While previous studies have touted the benefits of peripheral nerve decompression for patients with neuropathy, a new study in the Journal of the American Podiatric Medical Association (JAPMA) reveals positive effects on sensation, neuropathic pain and patient balance. Authors of the study found that 87 percent of patients with numbness reported improved sensation and 92 percent who had preoperative balance problems had improved balance a year after undergoing the procedure.
According to the study, which involved 60 patients with diabetic neuropathy and 40 patients with idiopathic neuropathy, the authors performed neurolysis of the peroneal nerve at the knee and the dorsum of the foot. They also released the tibial nerve in the four medial ankle tunnels.
The improved balance is important as it can prevent falls and further injury, according to study co-author A. Lee Dellon, MD, a Professor of Plastic Surgery and Neurosurgery at Johns Hopkins University in Baltimore. Researchers of the JAPMA study say the study is the first to depict a change in balance associated with restoring sensation. However, they note a previous report that demonstrated a relationship between progressive losses of sensation and balance.
In regard to neuropathic pain, the study found that the majority of patients had significant pain reduction a year after undergoing the surgery. Researchers ranked patients’ pain on a visual analog scale (VAS) from 1 to 10 (with 10 being the worst pain) and found that 86 percent of those with preoperative pain higher than a 5 on the VAS showed postoperative improvement. Out of the 99 patients who related having pre-op pain, their pain after surgery improved by an average of 6.4 points on the VAS. Forty-four patients reported pain at the highest level of 10 before surgery but only 2 percent of these patients noted their post-op pain at 10 on the VAS, according to the JAPMA study.
Stephanie Wu, DPM, says peripheral nerve decompression may be effective when nerve compression and entrapment contribute to neuropathy. On the other hand, surgical decompression may not be as effective when nerve entrapment and compression do not contribute to neuropathy, notes Dr. Wu, an Assistant Professor in the Department of Surgery at the William M. Scholl College of Podiatric Medicine at Rosalind Franklin University School of Medicine.
Does the surgery provide greater relief than the various pharmaceuticals available? Medications for neuropathy, such as gabapentin (Neurontin, Pfizer) or duloxetine HCl (Cymbalta, Eli Lilly), distract the brain from the “pain message” and treatments such as Anodyne (Anodyne Therapy) have no proven long-term efficacy, according to Dr. Dellon. As he asserts, medication neither prevents nor alters the progressive loss of nerve functioning in those with neuropathy.
Furthermore, the JAPMA study suggests peripheral nerve decompression may decrease patients’ post-op need for medications. Ninety-nine patients had taken pain medication before surgery while only 22 continued taking the same dose of medication after surgery, according to the study.
When it comes to treating neuropathy with medication, Dr. Wu says no drug available in the United States would repair the underlying nerve damage and have the effect on balance as the JAPMA study reported of the peripheral nerve decompression. While she notes that alpha lipoic acid has shown promise in treating diabetic peripheral and autonomic neuropathy, Dr. Wu says its affect on proprioception was not assessed during randomized trials.
However, noting that decompression may not be indicated for all those who have diabetic neuropathy, Dr. Wu cautions DPMs to weigh the risks versus benefits preoperatively and thoroughly review them with the patient. Dr. Dellon notes he does not operate on patients with diabetes unless the diabetes is under control.
Dr. Wu does not think patients with neuropathy would be reluctant to undergo surgery.
“In fact, numerous patients inquire about surgical decompression. With technological advances (such as the Internet), patients are more knowledgeable regarding their pathology and treatment options,” explains Dr. Wu. “I have had numerous patients, frustrated with the lack of complete symptomatic relief from their current treatment regimen, inquire about surgical options for their painful diabetic neuropathy.”
By Brian McCurdy, Associate Editor
The use of ultrasound to treat wounds has been well documented in recent years but a recent randomized, double-blind study shows the efficacy of delivering the ultrasound therapy via a saline mist. Researchers conclude the ultrasound not only has a positive effect on healing but also has an antimicrobial effect.
The study, published in Ostomy/Wound Management, tracked 55 patients with diabetic ulcers. Patients received either 40 KHz of ultrasound delivered by the MIST™ system (Celleration, Inc.) or a placebo treatment. Clinicians also provided all patients with the standard of care, which included facilitating a moist wound environment, debridement and offloading. After 12 weeks, researchers found the rate of wound healing was 40.7 percent in the ultrasound group versus 14.3 percent in the placebo group.
What advantages does ultrasound therapy offer? William J. Ennis, DO, the lead author of the study, cites the four-minute speed of the painless treatment and says there is no contact with the wound bed due to the saline vehicle. Ultrasound therapy also provides benefits such as increasing blood flow to the wound bed, cleansing and debridement, according to Dr. Ennis, the Medical Director of the Wound Treatment Program at Advocate Christ Medical Center in Oak Lawn, Ill.
Dr. Ennis says ultrasound therapy also provides an antimicrobial benefit, citing preliminary data that shows the disruption of methicillin resistant Staph aureus (MRSA) and Pseudomonas. He notes he will be researching the mechanism of the antimicrobial effect next year.
In addition, he notes there are other theoretical benefits that have yet to be proven. Noting that decreased vascular endothelial growth factor (VEGF) may prohibit healing, Dr. Ennis says there may be increased VEGF when tissues are exposed to ultrasound.
Dr. Ennis says the efficacy of ultrasound in treating ulcers is favorable in comparison to treatments such as Regranex, Dermagraft and Apligraf.
“It does seem to be very effective for not only diabetic ulcers but for other wound types,” says Dr. Ennis.
By Brian McCurdy, Associate Editor
With potential increases in Medicare patient premiums and potential decreases in physician payments looming on the horizon next year, the American Podiatric Medical Association (APMA) is lobbying legislators for relief.
Patient premiums are reportedly rising 13 percent in 2006 while physician payments may be cut by 4.3 percent. The Centers for Medicare and Medicaid Services (CMS) notes the cut in physician payments is necessary due to a statutory formula that measures substantial overall growth in Medicare’s 2004 spending. Such funding changes will affect both DPMs and their patients, according to APMA President Harold Glickman, DPM.
“Physicians encounter rising practice costs every year. Rent costs more, clinical staff expects a raise and supplies are more expensive,” says Dr. Glickman. “If payments decrease, many physicians may decide they can longer participate in the Medicare program. As a result, many physicians may stop seeing Medicare patients.”
Dr. Glickman also cites the fact that some Medicare patients live on fixed incomes and cannot afford higher premiums while many who can afford such premiums may have trouble finding a podiatrist willing to participate in Medicare.
What can CMS do to alleviate the situation? Dr. Glickman notes that for several years, the APMA has been part of a coalition of over 70 medical practitioner groups working with the CMS and Congress for change. Such a change would still result in cuts in 2006 payments but Dr. Glickman says the estimated decrease would be less than what is currently projected.
The APMA and its coalition are also working with Congress to eliminate the physician update formula upon which the Sustainable Growth Rate is based. The proposal suggests replacing it with a formula based on the Medicare Economic Index. As Dr. Glickman says, the change to the formula would, in theory, reimburse physicians more realistically for the costs of healthcare delivery.
The American Board of Podiatric Orthopedics and Primary Podiatric Medicine (ABPOPPM) has established the sunset year of 2007 for eligibility for its certification exam for those who have one year of qualifying residency training (POR or PPMR) and are not already board-qualified by ABPOPPM.
In regard to the Editor’s Perspective column in the September issue (see “Is Sports Medicine Getting Short Shrift At The Schools?” on page 17), the Temple University School of Podiatric Medicine does offer a semester-long course in Sports Medicine during the third year for podiatric students.