A Treatment Protocol for Patients With Diabetic Peripheral Neuropathy

Discussion

This study investigated whether or not a multimodal physical therapy approach would reduce several of the debilitating symptoms of DPN experienced by many veterans at WJBDVAMC. The results support the idea that a combined treatment protocol of MIRE and a standardized exercise program can lead to decreased POQ-VA pain levels, improved balance, and improved protective sensation in veterans with DPN. Alleviation of these DPN complications may ultimately decrease an individual’s risk of injury and improve overall QOL.

Because the POQ-VA is a reliable, valid self-reported measure for veterans, it was chosen to quantify the impact of pain. Overall, veterans who participated in this study perceived decreased pain interference in multiple areas of their lives. The most significant findings were in overall QOL, household and community mobility, and pain ratings. This suggests that the combined treatment protocol will help veterans maintain an active lifestyle despite poorly controlled diabetes and neuropathic pain.

Along with decreased pain interference with QOL, participants demonstrated a decrease in fall risk as quantified by the Tinetti Gait and Balance Assessment. The SWM testing showed improved protective sensation as early as 3 months and continued through the 6-month visit. As protective sensation improves and fall risk decreases, the risk of injury is lessened, fear of falling is decreased, and individuals are less likely to self-impose limitations on daily activity levels, which improves QOL. In addition, decreased fall risk and improved protective sensation can reduce the financial burden on both the patient and the health care system. Many individuals are hospitalized secondary to fall injury, nonhealing wounds, resulting infections, and/or secondary complications from prolonged immobility. This treatment protocol demonstrates how a standardized physical therapy protocol, including MIRE and balance exercises, can be used preventively to reduce both the personal and financial impact of DPN.

It is interesting to note that some POQ-VA and Tinetti subscores were significantly improved at 3 months but not at 6 months. The significance achieved at 3 months may be due to the time required (ie, > 12 visits) to make significant physiological changes. The lack of significance at 6 months may be due to the natural tendency of participants to less consistently perform the home exercise program and MIRE protocol when unsupervised in the home. Differences in the VAS and POQ-VA pain score ratings were noted in the data. The POQ-VA pain rating scale indicated significant improvement in pain levels over the course of the study. However, when asked about pain using the 10-cm VAS, patients reported no significant improvements. This may be because veterans are more familiar with the numerical pain rating scale and are rarely asked to use the 10-cm VAS. It may also be because the POQ-VA pain rating asks for an average pain level over the previous week, whereas the 10-cm VAS asks for pain level at a discrete point in time.

Historically, physical therapy has had little to offer individuals with DPN. As a result of this study, however, a standardized treatment program for DPN has been implemented at the WJBDVAMC Physical Therapy Clinic. Referred patients are seen in the clinic on a trial basis. If positive results are documented during the clinic treatments, a home MIRE unit and exercise program are provided. The patients are expected to continue performing home treatments of MIRE and exercise 3 times a week after discharge.

Strengths and Limitations

Strengths of the study include a stringent IRB review, control of medication changes during the study through alerts to all VA providers, and a standardized MIRE and exercise protocol. An additional strength is the long duration of the study, which included supervised and unsupervised interventions that simulate real-life scenarios.

Limitations of the study include a small sample size, case-controlled design rather than a randomized, double-blinded study, which can contribute to selection bias, inability to differentiate between the benefits of physical therapy alone vs physical therapy and MIRE treatments, and retention of participants due to travel difficulties across a wide catchment area.

This pilot study should be expanded to a multicenter, randomized, double-blinded study to clarify the most beneficial treatments for individuals with diabetic neuropathy. Examining the number of documented falls pre- and postintervention may also be helpful to determine actual effects on an individual’s fall risk.

Conclusion

The use of a multimodal physical therapy approach seems to be effective in reducing the impact of neuropathic pain, the risk of amputation, and the risk of falls in individuals who have pursued all standard medical options but still experience the long-term effects of DPN. By adhering to a standardized treatment protocol of MIRE and therapeutic exercise, it seems that the benefits of this intervention can be maintained over time. This offers new, nonconventional treatment options in the field of physical therapy for veterans whose QOL is negatively impacted by the devastating effects of diabetic neuropathy.