Nurse/podiatrist-led clinic for patients with non-ulcerated painful neuropathy
1
MODEL OF GOOD PRACTICE 140 Pract Diab Int June 2002 Vol. 19 No. 5 Copyright © 2002 John Wiley & Sons, Ltd. Model of Care Although the unpleasant and perplexing symptoms associated with diabetic peripheral neuropathy have been recognised for over 200 years, the treatment is often unsatisfactory. This is emphasised in various therapeutic combinations available, prescribed to the suf- ferer. The pain, which is characteristically worse at night, for many has the knock-on effect of poor quality sleep, aggravating the mis- ery of the condition. The prevalence of peripheral neuropathy in the diabetic popula- tion ranges from 10 to 100%, reflecting differing methods and cri- teria used to diagnose the condition and the observation that many diabetic patients with neuropathy have no symptoms. Unfortunately, for many patients developing painful neuropathy there is a lack of a structured approach to the problem, with many being lost in the general chaos of a ‘routine’ diabetes clinic. In Bournemouth, we have established a service for these diabetic ‘lost souls’ with non-ulcerated painful neuropathy, the Neuropathy Assessment Clinic, run by a Senior 1 Podiatrist and an F Grade Nurse with pre-determined protocols for investigations and treatment. The clinic runs fortnightly with 4–6 patients scheduled, with weekly telephone calls thereafter. There is immediate access to a consultant although not present in the clinic for advice and pre- scribing of various treatments if required. Within the clinic three distinct types of pain, based on potential anatomical and neuropathophysiological origins, can be identified. ● Superficial pain (burning and tingling) in a cutaneous or sub- cutaneous distribution. The pains and abnormal sensations can be summarised by the terms hyperalgesia, describing an increased intensity of pain caused by a normally painful stimu- lus, or allodynia, where a normally non-painful stimulus such as gentle tactile stimulation causes pain. ● Deep pain (pins and needles, lanciating and electric-shock-like). ● Muscular pain (cramping, aching and muscle tenderness). Although secondary causes of painful neuropathy occurring in a diabetic patient are rare, they should be considered and appropri- ate investigations carried out. In our own practice we routinely check for syphilis serology, vitamin B12 and folate levels, serology for coeliac disease, autoimmune profile, immunoglobulins, creati- nine, thyroid function and protein electrophoresis, although the return is low. This intensive level of investigation does not reduce the level of access to our clinic but the results aid in our full assess- ment of the individual patient. Numerically, excessive alcohol use or previous exposure to drugs associated with neuropathy may be relevant. As part of the work- up a Doppler assessment of ankle:brachial pressure indices is also performed. Formal biomechanical assessment is indicated to exclude other conditions such as tarsal tunnel syndrome or referred pain from other joints. The assessment includes pain severity (McGill questionnaire), sensation including vibration perception threshold and examina- tion of footwear. Educational advice about footcare is available with referral to orthotics as necessary. Data from clinical trials have confirmed the efficacy of drugs including tricyclic antidepressants, anti-convulsants, local anaesthetics and topical treatments. The challenge in treating the individual patient is finding which medication provides the best symptomatic relief and at a dose which has the fewest side effects. Within the clinic there are protocols for the initiation of topical and oral agents depend- ent on the nature of the pain. Commonly used drugs include parac- etamol, Opsite spray, Capsaicin cream, amitriptyline and gabapentin. The clinic staff have access to Diabetes Nurse Specialists and dietetic services for optimising glycaemic control, which includes, where appropriate, the use of insulin pump therapy. For those patients with persisting problems there is a consult- ant/podiatrist led neuropathy clinic for more specialist guidance. Advantages Painful diabetic neuropathy is unpleasant, troublesome and time consuming for both patient and the health care professional. This system allows for rapid access, individualised treatment plans and a structured approach to assessment by single observers, thus reduc- ing bias. Visual analogue assessments of pain and sleep scores are used to assess the efficacy of treatment. Above all education, sup- port, appropriate pain management and the potential remitting nature of the condition is emphasised on a regular basis. Despair is best treated with hope not dope (Richard Asher). Costs The costs are to cover an F grade nurse and a Senior 1 Podiatrist on a sessional basis. Evaluation Data on 60 patients (34 female) are available (age 64 ± 14 years, HbA 1c 8.6± 2.1%). 20% have evidence of concurrent peripheral vascular disease (ABPI < 0.9%), 3% vitamin B12 deficiency and 4% undetected chronic syphilis infection. 30% of patients required referral to the orthotics service. Nurse/podiatrist-led clinic for patients with non-ulcerated painful neuropathy June Murphy, Claire Best, David Cavan and David Kerr* June Murphy, Claire Best, David Cavan and David Kerr, Bournemouth Diabetes and Endocrine Centre, Royal Bournemouth Hospital, Castle Lane East, Bournemouth BH7 7DW, UK Correspondence to: David Kerr, Royal Bournemouth Hospital, Castle Lane East, Bournemouth BH7 7DW, UK Treatment initiated: Paracetamol Opsite Capsaicin Amitriptyline Gabapentin 33% 53% 8% 20% 8% The Neuropathy Assessment Clinic Referral Form is available online on diabetesonestop. www.diabetesonestop.com
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Transcript of Nurse/podiatrist-led clinic for patients with non-ulcerated painful neuropathy
M O D E L O F G O O D P R A C T I C E
140 Pract Diab Int June 2002 Vol. 19 No. 5 Copyright © 2002 John Wiley & Sons, Ltd.
Model of CareAlthough the unpleasant and perplexing symptoms associated withdiabetic peripheral neuropathy have been recognised for over 200years, the treatment is often unsatisfactory. This is emphasised invarious therapeutic combinations available, prescribed to the suf-ferer. The pain, which is characteristically worse at night, for manyhas the knock-on effect of poor quality sleep, aggravating the mis-ery of the condition.
The prevalence of peripheral neuropathy in the diabetic popula-tion ranges from 10 to 100%, reflecting differing methods and cri-teria used to diagnose the condition and the observation that manydiabetic patients with neuropathy have no symptoms.Unfortunately, for many patients developing painful neuropathythere is a lack of a structured approach to the problem, with manybeing lost in the general chaos of a ‘routine’ diabetes clinic.
In Bournemouth, we have established a service for these diabetic‘lost souls’ with non-ulcerated painful neuropathy, the NeuropathyAssessment Clinic, run by a Senior 1 Podiatrist and an F Grade Nursewith pre-determined protocols for investigations and treatment.
The clinic runs fortnightly with 4–6 patients scheduled, withweekly telephone calls thereafter. There is immediate access to aconsultant although not present in the clinic for advice and pre-scribing of various treatments if required.
Within the clinic three distinct types of pain, based on potentialanatomical and neuropathophysiological origins, can be identified.● Superficial pain (burning and tingling) in a cutaneous or sub-
cutaneous distribution. The pains and abnormal sensations canbe summarised by the terms hyperalgesia, describing anincreased intensity of pain caused by a normally painful stimu-lus, or allodynia, where a normally non-painful stimulus such asgentle tactile stimulation causes pain.
● Deep pain (pins and needles, lanciating and electric-shock-like).● Muscular pain (cramping, aching and muscle tenderness).Although secondary causes of painful neuropathy occurring in adiabetic patient are rare, they should be considered and appropri-ate investigations carried out. In our own practice we routinelycheck for syphilis serology, vitamin B12 and folate levels, serologyfor coeliac disease, autoimmune profile, immunoglobulins, creati-nine, thyroid function and protein electrophoresis, although thereturn is low. This intensive level of investigation does not reducethe level of access to our clinic but the results aid in our full assess-ment of the individual patient.
Numerically, excessive alcohol use or previous exposure to drugsassociated with neuropathy may be relevant. As part of the work-up a Doppler assessment of ankle:brachial pressure indices is also
performed. Formal biomechanical assessment is indicated toexclude other conditions such as tarsal tunnel syndrome or referredpain from other joints.
The assessment includes pain severity (McGill questionnaire),sensation including vibration perception threshold and examina-tion of footwear.
Educational advice about footcare is available with referral toorthotics as necessary.
Data from clinical trials have confirmed the efficacy of drugsincluding tricyclic antidepressants, anti-convulsants, local anaestheticsand topical treatments. The challenge in treating the individualpatient is finding which medication provides the best symptomaticrelief and at a dose which has the fewest side effects. Within the clinicthere are protocols for the initiation of topical and oral agents depend-ent on the nature of the pain. Commonly used drugs include parac-etamol, Opsite spray, Capsaicin cream, amitriptyline and gabapentin.
The clinic staff have access to Diabetes Nurse Specialists anddietetic services for optimising glycaemic control, which includes,where appropriate, the use of insulin pump therapy.
For those patients with persisting problems there is a consult-ant/podiatrist led neuropathy clinic for more specialist guidance.
AdvantagesPainful diabetic neuropathy is unpleasant, troublesome and timeconsuming for both patient and the health care professional. Thissystem allows for rapid access, individualised treatment plans and astructured approach to assessment by single observers, thus reduc-ing bias. Visual analogue assessments of pain and sleep scores areused to assess the efficacy of treatment. Above all education, sup-port, appropriate pain management and the potential remittingnature of the condition is emphasised on a regular basis.
Despair is best treated with hope not dope (Richard Asher).
Costs The costs are to cover an F grade nurse and a Senior 1 Podiatrist ona sessional basis.
EvaluationData on 60 patients (34 female) are available (age 64 ± 14 years,HbA1c 8.6± 2.1%).
20% have evidence of concurrent peripheral vascular disease(ABPI < 0.9%), 3% vitamin B12 deficiency and 4% undetectedchronic syphilis infection. 30% of patients required referral to theorthotics service.
Nurse/podiatrist-led clinic for patients withnon-ulcerated painful neuropathy
June Murphy, Claire Best, David Cavan and David Kerr*
June Murphy, Claire Best, David Cavan and David Kerr,Bournemouth Diabetes and Endocrine Centre, Royal BournemouthHospital, Castle Lane East, Bournemouth BH7 7DW, UK
Correspondence to:David Kerr, Royal Bournemouth Hospital, Castle Lane East,Bournemouth BH7 7DW, UK
Treatment initiated:Paracetamol Opsite Capsaicin Amitriptyline Gabapentin
33% 53% 8% 20% 8%
The Neuropathy Assessment Clinic Referral Form is availableonline on diabetesonestop. www.diabetesonestop.com
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