Does Diabetic Peripheral Neuropathy Really Have A Stocking Distribution?
- Stephen Barrett DPM FACFAS
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Tossing and turning, trying to decide if I was dreaming or truly awake in a seemingly restless, endless fog, I knew, or at least I thought, that I was watching a trial of some sort on the TV. It was not ESPN, but DSPN, the new network that had just hit the airwaves.
What the hell is DSPN, you ask? It is that new neuronal network that reaches the homes of 30 million Americans with diabetic peripheral neuropathy, with dendrites in every county of the United States. By the way, from the recesses of that nocturnal fog, I recalled them saying at every commercial break “DSPN — the Diabetic Sensory Peripheral Neuropathy Network.”
There it was on the flickering black and white pixelated screen — a “real” trial going on. (I might have been dreaming but let’s pretend that it was real. It wasn’t for literal folks who just like to reading boring stuff.) This debate had no lawyers as they did not qualify for this court. This court had standards of intelligence and the only verbose arbiters allowed in this arena were men and women of science, specifically neuroscience. I recall the one erudite scientist (let’s call him Darth) repeatedly calling out: “You can’t commit. The glove doesn’t fit.” This was followed by “The stocking is only for Santa Claus.”
Now what does that mean? “The stocking is only for Santa Claus”? Really?
A voice sternly came down from high above, the judge’s perch to be exact. A small, bespectacled man with a bow tie and neatly coiffed salt and pepper hair was wrapped in his velvet gown and multicolored sash (visualize crusty professor dudes marching down the aisle at an Ivy League graduation). He bellowed, “Tell me about the neuron, dammit!”
Holding his parchment roll tightly in his hand, he pounded it repeatedly on the bench in front of the supreme neuroscientist.
“Careful now,” the judge admonished. “Keep acting like this and I will find you in contempt of Dogma!”
“Contempt of Dogma,” the lowly investigator scientist whispered. “Contempt of Dogma. Isn’t that what our job is: to dispel myth and hype and false belief?”
“You don’t have to repeat yourself,” the stern judge replied.
“What do I get if I am found in contempt of Dogma?” the axonmeister asked.
“Maybe a Nobel Prize, you dolt, or perhaps something worse like a huge National Institutes of Health grant (and lots of paperwork). Or at the very least, you will have the knowledge that you have ended years and maybe decades of nonsense, and may actually help some people.” Wow, that is some heady stuff coming from the neatly coiffed one. “Get on with your case, sir.”
“Well, your honor, we’ve been told for decades now — in fact since 1953 — that diabetic sensory peripheral neuropathy presents in a stocking and glove distribution,” said the scientist. “That is frankly bovine feces to use laboratory vernacular and I have the facts to back that up.”
Now the supreme neuroscientist struggled to reign in his smile while scratching his chin and simultaneously continuing to feign impartiality. (He knew BF when he saw BF and in fact liked discussing BF as it meant stirring the pot, and this scientist loved nothing more than to stir the pot.) He knew that what the erudite Darth was saying was true.
“Present your evidence, sir!” Quaking, scientist Darth unwrapped the parchment roll and there it was. There on the parchment was a mini-iPad playing a surgical video (OK, it really is a dream now) showing a transmetatarsal amputation in a “completely” neuropathic patient without any anesthesia. This was a gruesome sight for this ultimate arbiter as he was a man of theoretical science and had never witnessed more than a rat renal tubule under electron microscopy.
Darth went on to narrate as the video played. “Notice how the man does not scream out in horrible pain until I reach the fifth metatarsal. He is totally insensate from medial to lateral until I hit the fifth metatarsal. That is sural nerve distribution, my gentlemen colleagues and esteemed science men. Therefore, if there were a stocking type distribution of DSPN, then why would he scream when we hit the sural distribution?”
“Can any of you disagree that the sural distribution would not be in the stocking?” He looked around the “court” room pausing for rebuttal. “No, sir. I would proffer, my good men and ladies, that if DSPN is the condition described as a purely length dependent metabolic polyneuropathy, which ‘dies’ back from distal to proximal, is solely a metabolic condition, with a true length dependent determinant of neuropathy, then this man would not have screamed, would he? The man screamed.”
Out of nowhere, a massive rotund boisterous gentleman grunted loudly in disgust after clearing his phlegmatic throat. “This is all poppycock. This is nothing more than a metabolic disease, pure and simple, and that video is just a stage production.”
“Who the hell are you?” the neurojudge questioned. The rotund man waddled up from the gallery bench and answered: “They call me Mr. Gabe Pentin, that’s who. My close friends call me Big Pharma.”
“Did you say big or pig?” the neurojudge sang out. Laughter, something rarely seen in these chambers, filled the erudite and serious room with the suddenness of stage fog rolling in on a Queen concert during the chorus of “Bohemian Rhapsody.” “It’s nothing more than a metabolic disease and that’s that,” Mr. Pentin flatly declared while waddling back to his seat.
“More BF. Look at this,” Darth was now pointing back to the parchment roll. “See these your honor? These are photo histomicrographs from the same patient. The first is from the plantar aspect of the foot and the second is from the dorsal lateral aspect of the foot.”
Darth was now floating as he had the goods on Mr. Pentin. “I have thousands more of these out in the truck if this one is not good enough for you.”
“What do they show?” Darth excitedly proclaimed. “Nothing in the first one from the plantar aspect of the foot and the presence of C and A delta fibers in the second. Do you know what that means?” he shouted. The courtroom could hear a large expunge of air coming out of the rotund one. It was not flatulence, mind you, but rather the bursting of a billion-dollar industrial bubble. Maybe only the others, all except Mr. Pentin, could foresee the future with what this neuroscientist was showing.
The scientist was showing that DSPN was not a truly length dependent, solely metabolic disease, and that there had to be a mechanical pressure component to it as well. What else could explain the complete absence of small nerve fibers in one specimen from the bottom of the foot while at the same transmetatarsal level in the specimen taken from the sural nerve distribution, there was a beautiful micro-flower of A delta and C fibers?
How A Conversation At The AENS Meeting Inspired My Dream
My fog suddenly lifted due to the noxious aural stimulation from my alarm clock. I was dreaming but how real it seemed. What thoughts had I been thinking before going to sleep that could “program” such a bizarre dream? Ah ha!
I was at the Association of Extremity Nerve Surgeons meeting and had been talking with Andy Rader, DPM, (Andy is brilliant by the way and has established a true research lab in Huntingburg, Ind.). He spoke to me off the podium about all the work he is doing down in Southern Indiana. He spoke about how he has conclusively demonstrated that diabetic peripheral neuropathy does not present in a “stocking and glove” distribution. He also told me about the experience he had when he presented his research at the 7th Annual International Symposium on Diabetic Peripheral Neuropathy near Capetown, South Africa.
Andy told me how upset the “dogmatics” had become while, at the same time, being unable to refute his science. In a blinded study, testing three sites (the dorsum of the foot for the deep peroneal nerve, the plantar foot for the medial plantar nerve and the dorsal lateral foot for the sural nerve), he only found two, yes two like me and you, out of 80 patients that had a “stocking” distribution.1 This proved that DSPN does not fit the current “belief” and, in his words, “the dying back of the nerve was way plantar dependent.”
Now after his presentation and the end of the meeting, one of the prominent scientific chairmen approached Andy, told him his findings were shattering and that they would most certainly be “buried.”
Why would they be buried? His finding is a game changer folks. It rocks the boat and it stirs the pot, and we need to stir the pot as this is a serious condition that needs to be attacked from all directions, not just million-dollar pharma.
Thanks, Andy, for letting me share this story, and for what you have taught me. I hope the readers of this hallucinogenic (disclosure: the only hallucinogen I have used in creating a way to tell this story is a five-hour hypoxic airplane induced one with no empty seats) tale get the incredible message and importance of what you and others are doing, and start jumping on the bandwagon of research. There is so much clinical data in every one of our practices that if we could just figure out how to harbor that, we would have a “databomb” that could wipe out Dogmaville.
1. Rader AJ, Barry TP. Symmetry of sensory loss in developing diabetic sensory polyneuropathy. Foot Ankle Spec. 2009; 2(1):16-21.