Method and apparatus to assess early stages of peripheral distal neuropathy in diabetic patients

Abstract

A method and apparatus to assess sudomotor function to detect early stage peripheral distal neuropathy. The method sends a low voltage direct current of 1 to 5 volts between pairs of electrodes for a time of between 15 and 60 seconds, switches the current at the middle of the time and measures the peak and slope of the decreased conductance. The method can be used to assess skin blood flow and/or sweat gland density depending on the direction of the current.

Claims

1. A device for detecting early stages of peripheral neuropathy, comprising: a set of 2 to 8 tactile electrodes configured for placement on a patient's skin, wherein each tactile electrode is configured for operating both as an active and a passive electrode; a low frequency filter coupled to one or more tactile electrodes of the set of tactile electrodes, wherein the low frequency filter generates a reference voltage signal from 1.28 V to 4 V direct current or alternating current at a frequency less than 100 Hz; a computing device communicatively coupled with said set of tactile electrodes, the computing device configured for controlling a polarity and a sequence of activation of each tactile electrode, the computing device further configured for: designating at least one of the set of tactile electrodes as a positive electrode and designating at least one of the set of tactile electrodes as a negative electrode; applying a voltage via the low frequency filter from the positive electrode to the negative electrode and measuring peak conductance after switching the voltage from the positive electrode to the negative electrode, wherein if the peak conductance after switching the voltage from the positive electrode to the negative electrode is less than 65 micro Siemens or 0.83 Volts, then determining that stage 1 peripheral neuropathy is detected, and displaying said determination; and applying a voltage via the low frequency filter from the negative electrode to the positive electrode and measuring peak conductance after switching the voltage from the negative electrode to the positive electrode, wherein if the peak conductance after switching the voltage from the negative electrode to the positive electrode is less than 90 micro Siemens or 1.23 Volts, then determining that stage 2 peripheral neuropathy is detected, and displaying said determination.

2. The device as claimed in claim 1, the computing device further configured for: applying a constant low voltage direct current from the positive electrode or the negative electrode to a contralateral electrode placed on 2 separate skin areas of the patient for a time period between 15 to 60 seconds; and switching the low voltage direct current at a midpoint of the time period and analyzing changes in conductance, voltage, intensity or resistance.

3. A device as claimed in claim 1, the computing device further configured for: performing electrical skin stimulation according to the following sequence: applying a voltage from the negative electrode to the positive electrode, switching polarity of the voltage that was applied from the negative electrode to the positive electrode, applying a current from the positive electrode to the negative electrode and switching the polarity of the voltage from the negative electrode to the positive electrode.

4. A device as claimed in claim 1, the computing device further configured for: generating a score for detection of peripheral neuropathy based on the peak conductance that was measured.

5. A device as claimed in claim 4, the computing device further configured for wherein if the score that was generated is greater than 50% of a total possible score, then determining that stage 1 peripheral neuropathy and/or stage 2 peripheral neuropathy has been detected in a diabetic patient, and displaying said determination.

Description

(1) The invention is further described with reference to the accompanying non limiting figures wherein

(2) FIG. 1 is a flow diagram of the apparatus and steps in a preferred embodiment of the invention

(3) FIG. 2 shows the traces generated in the phases of the measurement including the peak and slopes.

HARDWARE

(4) With reference to the diagram of FIG. 1, in a preferred embodiment of the apparatus the device has 2 to 8 tactile electrodes placed on skin areas with the highest sweat gland density. Each electrode can be active (10) or passive (12) and sequence and polarity are both managed by the software. There is a filter of low frequency (14), repeaters (16), (18), a reference voltage unit (20), analog-digital converter (ADCserial type AD7828) (22), electrical isolation (24), electrical isolation (26) to digital buses, high frequency filter (28), USB-controller (30), generator (32), circuit (34), memory (ROM) (36), power bus (38) and USB connectors (40) to the USB-port of the computer.

(5) Signal Pathway:

(6) Block (20) generates the reference voltage signal (from 1.28 V to 4V), in DC or frequency <100 Hz that is fed to the active electrode (10) that is connected to the skin of the patient. Then the signal passes through the liquid compartment of the patient and reaches the skin in contact with passive electrode (12). The noise is filtered, by passing through the low frequency filter (14) and then through repeaters (16, 18) providing galvanic isolation and then the signal processing analysis is performed at the analog-digital converter (ADC) (22). ADC converts the signal to digital code. The digital code goes through a galvanic isolation (26) to USB controller (30) and then is released to the slot (40) of the USB port of the computer for the further processing analysis by the software.

(7) The invention provides a new process to assess two components of the sudomotor pathway using hardware and software (SudoPath system) in order to screen the early stages of peripheral distal neuropathy in diabetic patients.

(8) The invention is a new improved process. The method uses pair(s) of tactile electrodes and is performed by electrical stimulation of the skin via passive electrode and contralateral electrical stimulation of the skin capillaries and C-fibers that provoke hyperemia and exit of water and ions on the bulk of the active electrode. The exit of water and ions provoke an electrochemical reaction that is measured as a current in millivolts or milliAmperes or resistance or conductance.

(9) The software receives the digital code of the ADC and can display the values in a graphic as shown in FIG. 2.

(10) During the measurement, the software controls the sequence for each electrode activation and the polarity of the signal (electrical stimulation).

(11) Phase 1 (P1): the voltage is sent from negative electrode () to positive electrode (+). The voltage is positive.

(12) Phase 2 (P2): the polarity of the voltage is switched from positive (+) to negative () electrode, the voltage is negative, there is no ion migration and the release of NO increases the skin blood flow and the slope of the decrease of conductance of the peak in phase 2 is detected in the graphic: The slope of the decreased of conductance of the peak in phase 2 reflects the blood flow of the skin in contact with the negative electrode. We named the slope of conductance in phase 2 Electro Skin Response Nitric oxide (ESRNO).

(13) Phase 3: (P3) the current is sent from positive electrode (+) to negative () electrode. The voltage is negative.

(14) Phase 4: (P4) the polarity of the voltage is switched from negative () to positive (+) electrode, the voltage is positive, the negative ions (preferably OH) migrated and a peak of conductance is detected in the graphic as well as the slope of the decreased of conductance in phase 4.

(15) The peak of conductance of the phase 4 and the slope of the decreased of conductance in phase 4 reflects the sweat gland function in the skin in contact with the positive electrode. We named the peak of conductance value Peak C (PC) and the slope of conductance in phase 4 Electro Skin Response negative ions (ESR i).

(16) In summary, the present invention is based upon the switch of polarity of the voltage during the measurement of each pathway between the pairs of electrodes and this method allows the possibility to separate the 2 effects of the electrical stimulation of the C-Fiber.

(17) Normal range of the 3 measured markers was evaluated in clinical studies with a supposed population without skin blood flow decreased or sweat function reduced

(18) ESRNO Normal range is greater than 65 Si or 0.83 Volt ESR i Normal range is greater than 65 Si or 0.83 Volt Peak C Normal range is greater than 90 Si or 1.23 Volts

(19) No differences were found according to gender and weight or height of the tested population. However, elderly subjects have a lower voltage comparing to the young subjects (average of 15%).

(20) ESRNO less than 65 Si suggests skin blood flow is decreased and phase 1 of peripheral distal neuropathy in diabetic patients and ESR i less than 65 Si or Peak C less than 90 Si {umlaut over (.Math.)} suggest reduced sweat gland function and phase 2 of peripheral distal neuropathy in diabetic patients. Both of these conditions suggest early signs of peripheral distal neuropathy and causes should be considered and appropriate action taken to prevent further nerve damage and the need for more disruptive treatments in the future.

(21) Early stage (1 and 2) of peripheral distal neuropathy score

(22) A Sudomotor Response (SMR) score is calculated using the 3 markers of the invention

(23) Each marker is scored as follow: ESRNO>=65 Si=>Score=0 ESRNO<65 and >=40 Si {acute over ({umlaut over (.Math.)})}=>Score=1 ESRNO<40 Si=>Score=2 ESR i>=65 Si=>Score=0 ESR i<65 and <=40 Si=>Score=1 ESR i<40 Si {umlaut over (.Math.)}=>Score=2 Peak C>=90 Si=>Score=0 Peak C>90 and >=70 Si=>Score=1 Peak C<70 Si=>Score=2

(24) The SMR Score is the sum of the score of each marker. The score can also be displayed as a number of as percent scale from 0 to 100.

(25) Clinical Study 1

(26) New approach in Type 2 Diabetes treatment management and early detection of complications.

(27) Pratiksha G Gandhi, Cardiologist, Mumbai, India

(28) Pr Gundu H. R. Rao, Ph.D University of Minnesota

(29) Summary

(30) Background: Since type 2 diabetes has become a pandemic disease in the last 10 years, and lab tests methods have failed in screening of diabetes and to detect complications before onset, this study aims to evaluate markers for diabetes by assessing endothelial function and autonomic nervous system.

(31) Materials and Method:

(32) One hundred sixty four patients were included in the study.

(33) The patients were separated in 4 groups:

(34) Group 1: One hundred two patients (70 males), with the mean age of 56 years (range 26-90), BMI 29 who were diagnosed with type 2 diabetes and undergoing treatment.

(35) Group 2: Subgroup of Group 1 comprised of twenty-five patients (16 males) with mean age of 66 years (range 56-88) and had signs and symptoms of peripheral neuropathy such as tingling, burning or electric-like pain or extreme sensitivity to touch in feet.

(36) Group 3: Subgroup of Group 1, comprised of sixty-seven patients (42 males) with mean age of 45 years (range 25-85) but did not have signs or symptoms of peripheral neuropathy.

(37) Group 4: Sixty-two patients with the mean age of 40 years (range 22-85) who are in healthy condition, have had no diagnosis of diabetes or signs/symptoms of foot neuropathy or autonomic neuropathy.

(38) All groups of patients underwent examination with the TM-Oxi and SudoPath system at IPC Heart Care Centre (Mumbai, India) for assessing autonomic nervous system and endothelial function. The SudoPath system uses a galvanic skin response technology to assess post sympathetic cholinergic fiber in order to detect skin microcirculation disorders (ESRNO) and sweat gland density (ESRC1 and PeakC). The system provides a Sudomotor Response Score (SMR Score) based on these 3 parameters for early detection of peripheral neuropathy.

(39) Statistical analysis was performed using Receiver-Operating Characteristic (ROC) curves to determine the specificity and sensitivity of markers and scoring system comparing diabetic group and healthy subjects as well as diabetic subgroups with symptoms and without symptoms.

(40) Results:

(41) Comparing the diabetes patients group (group 1) and healthy subjects (group 4) ESRNO returned a sensitivity of 68.6% and specificity of 87.1% (cutoff #>49) (P=0.0001). Area under the Roc curve (AUC)=0.865.

(42) Comparing the diabetes subgroups with symptoms of peripheral neuropathy (group 2) and the diabetes patients group without symptoms of foot neuropathy (group 3), SMR Score had a sensitivity of 91.4% and specificity of 79.1% (cutoff #>3) to detect foot neuropathy symptoms in diabetic patients (P=0.0001). Area under the Roc curve (AUC)=0.858.

(43) Conclusion:

(44) In conclusion, SudoPath will be useful to assess the susceptibility of patients with type 2 diabetes to develop peripheral neuropathy, thus reducing the occurrence of these complications in the long term.

(45) Clinical Study 2 (Updated Study)

(46) Gandhi P G, Rao G H. Detection of neuropathy using a sudomotor test in type 2 Diabetes. Degenerative Neurological and Neuromuscular Disease. January 2015, 5:1-7

(47) Summary

(48) Background: The sudomotor test is used to evaluate the postganglionic cholinergic sympathetic nervous system. The aim of this study was to evaluate the efficacy of a sudomotor testing device to detect peripheral distal neuropathy (PDN) and cardiac autonomic neuropathy (CAN) in patients with type 2 diabetes.

(49) Materials and methods: A total of 133 type 2 diabetic patients were included in the study. The patients underwent examination at the IPC Heart Care Centre (Mumbai, India) in order to assess the diabetic neuropathy symptoms (DNS) score, using a questionnaire and the CAN score, using heart rate variability analysis and Ewing tests. In addition, patients were given a sudomotor test using the SudoPath system. The diagnosis of PDN is based on the DNS score. A DNS score of 1 or higher is defined as a positive result for PDN. According to the DNS score, the patients were separated into two groups: Group 1 comprised 35 patients (21 males), with the mean age of 66 years (standard deviation [SD]=12.1), who had a DNS score 1. Group 2 comprised 98 patients (65 males), with the mean age of 56 years (SD=9.6), who had a DNS score=0. The SudoPath system is a galvanic skin response device that uses the quantitative sudomotor axon reflex approach to assess for small and unmyelinated fiber neuropathy. The system provides a sudomotor response (SMR) score based on these three measured sudomotor parameters. A statistical analysis was performed using the analysis of variance to compare mean differences between the groups as well as receiver operating characteristic (ROC) curves, to determine the specificity and sensitivity of SMR score to detect PDN, comparing the diabetic groups 1 and 2, and the coefficient of correlation between the CAN score and the SMR score in all the subjects included in the study.

(50) Results: When comparing the diabetes groups 1 and 2, the SMR Score had a sensitivity of 91.4% and specificity of 79.1% (cutoff number >3) to detect PDN (P=0.0001). Area under the ROC curve (AUC)=0.893. A correlation analysis of the CAN score and SMR score returned a coefficient of correlation r=0.68 (P<0.0001).

(51) Conclusion: The SudoPath system is easy to use, operator-independent, and fast (3-minute testing time). This study shows that the device will be useful to assess the susceptibility of type 2 diabetes patients in developing PDN complications.

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