A HIGHLY SUCCESSFUL AND NOVEL MODEL FOR TREATMENT OF CHRONIC PAINFUL DIABETIC PERIPHERAL NEUROPATHY

OBJECTIVE - To investigate why, in spite of a vast variety of treatmen t agents, the alleviation of pain in patients with diabetic neuropathy is difficult. Previous studies have not used a treatment algorithm ba sed on anatomic site and neuropathophysiological source of the neuropa thic pain. RESEARCH DESIGN AND METHODS - A model that categorizes the types of pain into three groups (superficial, deep, and muscular) was applied in 75 diabetic patients with chronic (> 12 mo) painful distal symmetrical polyneuropathy in a controlled case series. Twenty-two pat ients were untreated and 53 patients were treated with imipramine +/- mexiletine for deep pain, capsaicin for superficial pain, and stretchi ng exercises and metaxalone +/- piroxican for muscular pain. Each type of pain was scored separately on a scale of 0 (none) to 19 (worst), a nd the total of all three types was used as an index of overall pain. Ability to sleep through the night was scored by a scale of 1 (never) to 5 (always). RESULTS - No significant differences were observed in i nitial pain scores, sleep scores, demographics, biochemistries, or phy sical findings between the two groups. After 3 mo a significant improv ement in scores was noted in the treated but not the untreated patient s. In addition, a significant difference was found in the change of sc ores between die treated and untreated patients: total pain (- 18 +/- 2 vs. 0 +/- 2), deep pain (- 7 +/- 1 vs. 0 +/- 1), superficial pain (- 5 +/- 1 vs. 0 +/- 1), muscular pain (-6 +/- 1 vs. 0 +/- 1), and sleep (1.2 +/- 0.2 vs. 0.2 +/-0.2), all P < 0.0001. In treated patients 21% became pain-free (total pain < 2), 66% had improvement (decrease in to tal pain >5, but not total elimination of painful symptoms), and 13% w ere considered treatment failures (a decrease in total pain of less-th an-or-equal-to 5). This compares with 0 (P < 0.02), 10 (P < 0.0001), a nd 90% (P < 0.0001), respectively, in the untreated patients. CONCLUSI ONS- This study presents a new rationale and hypothesis for the succes sful treatment of chronic painful diabetic peripheral neuropathy. It u niquely bases the treatment algorithm on the types and sources of the pain.