transcutaneous electrical nerve stimulation in diabetic neuropathy sanjay kalra, bharti kalra,...
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TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION IN
DIABETIC NEUROPATHY
Sanjay Kalra, Bharti Kalra,
Bharti Hospital, Karnal
INDIA
bhartihospital@rediffmail.com
• The first uses of electroanalgesia were recorded by Aristotle, Plinyand Plutarch, who reported application of electrical fish to pain sites.
BACKGROUND
• Neuropathy is a common complication of diabetes.
• Painful neuropathy (PN) is a significant cause of
morbidity in diabetes.
• Many drugs are available to manage PN, but all have
limited success.
• There is a need for non pharmacological means of
symptom management.
TENS
Transcutaneous electrical nerve stimulation (TENS) is an
electrical modality of pain relief (Chabel et al;
1997, Shealy 2003) .
Considered gold standard amongst non pharmacological
modalities of pain relief (Mc Quay et al;1997).
PRESENT STATUS
Few reports are available, however, on the use of TENS
in diabetic painful neuropathy (Kumar et al 1997, 98, Alvarez et al
1999).
No reports are available on effect of TENS on varying
symptoms such as burning, lancinating pain, deep pain,
crawling sensation and allodynia.
No reports are available on effect of TENS on VPT
(vibratory perception threshold).
TENS
TENS devices consist of electronic stimulus generator
which transmits pulses to electrodes on skin for pain
management .
Electrical pulses may block transmission of pain fibres
( large diameter myelinated A vs non
myelinated slow C fibres) or may stimulate release of
endogenous opioids.
STUDY DESIGN
Single blind, randomized, prospective, single centre study
at Bharti Hospital, Karnal.
To assess efficacy of TENS, compared with oxcarbamazepine,
in painful neuropathy in patients of type 2 diabetes mellitus.
To assess efficacy of TENS in different symptoms of pain.
To assess efficacy of TENS in improving vibration perception
threshold (VPT) in patients of diabetic neuropathy.
PATIENT POPULATION
125 patients in group I
• oxcarbamazepine 300 mg b d x 3 weeks.
• Five o d/ EOD sittings of 15 min using sham electrodes with no
stimulation.
180 patients in group II
• 5 o d/ EOD sittings of TENS.( Life Care, Ghaziabad, India)
Duration, intensity of TENS decided on daily basis by physiotherapist (current
modulation; hold: relax ratio modulation)
STUDY DESIGN
Glycemic control: Insulin/OHA
No opioids, TCAs, SSRIs etc. given to TENS group.
Supportive management as needed.
Pain severity assessed by visual analog scale 0 - 10.
Glycemic control assessed by weekly FBG, baseline
HbA1c.
VPT assessed by biothesiometry ( Dhansai Labs, India)
TENS PARAMETERS
• WAVE FORMS
Biphasic (containing both + ve and –ve waveforms).
may be –
Square
Rectangular
Sinusoidal
Triangular /spiked
Selection depends on patient’s comfort.
TENS PARAMETERS
• FREQUENCY OF DOSING
• EOD to q6h (od or EOD)
• DURATION OF SITTING
• 15 mins to 1 hour (15 mins)
• FREQUENCY
• 80-150 Hz (150 Hz)
• PULSE WIDTH / DURATION
50 -400 µs (100-200 µs)
TENS PARAMETERS
• CURRENT
0 – 60 mA ; treatment based on patients sensation
(12 – 30 mA).
• CONSTANT CURRENT VS VOLTAGE
constant voltage.
• HOLD TIME
10:1 to 1:1 ratio (6” hold 4” rest ratio)
TENS PARAMETERS
• PLACEMENT OF ELECTRODES
Associated nerve roots and dermatomes.
Point of pain
Acupuncture point proximal/distal to point of pain.
Trans artheral placements ( knee & foot).
Contra lateral placements in inaccessible areas due to
amputations, dressings, open wounds & casts.
MODULATION IN TENS
Frequency modulation
Pulse width modulation
Current modulation
May vary about 10% periodically.
(e.g 12 to 15 to 12 to 15 mA etc.)
Hold: relax ratio modulation
Group Oxcarbamazepine +
Sham electrodes
TENS
Age (years) 47.60 ± 22.40 46.11 ± 23.88
Gender (male/female) 79/46 112/68
Duration of diabetes (years)
6.04 ± 1.11 6.12 ± 0.64
Durn of neuropathy (years)
1.86 ± 1.12 1.86 ± 1.21
HbA1c (%) 8.48 ± 0.63 8.62 ± 0.91
bl glucose fasting
baseline
3 weeks
148.1 ± 48.2 mg%
112.2 ± 21.9 mg %
161.6 ± 48.3 mg %
109.5 ± 23.5 mg%
BASELINE CHARACTERISTICS
BASELINE CHARACTERISTICS
Symptom Oxcarbamazepine TENS
Tingling 60/125 (48.00%) 84/180 (46.66%)
Burning30/125 (24.00%)
42/180 (23.33%)
Deep pain 18/125 ( 14.40%)
29/180 (16.11%)
Restless legs 11/125 (8.80%)
11/180(7.22%)
Allodynia3/125 (2.40%)
11/180 (6.11%)
Lancinating3/125 (2.40%) 3/180 (1.66%)
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
IST GROUP
IIND GROUP
TINGLING BURNING PAIN RESTLESS ALLODYNIA LANCINATING LEGS
EXTENT OF NEUROPATHY: TENS GROUP
Symptom below ankle ankle mid calf knee thigh
burning 41 26 14 1 2
tingling/ants crawling
10 13 10 9 0
lancinating 14 5 8 1 1
deep pain 0 0 10 0 1
restless legs 0 2 1 8 0
allodynia 1 2 0 0 0
Total 66 48 43 19 4
0
5
10
15
20
25
30
35
40
45
B T L DP RL AL
belowankle
ankle
mid calf
knee
thigh
Symptom TENS GROUP
mean improvement
(pain score)
OXCARB GROUP
mean improvement
(pain score)
burning*** 3.28 ± 0.64 1.12 ± 0.33
tingling/ ants crawling* 2.62 ± 0.35 1.68 ± 0.72
lancinating*** 3.12 ± 0.64 1.01 ± 0.63
deep pain*** 3.00 ± 0.00 2.00 ± 0.15
restless legs* 2.16 ± 0.56 0.91 ± 0.12
Allodynia* 2.15 ± 0.35 1.51 ± 0.35
5
4
3
2
1
Tingling Burning Pain Restless Allodynia Lancinating Legs
I
II
I***
II
I***
II
I = TENS GROUPII = OXCARBAMAZEPINE GROUP
p < 0.05 for all groupsP < 0.01 for ***
I
II
I
II
I***
II
Gender n male female total
Burning 42 2.46 ± 0.96 3.58 ± 0.24 3.28 ± 0.64
Tingling 84 2.15 ±1.24 2.88 ±1.27 2.62 ± 0.35
Lancinating 3 - 3.12 ± 0.64 3.12 ± 0.64
Deep pain 29 3.00 ± 0.00
3.00 ± 0.00 3.00 ± 0.00
Restless legs
11 - 2.16 ± 0.56 2.16 ± 0.56
Allodynia 11 2.00 ± 0.00 2.31 ± 0.31 2.15 ± 0.35
TENS GROUP: PAIN SCORE IMPROVEMENT
0
0.5
1
1.5
2
2.5
3
3.5
4
MALE
FEMALE
BURNING TINGLING LANCINATING DEEP PAIN RESTLESS ALLODYNIA
Age n <40 y 41-60 y >60 y total
Burning 42 4.00 ± 0.00 3.12 ± 0.64 2.86 ± 1.24 3.28 ± 0.64
Tingling 84 3.12 ± 0.96 2.75 ± 0.62 2.00 ± 0.00 2.62 ± 0.35
Lancinating 3 3.12 ± 0.64 -- -- 3.12 ± 0.64
Deep pain 29 3.00 ± 0.00 3.00 ± 0.00 3.00 ± 0.00 3.00 ± 0.00
Restless legs
11 2.16 ± 0.56 -- -- 2.16 ± 0.56
allodynia 11 2.00 ± 0.00 2.31 ± 0.20 2.31 ± 0.20 2.15 ± 0.35
TENS GROUP: PAIN SCORE IMPROVEMENT
0
0.5
1
1.5
2
2.5
3
3.5
4
<40 y
41-60 y
>60 y
BURNING TINGLING LANCINA- DEEP REST- ALLODYNIA TING PAIN LESS LEGS
TENS GROUP/OXCARBAMAZEPINE GROUP
Symptom Oxcarb group Mean improvement
(VPT)
TENS group Mean
improvement (VPT)
Burning* 5.66 ± 1.50 9.00 ± 4.00
Tingling* 3.80 ± 1.09 7.83 ± 2.40
Lancinating* 3.80 ± 1.09 7.50 ± 2.73
Deep pain* 1.60 ± 0.89 4.00 ± 1.00
Restless legs* 2.50 ± 2.88 8.33 ± 2.88
Allodynia* 0.33 ± 0.57 4.66 ± 0.57
* = p<0.05
• Change in pain score:• No correlation with extent of neuropathy• No correlation with HbA1c
• Change in VPT:• No difference in gender groups• No difference in age groups• No correlation with extent of neuropathy • No correlation with HbA1c
TENS GROUP :VPT IMPROVEMENT
DISCUSSION
Till date no study has tried to assess effect of TENS in
different symptoms of neuropathy and its effects on
improving VPT.
This study demonstrates the increased efficacy of TENS
in diabetic neuropathy with predominant sensory
symptoms and altered VPT
CONCLUSION
TENS is more effective in
young patients
women
lancinating pain, burning pain, deep pain
The efficacy and efficiency of TENS as a therapeutic
modality in diabetes with painful neuropathy is worthy of
more extensive study.
ACKNOWLEDGEMENTS
STAFF AND PATIENTSof
BHARTI HOSPITALKARNAL
MEMBERS of
THE PEER GROUP INDIA
Thank you
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