A Novel Non-Pharmacological Treatment of Diabetic Neuropathy

The objective of the proposed work is to develop non-pharmacological interventions for diabetic peripheral neuropathy (DPN), to improve quality of life of individuals with diabetes, and reduce the prevalence of opiate prescription, sensation loss, falls, and deaths caused by DPN. To this end, the proposed study will investigate and determine the feasibility of the non-pharmacological intervention device. The feasibility study involves 16 participants, split evenly between pre-neuropathic diabetic and neuropathic diabetic participants. During the study, each group will receive the same 45-minute intervention on 10 days spread over no more than 14 days total. Feasibility will be determined by change in pain assessed before and after intervention.

Study Overview

• Status: Recruiting
• Conditions: Diabetic Peripheral Neuropathy
• Intervention / Treatment: Device: Non-pharmacological Heat, Pressure, and Vibration

Detailed Description

To address a gap in DPN treatments, we propose a pragmatic approach towards the development of mechanistically justified therapies to treat DPN. Specifically, we seek to explore undertested non-pharmacological approaches to DPN management through a pilot study establishing safety and feasibility as quantified by biomechanical and sensory-perception changes.

The innovation central to this approach is in the multifactorial combination of pressure, heat, and vibration stimuli to improve foot sensation by 1) reducing edema in the foot and leg via improved venous return and lymphatic return, 2) improving arterial flow both in large, small, and micro-vascular vessels, 3) stimulating endothelial mechanisms like the increase of nitrous oxide that increases microvascular health through alternating compressive pressures from the foot to the thigh, and 4) stimulating nerves through vibration to facilitate nerve repair. This approach has the potential to address an unmet need in DPN, namely, interventions that can address underlying causes of neuropathy. To this end, the proposed research has two specific aims: 1) the construction of a device capable of applying pressure, heat, and vibration to the entire lower extremity for treatment of neuropathy and 2) validation of safety and feasibility of the non-pharmacological intervention device.

At the beginning of the study, foot sensation and blood flow baseline measures will be taken with the foot sensation diagnostic tool and phase-contrast MRI with a foot/ankle coil (Siemens Foot/Ankle 16) at the Auburn University MRI Research Center, respectively. The foot sensation diagnostic tool has undergone testing with over 100 participants with diabetes, and has shown the ability to establish the threshold sensitivity of the sole of the foot from 0.5 to 10 grams force, an order of magnitude more accurate than the standard clinical monofilament-based measure used to establish foot sensitivity and diagnose DPN. The phase-contrast MRI is a highly accurate measure of blood flow, which we will use to validate the mechanistic hypothesis of the proposed non-pharmacological intervention. The phase-contrast MRI does not require the use of contrast-enhancing dyes, and will therefore exclude fewer diabetic participants than contrast-enhanced MRI scans.

During the study, each participant will receive the same 45-minute intervention on 10 days spread over no more than 14 days total, in a similar manner to IPC studies. At the end of each session, pain will be assessed on scales such as the Defense and Veterans Pain Rating Scale (DVPRS) to establish the safety of the proposed intervention. Feasibility will be determined of time to set up, put on, and take off the device. Pre-study baseline measurements of foot sensation via the assessment tool will be compared to post-study measurements to establish any beneficial effect and provide variance for a power analysis to guide the design of future studies. We hypothesize that non-neuropathic diabetic participants may have subclinical neuropathic symptoms which cannot be measured by standard clinical tools but can be measured by the diagnostic device, which may identify the potential for the device to have preventative as well as treatment applications.

Sample Size Justification: A sample size of 16 subjects (8 with non-neuropathic diabetic and 8 with neuropathic diabetic participants) achieves 80% power to detect an effect size as measured in the change in pain scores of 0.55 using a paired t-test with a one tailed Type I error rate of 0.10. Examination of each subgroup will also be conducted. A sample size of 8 subjects achieves 80% power to detect an effect size as measured in the change in pain scores of 0.8 using a paired t-test with a one tailed Type I error rate of 0.10. Therefore, this small study will have statistical power to observe medium to large changes in pain rating (or foot sensation or blood flow). However, it must be noted that achieving statistical significance is not the primary objective of a pilot study. The primary objective is to demonstrate feasibility of the trial by initiating a small version of the trail, identifying areas requiring refinement, and collecting preliminary data provides preliminary evidence of intended effect.

• Study Type: Interventional
• Enrollment (Estimated): 16
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Chad G Rose, PhD; Phone Number: 8655672205; Email: chadgrose@auburn.edu
• Study Contact Backup: Name: Michael E Zabala, PhD; Phone Number: (334) 844-4916; Email: zabalme@auburn.edu

Study Locations

• United States
  • Alabama
    • Auburn, Alabama, United States, 36849
      • Recruiting
      • Auburn University
      • Contact: Chad G Rose, PhD; Phone Number: 334-844-3401; Email: chadgrose@auburn.edu

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• diagnosis of type 2 diabetes for at least 5 years
• lab histories that verify participant's control or lack of blood sugars dating back for a period of 1-5 years

Exclusion Criteria:

• other diseases or impairments that could affect results (vascular disease verified from medical history
• ankle-brachial index (ABI) of 0.9 or less

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Device Feasibility
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm

Intervention / Treatment

Experimental: Pilot Feasibility Arm; Each participant will receive the same 45-minute intervention on 10 days spread over no more than 14 days total. At the end of each session, pain will be assessed on scales such as the Defense and Veterans Pain Rating Scale (DVPRS) to establish the safety and feasibility of the proposed intervention.

Device: Non-pharmacological Heat, Pressure, and Vibration; The innovation central to this approach is in the multifactorial combination of pressure, heat, and vibration stimuli to improve foot sensation. The heat stimuli will be provided with commercially available heating elements. The pressure stimuli will be provided via pneumatic garment. Lastly, the vibrotactile stimuli will be provided with commercially available vibrotactile motors. The non-pharmacological DPN device will be able to safely and consistently control temperature to 100-105°F within 1°F, control pressure to 50 mmHg within 5 mmHg at 0.25 Hz, and provide 5 distinguishable vibrational stimuli to 5 zones on the leg and foot.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change from Baseline Pain Assessment	Defense and Veterans Pain Rating Scale (DVPRS)	immediately after each session (up to 30 minutes)

Collaborators and Investigators

• Sponsor: Auburn University
• Investigators: Principal Investigator: Chad G Rose, PhD, Auburn University

Publications and helpful links

General Publications

• Feldman EL, Nave KA, Jensen TS, Bennett DLH. New Horizons in Diabetic Neuropathy: Mechanisms, Bioenergetics, and Pain. Neuron. 2017 Mar 22;93(6):1296-1313. doi: 10.1016/j.neuron.2017.02.005.
• Lotz J, Meier C, Leppert A, Galanski M. Cardiovascular flow measurement with phase-contrast MR imaging: basic facts and implementation. Radiographics. 2002 May-Jun;22(3):651-71. doi: 10.1148/radiographics.22.3.g02ma11651.
• Buckenmaier CC 3rd, Galloway KT, Polomano RC, McDuffie M, Kwon N, Gallagher RM. Preliminary validation of the Defense and Veterans Pain Rating Scale (DVPRS) in a military population. Pain Med. 2013 Jan;14(1):110-23. doi: 10.1111/j.1526-4637.2012.01516.x. Epub 2012 Nov 8.

Study record dates

Study Major Dates

• Study Start (Actual): March 22, 2023
• Primary Completion (Estimated): December 31, 2024
• Study Completion (Estimated): June 1, 2025

Study Registration Dates

• First Submitted: June 7, 2022
• First Submitted That Met QC Criteria: June 8, 2022
• First Posted (Actual): June 10, 2022

Study Record Updates

• Last Update Posted (Actual): August 4, 2023
• Last Update Submitted That Met QC Criteria: August 2, 2023
• Last Verified: August 1, 2023

More Information

Terms related to this study

• Keywords: nonpharmacological intervention
• Additional Relevant MeSH Terms: Nervous System Diseases; Endocrine System Diseases; Diabetes Complications; Diabetes Mellitus; Neuromuscular Diseases; Peripheral Nervous System Diseases; Diabetic Neuropathies
• Other Study ID Numbers: 22-114

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: If requested, final, de-identified research data will be made available for sharing to qualified parties by the PI's, so long as such a request does not compromise intellectual property interests, interfere with publication, invade subject privacy, betray confidentiality, or precede data curation. All logs will be anonymized before storage.
• IPD Sharing Time Frame: Data will become available no later than 1 year after conclusion of the study, and for at least three years after the conclusion of the study.
• IPD Sharing Access Criteria: PI Approval.
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; ANALYTIC_CODE

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No