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Neurophysiological changes in context to duration of exposure In Insulin Dependent

And Non Insulin Dependent Diabetes Mellitus

NEUROPHYSIOLOGICAL CHANGES IN CONTEXT TO DURATION OF


EXPOSURE IN INSULIN DEPENDENT AND NON INSULIN DEPENDENT
DIABETES MELLITUS
1

Dr. Maitrey Pandya , Dr. Priyanshu Rathod , Dr. Shweta Rakholiya


1

(MPT) RK University, Rajkot, PT, PhD, Dean, RK University, Rajkot, MPT, Rajkot, Gujarat.

ABSTRACT
Background: Diabetes mellitus is characterised by inability of the body to
metabolize glucose properly. The prevalence of diabetes is rapidly rising all over the
globe at an alarming rate. As IDDM and NIDDM shows effect on central nervous
system, peripheral nervous system, autonomic nervous system, cardiovascular
system and other physiological system. A common complication due to the IDDM
and NIDDM includes peripheral neuropathy, retinopathy, nephropathy and vascular
complication. Insulin and non-insulin dependent diabetes mellitus both affect the
peripheral nervous system depending on the duration of exposure and blood glucose
level. Aim: Neurophysiological changes in context to duration of exposure in insulin
dependent and non insulin dependent diabetes mellitus Materials and Method: 120
healthy individuals with IDDM and NIDDM were included screened with SF-36, with
age limit between 25 to 60 years. Those individuals having a history of
hospitalization in last 1 year, acute fever, present history of radiculopathy and open
wound were excluded. Nerve conduction studies of common peroneal, tibial and
sural nerves were examined in both groups. Distal Latency, NCV and CMAP/SNAP
were taken as outcome measures. Result and Discussion: Bio-statistical analysis
has been done using Mann-Whitney test. Result suggest that long duration of
exposure has significant (p<0.05) effect on neurophysiological changes compare to
short duration of exposure in IDDM and NIDDM. With longer exposure of diabetes,
there is increase in latency, decrease in amplitude and NCV. Conclusion: long
duration of exposure shows significant Neurophysiological changes compare to short
duration of exposure in IDDM and NIDDM.
Keywords: Insulin dependent diabetes mellitus (IDDM), Non-insulin dependent
diabetes mellitus (NIDDM), Nerve conduction velocity (NCV)

Neurophysiological changes in context to duration of exposure In Insulin Dependent


And Non Insulin Dependent Diabetes Mellitus

Introduction:

Diabetes

characterised

mellitus

by

is

chronic

and

vascular

diabetes

.carbohydrate,

peripheral

and

protein

Insulin

dependent and non insulin dependent

hyperglycaemia with disturbance of


fat,

complication.

mellitus,

both

affect

nervous
[5]

the

system

metabolism resulting from defects in

significantly.

insulin secretion, insulin action or both.

neuropathy (DPN) is among the most

The two broad categories of diabetes

distressing

are designated Insulin dependent and

complications of diabetes and is a

non-dependent. IDDM is the result of

cause of significant disability and poor

complete

quality

or

near-total

insulin

of

of

life.

Diabetic

all

the

The

chronic

presence

of

neuropathy

is

deficiency. NIDDM is a heterogeneous

peripheral

group of disorders characterized by

suggested by complaints of numbness,

varying degrees of insulin resistance,

pain, or both, usually in a symmetrical

impaired

insulin

distribution and noticed first in the

increased

glucose

secretion,

and
[1]

production.

diabetic

peripheral

toes. [6]

According to the Diabetes Atlas 2006

Electrophysiological

published by the International Diabetes

have

Federation, the number of people with

abnormalities in diabetic neuropathy.[7-

diabetes in India currently around 40.9

10]

million is expected to rise to 69.9

have

million

velocities and smaller amplitudes than

by

2025

unless

urgent

preventive steps are taken. [2]


Insulin

dependent

and

revealed

studies

number

of

Patients with signs of neuropathy


slower

nerve

conduction

those without symptoms [11, 12], showing


non

a close correlation between clinical

insulin dependent diabetes shows their

findings and the degree of conduction

effect on various physiological system

changes.[13, 14]

like Central nervous system, peripheral


nervous

system,

The

prevalence

of

diabetic

musculoskeletal

neuropathy appears to parallel with

system, autonomic nervous system

duration of exposure of diabetes in

4]

both type 1 and type 2 diabetes.

Common complication due to the

People with diabetes can develop

IDDM and NIDDM includes peripheral

neurological problems at any time, but

neuropathy, retinopathy, nephropathy

the

and

cardiovascular

system.

[3,

risk

of

developing

diabetic

Neurophysiological changes in context to duration of exposure In Insulin Dependent


And Non Insulin Dependent Diabetes Mellitus
neuropathy increases with duration of
[15]

diabetes.

skin

resistance

was

reduced

by

Few studies suggest that

cleaning with spirit. Supra maximal

duration of diabetes is also a factor for

stimulation was given for the nerve

neuropathy. Therefore, we would like

conduction examination.

to find neurophysiological changes in


context to duration of diabetes in IDDM
and NIDDM.
Aim

of

the

study

is

to

Neurophysiological changes in context


to duration of exposure in insulin
dependent and non insulin dependent

Flow chart 1: Procedure and


data collection
120 diabetic individuals were selected
based on inclusion and exclusion
criteria and informed consent was
taken.

diabetes mellitus.
Review
Arindam

of
[16]

related

literatures:

had observed that there is

significant correlation between peripheral

Screen with basic assessment form


and NCV examination was performed
on sural, tibial and peroneal nerves
with RMS Aleron-2012 machine

neuropathy and duration of diabetes, age


of patients and postprandial blood glucose
level. Major Sharmeen Sultan

[17]

had

observed that neuronal dysfunction of

Distal latency, CMAP, SNAP and NCV


were taken as outcome measures

sensory nerves appears after prolonged


exposure to hyperglycaemia.
Method: This is an observational cross
sectional

study

which

included

120

Bio-Statistical analysis was performed


by using Mann-Whitney test in
SPSS 21.

subjects. (IDDM 40 and NIDDM 80)


Subjects between 25 to 60 years of age
and individuals with IDDM and NIDDM

Surface

screen with SF-36, general health good

peroneal nerve were obtained from

and above were included in the study.

extensor

Subjects having present history of lower

stimulation was given at the ankle and

limb

Radiculopathy,

history

of

hospitalization in last 1 year, open wound


and acute fever were excluded from the
study. The

room temperature was

maintained between 21c to 23c . The

recordings

digitorum

for

common

brevis

and

at the neck of the fibula. For Sural


nerve

examination,

the

surface

electrode between lateral malleolus


and

tendoachilles

records

nerve

Neurophysiological changes in context to duration of exposure In Insulin Dependent


And Non Insulin Dependent Diabetes Mellitus
conduction of sural nerve. The nerve

and proximal to the medial malleolus

was stimulated antidromically 10-16

and in the popliteal fossa.

cm proximal to the recording electrode,


distal

to

the

lower

border

Result:

of

gastrocnemius. The active surface

Bio-Statistical analysis was done using

recording electrode for Tibial nerve

SPSS (version 21). Mann-Whitney test

was placed on abductor hallusis or

was used for data analysis. Level of

abductor digiti quiniti slightly below and

significance was 0.05.

anterior

to

navicular

tuberosity.

Surface stimulation was used behind


Table 1: Neurophysiological changes in context to Duration of Exposure In
Sural nerve
GROUP
A-IDDM
B-NIDDM

DURATION
In years
1(>10 Years)
2 (<10Years)

A1 (n-21)
15.29 2.76
A2 (n-19)
5.95 1.9
Mann Whitney test (P < 0.05)
B1 (n-14)
11.29 1.07
B2 (n-66)
5.5 2.01
Mann Whitney test (P < 0.05)

Latency

SURAL NERVE
SNAP

NCV

ms

m/s

3.89 0.59
3.08 0.67
0.0002*
3.61 0.74
3.05 0.55
0.0001*

6.41 2.64
14.47 5.68
0.0001*
8.02 3.83
15.48 5.48
0.0001*

38.76 2.91
41.74 2.51
0.0004*
39.35 2.28
42.71 2.32
0.0003*

Table 2: Neurophysiological changes in context to Duration of Exposure In

Tibial and Peroneal nerves


GROUP
TIBIAL NERVE
Latency
CMAP
NCV
A-IDDM
B-NIDDM
ms
mv
m/s
A1 (>10 Years)

PERONEAL NERVE
Latency
CMAP
NCV
ms
mv
m/s

5.150.6

4.361.44

382.65

5.40.61

3.531.17

37.483.16

A2 (<10Years)
Mann Whitney test
(P < 0.05)
B1 (>10 Years)

4.410.62

6.151.29

40.131.75

4.640.62

5.260.77

39.632.04

0.0025*

0.0002*

0.0024*

0.0003*

0.0001*

0.0030*

5.090.66

4.441.21

38.262.5

5.340.68

3.691.2

37.692.29

B2 (<10Years)

4.460.62

6.371.07

40.291.7

4.60.57

5.190.58

39.921.66

Mann Whitney
test (P < 0.05)

0.002*

0.0002*

0.0028*

0.0003*

0.0001*

0.004*

* = suggest significant difference

Neurophysiological changes in context to duration of exposure In Insulin Dependent


And Non Insulin Dependent Diabetes Mellitus
Table1 2 suggest that Duration has

demyelination. These changes indicate

significant

on

that duration of hyper glycemia plays a

neurophysiological changes in IDDM

detrimental role on neurophysiological

and NIDDM groups. Long duration of

changes. Increase in latency and

exposure shows major impact on

decreases in NCV are suggestive of

neurophysiological changes in sural,

demyelinating changes. While reduced

tibial and peroneal nerve compare to

amplitude is suggestive of axonal loss.

short duration.

[17]

effect

Here longer duration of exposure

Long duration of exposure has

has more demyelinating and axonal

more increase in latency compare to

changes compared to shorter duration

short

of exposure in IDDM and NIDDM.

duration.

exposure

has

Long
more

duration

of

reduction

in

amplitude compare to short duration.

Summary: 120 healthy individuals

Long duration of exposure has more

with IDDM and NIDDM were included

reduction in NCV.

(screen with SF-36), with age limit

Discussion:

Duration

of

between 25 to 60 years. Those

exposure has a significant effect on

individuals

the peripheral nervous system. Our

hospitalization in last 1 year, acute

finding is consistent with the previous

fever, present history of radiculopathy

findings of Vinik, Gregersen, Valensi et

and

al [18-20]. Knuiman et al [21] also reported

Nerve conduction studies of common

that

peroneal, tibial and sural nerves were

sensory

neuropathy

is

more

open

having

wound

history

were

of

excluded.

common in long standing diabetic

examined in both groups.

subjects

who

Latency, NCV and CMAP/SNAP were

develop the disease late in life. No

taken as outcome measures. Bio-

significant sensory nerve dysfunction

statistical analysis has been done

was found in the diabetic group with

using

relatively short duration of diabetes. In

suggest that long duration of exposure

hyperglycemias,

shunted

has significant (p<0.05) effect on

through the Sorbitol pathway, causes

neurophysiological changes compare

the

in

to short duration of exposure in IDDM

Schwann cells, which undergo osmotic

and NIDDM. With longer exposure of

especially

accumulation

damage

leading

in

those

glucose

of

to

sorbitol

segmental

Mann-Whitney

test.

Distal

Result

Neurophysiological changes in context to duration of exposure In Insulin Dependent


And Non Insulin Dependent Diabetes Mellitus
diabetes, there is increase in latency,

Future study scope

decrease in amplitude and NCV.

(1) The study can be repeated to find

Conclusion: In context to our study

the therapeutic effect of exercise on

and

neurophysiological changes in context

neurophysiological

individuals

with

long

exposure

must

be

consideration

for

findings,

duration
taken

of

duration of exposure.

into

promotion,

(2) The study can be repeated to find

prevention, and care as compared to

proximal nerve involvement in IDDM

short duration in IDDM and NIDDM for

and NIDDM with different duration of

secondary complications

exposure.

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