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Effectiveness of electrical stimulation and low- intensity laser therapy on diabetic neuropathy: A systematic review
Abstract
Diabetes mellitus (DM) is a group of metabolic diseases which typically presents with frequent urination, increased thirst and increased hunger. DM be classified into three main types: type I (insulin-dependent DM), type-II (non-insulin dependent DM) and type III (gestational DM). Diabetes is a group of diseases of global health significance as 382 million people worldwide had diabetes in the year 2013 and this was projected to increase to an estimated 415 million in 2015. Damage to the nerves of the body (diabetic neuropathy) is the most common complication of diabetes. The signs and symptoms of diabetic neuropathy include numbness, diminished sensation, pain etc. Various types of electrotherapy, such as transcutaneous electrical nerve stimulation (TENS), pulsed-dose electrical stimulation, frequency-modulated electromagnetic neural stimulation, have been reported effective in managing diabetic neuropathy. This study is a systematic review of the evidence to enable the determination of the effectiveness of electrical stimulation and low-intensity laser therapy (LILT), and also aid their recommendation if proven to be effective. The outcome of this study was that TENS and other forms of electrical stimulation reviewed in this study may be effective and safe non-pharmacological treatment modalities in relieving the symptoms associated with diabetic neuropathy. The effectiveness of LILT couldn't be determined due to the different parameters used to evaluate patients' outcome and limited number of studies. Authors recommend that further randomized controlled trials with similar World News of Natural Sciences 23 (2019) 110-127-111-methodological parameters and studies with higher quality of evidences are needed to establish the true effectiveness of these modalities in diabetic neuropathy.
... The number of articles obtained and met the inclusion and exclusion criteria is 15, of which 9 were systematic review articles and 6 RCT articles. For example, research on the management of neuropathic pain may be performed with electrical stimulation [12], acupuncture therapy [13][14][15], massage therapy and aromatherapy [16,17], herbal therapy [18], ACT psychotherapy [19], and Exercises Training [20,21]. Those articles are then analyzed. ...
... Electrical stimulation is a therapy that delivers electricity to certain parts of the skin to activate the nerves under the skin, which are usually used to reduce pain symptoms such as diabetic neuropathy [12]. Transcutaneous electrical nerve stimulation, which conducts electricity and results in paresthesias or inhibits nerve fibers to have an analgesic effect (TENS) [22]. ...
... Electrical stimulation and Low-Intensity Laser Therapy (LILT) can be used together. Emannual et al. (2019) which was conducted to assess the efficacy of electrical stimulation paired with LILT, demonstrated its efficacy in the management of diabetic neuropathy pain [12]. ...
Background: Pharmacological treatment of neuropathic pain has various side effects, while complementary therapies have minimal risk of side effects. Aim: To explore more deeply the types of complementary therapies that can be used to treat painful diabetic neuropathy. Methods: Articles were searched using Science Direct, Pubmed, Google Scholar, and EBSCO to find articles according to inclusion and exclusion criteria. Articles that meet the criteria set by the author are then analyzed, determined by the level of evidence extracted, and then synthesized. Results: Complementary therapies that can reduce neuropathic pain in diabetic patients are electrical stimulation, Low-Intensity Laser Therapy (LILT), Repetitive Magnetic Stimulation, Acceptance and Commitment Therapy (ACT), Aromatherapy Massage, Exercise Training, Acupuncture, and China Herbal Medicine. Conclusion: Among these interventions, Acupuncture and electrical stimulation were the most widely used interventions to reduce neuropathic pain in diabetic patients. Complementary therapies can reduce neuropathic pain in people with diabetes. It is hoped that future research using the RCT method with many samples can be generalized.
Background
MR-DTI parameters namely fractional anisotropy (FA) and apparent diffusion coefficient values (ADC) of diffusion imaging demonstrate the directional preference and speed of diffusion of water molecules. The purpose of this case report is to explore the effect of massage, passive neural mobilization and transcutaneous electrical nerve stimulation on MR-DTI of the tibial nerve in a patient with type 2 diabetes mellitus having chronic distal symmetrical sensorimotor neuropathy.
Case Description
A 63-year-old male with type 2 diabetes mellitus diagnosed with chronic symmetrical sensorimotor diabetic peripheral neuropathy on the basis of medical examination and electrophysiological testing. Altered mechanosensitivity of the tibial nerve was confirmed through neurodynamic testing. MR-DTI revealed severe damage of the tibial nerve as shown by chaotic diffusion of water molecules and damaged microstructural integrity.
Intervention
A total six sessions over 3 weeks including nerve massage in a longitudinal and transverse direction; passive neural mobilization consisting of sliders and tensioners of the tibial nerve; and followed by 15 minutes of continuous transcutaneous electrical nerve stimulation directed along the nerve course.
Outcome
FA and ADC values, pain,neuropathy quality of life and range of motion data were collected pre and post intervention. Analysis revealed clinical improvement in all the outcome measures.
Conclusion
This case report identified improvement in radiological MR-DTI outcomes following rehabilitation in a patient with diabetic peripheral neuropathy.
Although a number of the diabetic neuropathies may result in painful symptomatology, this review focuses on the most common: chronic sensorimotor distal symmetrical polyneuropathy (DSPN). It is estimated that 15-20% of diabetic patients may have painful DSPN, but not all of these will require therapy. In practice, the diagnosis of DSPN is a clinical one, whereas for longitudinal studies and clinical trials, quantitative sensory testing and electrophysiological assessment are usually necessary. A number of simple numeric rating scales are available to assess the frequency and severity of neuropathic pain. Although the exact pathophysiological processes that result in diabetic neuropathic pain remain enigmatic, both peripheral and central mechanisms have been implicated, and extend from altered channel function in peripheral nerve through enhanced spinal processing and changes in many higher centers. A number of pharmacological agents have proven efficacy in painful DSPN, but all are prone to side effects, and none impact the underlying pathophysiological abnormalities because they are only symptomatic therapy. The two first-line therapies approved by regulatory authorities for painful neuropathy are duloxetine and pregabalin. α-Lipoic acid, an antioxidant and pathogenic therapy, has evidence of efficacy but is not licensed in the U.S. and several European countries. All patients with DSPN are at increased risk of foot ulceration and require foot care, education, and if possible, regular podiatry assessment.
In 2000, the prevalence of diabetes among the 46 countries of the WHO African Region was estimated at 7.02 million people. Evidence from North America, Europe, Asia, Latin America and the Caribbean indicates that diabetes exerts a heavy health and economic burden on society. Unfortunately, there is a dearth of such evidence in the WHO African Region. The objective of this study was to estimate the economic burden associated with diabetes mellitus in the countries in the African Region.
Drawing information from various secondary sources, this study used standard cost-of-illness methods to estimate: (a) the direct costs, i.e. those borne by the health systems and the families in directly addressing the problem; and (b) the indirect costs, i.e. the losses in productivity attributable to premature mortality, permanent disability and temporary disability caused by the disease. Prevalence estimates of diabetes for the year 2000 were used to calculate direct and indirect costs of diabetes mellitus. A discount rate of 3% was used to convert future earnings lost into their present values. The economic burden analysis was done for three groups of countries, i.e. 6 countries whose gross national income (GNI) per capita was greater than 8000 international dollars (i.e. in purchasing power parity), 6 countries with Int2000. GNI for Zimbabwe was missing.
The 7.02 million cases of diabetes recorded by countries of the African Region in 2000 resulted in a total economic loss of Int11,431.6, Int 2,144.3 per diabetes case per year in the three groups respectively.
In spite of data limitations, the estimates reported here show that diabetes imposes a substantial economic burden on countries of the WHO African Region. That heavy burden underscores the urgent need for increased investments in the prevention and management of diabetes.
The purpose of this study was to determine the effects of laser therapy in pain reduction and/or recovery of patients at the onset of Rheumatoid Arthritis (RA), comparatively with the traditional nonsteroidal anti-inflammatory drugs (NSAIDs). Fifty-nine patients with RA of 6-12 months duration were included in the study. The patients were divided into 3 groups: Group 1 (21 patients) received laser therapy; Group 2 (18 patients) was submitted to placebo laser therapy and NSAIDs medication; Group 3 (20 patients) was treated only with NSAIDs. Physical therapy was instituted in all three groups. GaAIAs diode laser of 830 nm wavelength and 200 mW maximum output power was used. Group 1 received laser therapy once each day, eight days per month, for a total of 32 treatments during a four-month period. The parameters used were 2-4 J/cm2 energy density, and a frequency of 5 Hz or 10 Hz depending on the number and severity of pain in the affected joints. Placebo laser treatment was given to group 2. The functional activity score, the acute phase reactants (ESR and C - reactive protein), T - lymphocytes and NK (natural killer) - cells were estimated. Synovial biopsies and Magnetic Resonance Imaging (MRI) of the synovial membrane were performed as well. The analysis of the clinical and biological parameters at the end of treatment showed a statistically significant decrease of duration of morning stiffness, of pain at rest and during movements, and improved acute phase reactants. The overall efficacy rate in these studies was 86% in the fttst group, 50% in laser placebo group and 40% in the NSAIDs-treated third group. After four months of treatment, our investigations showed that 830 nm infrared laser therapy promoted the restoration of function, relieved pain and limited the complications of RA.
The failure of foot wounds to heal results in 54,000 people with diabetes having to undergo extremity amputations annually. Therefore, treatment is needed to speed healing in people with diabetes in order to reduce the need for amputation. This study tested the effect of high-voltage pulsed current on foot blood flow in human beings who are at risk for diabetic foot ulcers. Neuropathy, vascular disease, Wagner Class, glucose, gender, ethnicity, and age were measured. A sample of 132 subjects was tested using a repeated-measures design. A baseline transcutaneous oxygen level was obtained; stimulation was applied, and transcutaneous oxygen measurements were recorded at 30- and 60-minute time intervals. The grouped foot transcutaneous oxygen levels decreased ({ifF = 5.66, p = .0039}) following electrical stimulation. Analysis of variance (Scheffe, p < .05) showed that initial transcutaneous oxygen was significantly higher than subsequent readings. However, oxygen response was distributed bimodally: 35 (27%) subjects showed increased transcutaneous oxygen (mean 14.8 mm Hg), and 97 (73%) experienced a decreased transcutaneous oxygen reading (mean 12.2 mm Hg). Logistic regression analysis did not explain these differences. Although this treatment appears to increase blood flow in a subset of patients, further study is needed to identify probable mechanisms for this response.
Pulsed-dose electrical stimulation is evaluated as an analgesic modality in patients-with painful diabetic neuropathy. Using a knitted silver-plated nylon/dacron stocking electrode, patients were given electrical stimulation over the course of 1 month. Pain was measured weekly, using a 10-cm. visual analog scale. Pain measurements at the end of the 4-week therapy and at 1 month after complete discontinuation of therapy were significantly lower than at the initiation of therapy. The results of this pilot study suggest that nocturnal doses of pulsed-electrical stimulation may be effective in alleviating subjective, burning, diabetic neuropathic pain in a population consisting of patients with grossly intact protective sensation, relatively good distal vascular perfusion and less than ideal glucose control. To the authors' knowledge, this is the first analytic report of pulsed-dose electrical nerve stimulation delivered through a stocking electrode for treatment of symptomatic diabetic neuropathy in medical literature.
Foot problems occur in around 5% of patients with diabetes each year and cause considerable morbidity and mortality
Problems are caused by peripheral neuropathy or peripheral arterial disease (or both)
Patients with diabetes should be assessed at least once a year for foot pulses, foot sensation, and risk of ulceration
Up to a third of patients with foot ulcers have osteomyelitis, which can be difficult to diagnose
Charcot’s neuroarthropathy must be considered in patients presenting with a unilateral hot or swollen foot
Advice and education on foot care are essential for patients with diabetes
To determine whether repetitive and cumulative exposure to low-frequency pulsed electromagnetic fields (PEMF) targeting painful feet can reduce neuropathic pain (NP), influence sleep in symptomatic diabetic peripheral neuropathy (DPN), and influence nerve regeneration.
Randomized, double-blind, placebo-controlled parallel study.
Sixteen academic and clinical sites in 13 states.
Subjects (N=225) with DPN stage II or III were randomly assigned to use identical devices generating PEMF or sham (placebo) 2 h/d to feet for 3 months.
Nerve conduction testing was performed serially.
Pain reduction scores using a visual analog scale (VAS), the Neuropathy Pain Scale (NPS), and the Patient's Global Impression of Change (PGIC). A subset of subjects underwent serial 3-mm punch skin biopsies from 3 standard lower limb sites for epidermal nerve fiber density (ENFD) quantification.
Subjects (N=225) were randomized with a dropout rate of 13.8%. There was a trend toward reductions in DPN symptoms on the PGIC, favoring the PEMF group (44% vs 31%; P=.04). There were no significant differences between PEMF and sham groups in the NP intensity on NPS or VAS. Twenty-seven subjects completed serial biopsies. Twenty-nine percent of PEMF subjects had an increase in distal leg ENFD of at least 0.5 SDs, while none did in the sham group (P=.04). Increases in distal thigh ENFD were significantly correlated with decreases in pain scores.
PEMF at this dosimetry was noneffective in reducing NP. However neurobiological effects on ENFD, PGIC and reduced itching scores suggest future studies are indicated with higher dosimetry (3000-5000 G), longer duration of exposure, and larger biopsy cohort.
External muscle stimulation (EMS) of the thighs was previously shown to have beneficial effects in a pilot study on painful diabetic neuropathy. However, differential effects on specific symptoms of neuropathy as well as determinants of treatment response have not been described.
Ninety-two type 2 diabetes patients with different neuropathic symptoms were included in a prospective uncontrolled trial. Patients were treated twice a week for 4 weeks. Symptoms were graded on numeric scales at baseline, before the second and the eighth visit.
Seventy-three percent of the participants reported marked improvement of symptoms. Subjective treatment response was positively and independently associated with symptom intensity but independent of disease extent, metabolic factors, age, or gender. Total symptoms graded by patients on numerical scales decreased significantly after 4 weeks of treatment. Patients in the upper tertile of symptom intensity showed significant improvement of paresthesia, pain, numbness and most pronounced for burning sensations and sleeping disturbances.
In an uncontrolled setting, EMS seems to be an effective treatment for symptomatic neuropathy in patients with type 2 diabetes, especially in patients with strong symptoms.
Selected morphological and metabolic properties of single fibers were studied in biopsy samples from the tibialis anterior of normal control and spinal cord-injured (SCI) subjects. In the SCI subjects, one muscle was electrically stimulated progressively over 24 wk, in 6-wk blocks for less than or equal to 8 h/day, while the contralateral muscle remained untreated. The percentage of fibers classified as type I [qualitative alkaline preincubation myofibrillar adenosinetriphosphatase (ATPase)] was significantly less in the unstimulated paralyzed muscles than in the muscles of normal control subjects. Electrical stimulation increased the proportion of type I fibers in the SCI subjects. For both type I and type II fibers, the cross-sectional area, activities of myofibrillar ATPase and succinate dehydrogenase, and the capillary-to-fiber ratio were also significantly less in the paralyzed muscles than in the normal control muscles. Electrical stimulation increased only the activity of succinate dehydrogenase in both fiber types of the SCI subjects. These data are discussed in relation to the electromechanical properties of the respective muscles described in an accompanying paper (J. Appl. Physiol. 72: 1393-1400, 1992). In general, the electrical stimulation protocol used in this study enhanced the oxidative capacity and endurance properties of the paralyzed muscles but had no effect on fiber size and strength.