Welcome

Welcome to the Ledderhose disease (plantar fibroma) blog.

My name is Gary and I am the author of this blog. I am a ledderhose patient from the UK. I am an ex-scientist and hold a degree in Molecular Genetics and I try and put this experience to good use exploring this condition.

I have pages here about the treatment options, patient experiences including my own, insights from medical professionals, explanations of the science and whatever else I think may be useful for fellow patients. Through the blog I have made contacts with many patients, professionals and charities and now work as a trustee for the British Dupuytren's Society.

Hopefully you can find the pages you want using the navigation menu above or use the search box to look for specific information.

Hope you enjoy reading the blog and please contact me at ledderhosedisease@gmail.com or leave a message on here to get in touch. All information will be kept private unless you tell me otherwise.

Thank you for visiting.

Sunday, 28 September 2014

Calorie Restriction to help Dupuytren's and Ledderhose?

A literature review to analyse the link between calorie restriction and pathways associated with Dupuytren's disease

Over recent weeks I have heard several patients talking about calorie restriction and how eating a low calorie diet really seems to help with the pain that they were experiencing with Dupuytren's and Ledderhose and that when they stopped the diet it seemed to get worse. 


The IGF-2 link:



There is some logic behind this, after all I have already discussed how these conditions can be linked to IGF2 and IGF1 is linked to calorie restriction. However further research did not seem to come up with any evidence to suggest a good link between IGF1 and collagen. The only way I could see that the IGF2 information could help is as follows: 


  • I know that IGFBP6 binds to both IGF1 and IGF2, albeit more strongly to IGF2, and that calorie restriction causes a decrease in IGF1.
  • So of you have less IGF1 then the IGFBP6 is more likely to bind to IGF2, assuming that the concentrations are at a level where the increased availability of IGFBP2 still results in an increased binding affinity for IGF2. 

I think that the above is a little bit of a stretch but you never know. That was all I could find using IGF1 and collagen.

Figure 1: Overview of the impact of TGF-B1 on Collagen production and how calorie restriction impacting IGF-1 levels may result in a lowering of Collagen production.

Calorie Restriction and Collagen:



So instead of that I took a different approach and decided to look for a straight linked between calorie restriction and collagen. Here I managed to find a link, in that the following paper states that calorie restriction results in a decrease in collagen production, perhaps this would also hold true a) in humans b) under conditions where Dupuytren's is present. (Ref 1). I did not have full access to the paper so could not really see what they had done but it also states that this decreased collagen production also has a negative impact on would healing which of course relies, to some extent, on the same pathways as Dupuytren's. This may be a good thing for Dupuytren's or Ledderhose patients.  



The MMPs



Another key set of proteins in the extracellular matrix (ECM) is the MMP protein. These are involved in breaking things down and it has been shown that knock-down (removal in cells) of  MMP2 (Ref 2) inhibited cell mediated contraction. Interestingly there have been studies in rats that have shown that a calorierestricted diet results in a decrease in MMP2, so you could argue that a calorie restriction diet will lower MMP2 and that a lowered MMP2 will aid Dupuytren's and or Ledderhose. Furthermore they showed that it appears that calorie restriction also lowers the TGFB1 pathway which I discuss in the IGF2 link at the top. 


Figure 2: The role of MMP2 in Dupuytren's and the potential impact of calorie restriction on Dupuytren's and Collagen production. 

Collagen, the extra-cellular matrix and calorie restriction:



My final search I just thought I would have a look for ECM itself and calorie restriction and see what I could find and I found a couple of very interesting papers which I believe are both free to download. 



The first paper (Reference 4) is looking at the impact of calorie restriction in tumours. Interestingly they found that there was a decrease, as expected in IGF-1 which I have discussed above but they also observed that in calorie restricted mice there was a decrease in MMP2, which as discussed above is linked to the development of Dupuytren's. There was also a decrease in the levels of TGFB-1 which again I have also discussed above. 


Another protein that they mentioned that took my interested was collagen 4. Although Collagen 3 is the main component of the Dupuytren's lumps it is interesting that there are downstream effects on the levels of a collagen type. The second paper I am not going to go into as it basically has similar but less information as in the above paper though it does have a good picture on page 6 (Reference 5). 

The other side of the argument

You cannot construct a complete article without looking at both sides of the story. My research into this side was not as extensive because it is hard to find information disproving something that it just an idea but did bring up some interesting points.

The following paper (Ref 6) shows that despite the information I have seen above that TGF-B2 (yes 2 not 1, still looking into this but from what I have seen so far 1 and 2 act through the same pathways) does not affect the collagen levels in Dupuytren's cultures. In fact I am not sure what else to say on this side, if anyone has any information they would like to add then let me know.

Conclusions

Would having a calorie restricted diet hurt someone? It might but at the same time you can come off of it and may not have lost anything but you may have gained the used of your foot or stopped your hand from progressing. There is no information out there that says that it will work like that, in fact there is no direct evidence at all linking calorie restriction and Dupuytren's (for or against). The above data is a collection of the information that I could find that linked calorie restriction to pathways that have been linked to Dupuytren's. A lot of this data suggests that there could be some impact but there was nothing there that made me think that it definitely will work. 

As a non-medical professional I cannot endorse having a low calorie diet in general or a as a treatment for these conditions, although the information above suggests that it may have some impact. Note that many of the above studies were in cells or cancer and not in humans and none were related directly to Dupuytren's or related conditions. You should always consult a doctor before starting a very low calorie diet. If a doctor was interested in using this then I would be happy to work with them to look into this.

If any patients have experience of this and would like to share their story it would be great to add the information to the blog.

Other areas of interest

There is another signalling pathway called the Wnt signalling pathway. I know from back in my degree that this is using is development and it is still active in adults. I mention this pathway because it has been shown that a high number of Dupuytren's patients have SNPs (differences to everyone else) in genes that are associated with that patients (Ref 7). Although this is as far as the evidence go the Wnt signalling pathway has been linked to diabetes, cell growth and certainly warrants more investigation. 

Reference 1:
Access 29-09-2014
J 1995 Jan;50A(1):B40-7.Effects of aging and caloric restriction on extracellular matrix biosynthesis in a model of injury repair in rats.
http://www.ncbi.nlm.nih.gov/pubmed/7814778

Reference 2
 2012 Jun;1822(6):897-905. doi: 10.1016/j.bbadis.2012.02.001. Epub 2012 Feb 9. MMP-14 and MMP-2 are key metalloproteases in Dupuytren's disease fibroblast-mediated contraction.
http://www.ncbi.nlm.nih.gov/pubmed/22342364

Reference 3
Calorie Restriction Reduces MMP-2 Activity and Retards Age-associated Aortic Restructuring in Rats , Mingyi Wang et al
http://circ.ahajournals.org/cgi/content/meeting_abstract/114/18_MeetingAbstracts/II_335-b

Reference 4:
Caloric restriction reduces growth of mammary tumors and metastases - Mariana S. De Lorenzo et al
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3165123/

Reference 5
Molecular Mechanisms of Calorie Restriction’s Protection against Age-related Sclerosis, Elena Chiarpotto et al - http://onlinelibrary.wiley.com/doi/10.1080/15216540601106365/pdf

Reference 6
Enhanced Dupuytren's disease fibroblast populated collagen lattice contraction is independent of endogenous active TGF-βRaymond Tse14, Jeffrey Howard124, Yan Wu14 and Bing Siang Gan1234*
http://www.biomedcentral.com/1471-2474/5/41

Reference 7
Wnt Signaling and Dupuytren's Disease, Guido H. Dolmans,  et al
http://www.nejm.org/doi/full/10.1056/NEJMoa1101029

Tuesday, 23 September 2014

Progression of Ledderhose disease

Below is some information that a visitor to the blog felt was missing. They said they had some information on it and they were happy to write it up. All information is posted with their permission, in fact they wrote it for the purpose of me posting it. 

It is true that I do not have much information on the progression of the disease, this is partly because, as you can see below, there is not a huge amount of information out there and secondly because I started the blog looking at treatments as that was the stage as I was. So for all of those that are new to the condition you may find the information below interesting to read. I felt that the paragraphs below were not enough to warrant a complete post so I conducted a small survey to complement the information. 

There is very little statistical information on the potential progression of Ledderhose Disease (LD)/Plantar Fibroma (PF).  There are individual disease trajectories provided by individuals on various patient forums. These patient histories can not be properly weighed as indicative of the normal course of the disease because there is no broad sampling of patients, no regular follow up, no quantitative measurements.  Therefore, the reader does not know if these patients are outliers or the norm.  In addition, there may be completely fabricated patient histories that have been authored by unscrupulous people preying on the fear and desperation of patients to sell their products.

The most rigorous published scientific studies that I have found on the LD have been performed by German researchers who were investigating the effectiveness of radiation therapy on Dupuytren's Disease (DD) and Ledderhose Disease(LD).  What is of most value in these studies is their use of a control (untreated) population.  For example, Seegenschmiedt[1] reported that for a control patient population of 47 people with 67 affected feet with minimal symptoms, 6 year average time of observation, minimum observation time of 1 year, 10 feet (15%) had a spontaneous remission, 34 feet (51%) remained stable, and 23 feet (34%) progressed and required treatment.  

These data are quite remarkable as they indicates that for a large percentage of LD patients  (66%), the expected disease trajectory is stability or regression for a non trivial period.  

I wanted to complement this information with anything extra that I could find, this included information from a patient that contacted me around that time. They suffered from Ledderhose and despite having nodules bigger than mine they did not experience pain. I do think that up to a certain point the size of the nodule is not the problem, it is the location and depth under the skin and whether it hits a nerve. Once it protrudes significantly out of the sole of the foot this can then cause issues based on the size of the lump (that is all just my opinion and thoughts but is based on the size of the fibroma not necessarily being related to the pain caused, which as it turns out is the case in the survey).

In order to gather more information on this I conducted a small survey which revealed some interesting results. 

Participants were asked to rank from 1 to 10 (10 being most painful) their condition from year 0 (diagnosis) up until now or year 30 (only 1 participant had had the condition for 30 years). Below I have 2 tables showing some of the results. 

ChangeNum OccurrencesComment
-100
-90
-81*Year after RT treatment, no later pain increase
-70
-61*Year after RT treatment, no later pain increase
-53*all 3 after surgery and again increased
-40
-31
-23
-114
0107
155*High number of 0/1/ 2 suggest that progression is normally slow
219
37
47
53
63*But over 1/2 of respondents experience a sharp increase
71
80
91
101
Table 1: Column 1 shows the change from the previous year, column 2 shows the number of years in which this change occurred and the third column shows a comment. Colouring is used to group results together.

Avg Max pain
2.28 Max yr on yr diff 2
7.22 > 3 year on year diff

Table 2: The average max pain for patients split by those that report a max change year on year of 2 and those that reporting having a change of greater than 2.

Table 1 shows that in most cases year on year there is little change in the condition however 50% of patients experience at least one year where there is an increase of 3 or more. When used in conjunction with table 2 this shows that those patients that experience a large jump are more likely to have significant pain. I have not calculated a number to show this but this is not simply due to an increase in the number of years a patient has the condition but it is that those with high levels have pain have had a large jump and not a gradual increase. In fact with only 1 exception the highest pain level reached by someone someone without a large jump was 3 (the exception being level 8).

Several patients report large decreases in pain, the 2 largest pain decreases were both as a result of radiotherapy. There were 3 patients that report a minus 5 in pain, all of these were because of surgery but in all 3 cases the pain then rose again. In no patients did the condition naturally regress year on year by a significant amount when there was no treatment involved. 

The above information and the rest of the results are summarised below. 
  •  The size of the nodule is not proportional to the amount of pain
  • Age of onset does not impact on progression
  • Male or Female does not impact on progression
  • Generally when gets bad seems to progress quickly
  • It appears that without a large increase in pain you are not like to be experiencing too much pain
  • Significant decreases have been observed post treatment with radiotherapy and surgery, after surgery pain rose again.
Of course to get these results I arbitrarily chose a jump of 3 as being large. I did chose this before analysing any data to try and avoid bias. Also this survey did not have many answers as it was just an initial survey which may help in the future development of a more comprehensive survey on the subject or a database to collect patient information. The results in the summary are all results which were clear from looking at the data and no numbers or graphs have been provided but I can make upon request. 

Below are some examples of patients pain levels over time. 



(1) Radiotherapy for primary or recurrent morbus ledderhose: 12 year long-term outcome of a prospective phase 2 trial. M. Heinrich Seegenschmiedt, Etienne Hanslian, Mark Wielpütz