful diabetic peripheral neuropathy (DPN) is difficult to manage, as treatment response is often varied. The primary aim of this study was to examine differences in pain phenotypes between responders and nonresponders to intravenous lidocaine treatment using quantitative sensory testing. The secondary aim was to explore differences in brain structure and functional connectivity with treatment response. Forty-five consecutive patients who received intravenous lidocaine treatment for painful DPN were screened. Twenty-nine patients who met the eligibility criteria (responders, n = 14, and nonresponders, n = 15) and 26 healthy control subjects underwent detailed sensory profiling. Subjects also underwent multimodal brain MRI. A greater proportion of patients with the irritable (IR) nociceptor phenotype were responders to intravenous lidocaine treatment compared with nonresponders. The odds ratio of responding to intravenous lidocaine was 8.67 times greater (95% CI 1.4-53.8) for the IR nociceptor phenotype. Responders to intravenous lidocaine also had significantly greater mean primary somatosensory cortex cortical volume and functional connectivity between the insula cortex and the corticolimbic circuitry. This study provides preliminary evidence for a mechanism-based approach for individualizing therapy in patients with painful DPN.
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Affiliation(s)
- Iain David Wilkinson
- Academic Department of Radiology, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, U.K
| | - Kevin Teh
- Academic Department of Radiology, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, U.K
| | | | - Mohammad Awadh
- Department of Oncology and Human Metabolism, University of Sheffield, Sheffield, U.K
| | - Alan Kelsall
- Diabetes Research Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, U.K
| | - Pallai Shillo
- Diabetes Research Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, U.K
| | - Gordon Sloan
- Diabetes Research Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, U.K
| | - Solomon Tesfaye
- Diabetes Research Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, U.K
| | - Dinesh Selvarajah
- Department of Oncology and Human Metabolism, University of Sheffield, Sheffield, U.K.
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50
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Tesfaye S, Sloan G. Diabetic Polyneuropathy - Advances in Diagnosis and Intervention Strategies. EUROPEAN ENDOCRINOLOGY 2020; 16:15-20. [PMID: 32595764 DOI: 10.17925/ee.2020.16.1.15] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 01/28/2020] [Indexed: 12/19/2022]
Abstract
Over half of people with diabetes mellitus develop diabetic polyneuropathy (DPN), which is a major cause of reduced quality of life due to disabling neuropathic pain, sensory loss, gait instability, fall-related injury, and foot ulceration and amputation. The latter represents a major health and economic burden, with lower limb amputation rates related to diabetes increasing in the UK. There is a need for early diagnosis of DPN so that early management strategies may be instigated, such as achieving tight glucose control and management of cardiovascular risk factors, in an attempt to slow its progression. To this end, a one-stop microvascular assessment involving a combined eye, foot and renal screening clinic has proven feasible in the UK. Unfortunately, there are currently no approved disease-modifying therapies for DPN. Some disease-modifying agents have demonstrated efficacy, but further large trials using appropriate clinical endpoints are required before these treatments can be routinely recommended. There has been emerging evidence highlighting a reduction in vitamin D levels in cases of painful DPN and the potential for vitamin D supplementation in deficient individuals to improve neuropathic pain; however, this needs to be proved in randomised clinical trials. The use of established agents for neuropathic pain in DPN is limited by poor efficacy and adverse effects, but patient stratification using methods such as pain phenotyping are being tested to determine whether this improves the outcomes of such agents in clinical studies. In addition, innovative approaches such as the topical 8% capsaicin patch, new methods of electrical stimulation and novel therapeutic targets such as NaV1.7 offer promise for the future. This article aims to discuss the challenges of diagnosing and managing DPN and to review current and emerging lifestyle interventions and therapeutic options.
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Affiliation(s)
- Solomon Tesfaye
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Gordon Sloan
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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