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Electrotherapy for the treatment of painful diabetic peripheral neuropathy – a review
OBJECTIVE: To review different types of electrotherapy for the treatment of painful diabetic peripheral neuropathy.
METHODS: A structured search of the electronic database MEDLINE was performed from the time of its initiation to July 2009. Articles in English and German were selected.
RESULTS: The efficacy of different types of electrotherapy for painful diabetic peripheral neuropathy has been evaluated in 15 studies; the effects of transcutaneous electrical nerve stimulation are consistent. The beneficial effects of prolonged use have been reported in three large studies and one small study. The effects of frequency-modulated electromagnetic neural stimulation were assessed in one large study, and a significant reduction in pain was reported. Treatment with pulsed and static electromagnetic fields has been investigated in two small and three large studies, and analgesic benefits have been reported. In one large study focusing on pulsed electromagnetic fields, no beneficial effect on pain was registered. Only small studies were found concerning other types of electrotherapy, such as pulsed-dose electrical stimulation, high-frequency external muscle stimulation or high-tone external muscle stimulation. The conclusions drawn in these articles are diverse. Shortcomings and problems, including a poor study design, were observed in some.
CONCLUSION: Further randomized, double-blind, placebo-controlled studies comprising larger sample sizes, a longer duration of treatment, and longer follow-up assessments are required.
Key words: review; electrotherapy; painful diabetic peripheral neuropathy.
Karin Pieber, Malvina Herceg, Tatjana Paternostro-Sluga
Table I. Electrotherapy for the treatment of painful diabetic peripheral neuropathy
Level of evidence
Kumar & Marshall (26)
TENS or sham treatment, 4 weeks, 30 min daily
Transient reduction in pain and discomfort in 83% of patients
Kumar et al. (27)
Randomized, controlled, 2 arm
TENS or sham treatment in combination with amitriptyline, 12 weeks, 30 min daily
85% of patients beneficial effect, 36% asymptomatic, recurrence after termination of TENS
Julka et al. (28)
TENS long-term use (average: 1.7 years)
Treatment remains effective even with prolonged use
Forst et al. (30)
TENS or sham treatment, 12 weeks, at least 30 min daily
After 6 weeks significant improvements in VAS, sign. improvements in NTSS-6-score after 6 and 12 weeks
Armstrong et al. (31)
Pulsed-dose electrical stimulation by stocking electrodes, 4 weeks active treatment, 8 h/day, nightly
Therapy may be effective in patients with grossly intact protective sensation and relatively good distal vascular perfusion
Oyibo et al. (32)
Pulsed-dose electrical stimulation by stocking electrodes, 6 weeks active treatment, 8 h/day, nightly
No evidence, poor compliance
Weintraub & Cole (33)
PEMF, 1 h on 9 consecutive days
Short-term analgesic effect in more than 50% of patients
Musaev et al. (34)
PEMF at different frequencies (100 Hz, 10 Hz), 10 days, 10–15 min., + massage and exercise
Reduction in pain, significant regression of major subjective symptoms and improvements in the conductive functions of peripheral nerves
Wróbel et al. (35)
Low-frequency pulsed magnetic field, 15 days, 20 min
Positive impact on pain, quality of life and sleep, but not better than placebo
Weintraub et al. (36)
PEMF, 3 months, 2 h/day
No significant reduction in pain and sleep disturbance, but neurobiological changes in skin biopsy
Weintraub et al. (37)
Static magnetic field, shoe insoles for 4 months (24 h/day)
Significant reduction in pain pronounced during the third and fourth month
Reichstein et al. (38)
Randomized, controlled, prospective pilot study
High-frequency external muscle stimulation or TENS, 30 min daily for
3 consecutive days
Amelioration of symptoms and pain, more effective than TENS
Klassen et al. (39)
Prospective, non-randomized pilot study
High-tone external muscle stimulation,
1 h, 3×/week, 1–3 months
Significant improvements of discomfort, pain and sleep disorders
Humpert et al. (40)
External muscle stimulation 4 weeks,
60 min, 2×/week
EMS seems to be effective for symptomatic neuropathy, especially in patients with strong symptoms
Bosi et al. (41)
Frequency-modulated electromagnetic neural stimulation, 20 treatments,
Significant reduction in pain, significant increase in sensory tactile perception, increase in motor nerve conduction velocity for at least 4 months
NTSS-6-score: New Total Symptom Score; VAS: visual analogue scale; TENS: transcutaneous electrical nerve stimulation; EMS: external muscle stimulation. A (high): several high-quality studies with consistent results; B (moderate): one high-quality study, several studies with some limitations; C (low): one or more studies with severe limitations; D (very low): expert opinion, one or more studies with very severe limitations (43).
- Carrington AL, Abbott CA, Griffiths J, Jackson N, Johnson SR, Kulkarni J, et al. Peripheral vascular and nerve function associated with lower limb amputation in people with and without diabetes. Clin Sci (Lond) 2001; 101: 261–266.
- Harris MH, Eastman R, Cowie C. Symptoms of neuropathy in adults with NIDDM in the U.S. population. Diabetes Care 1993; 16: 1446–1452.
- Galer BS, Gianas A, Jensen MP. Painful diabetic neuropathy: epidemiology, pain description, and quality of life. Diabetes Res Clin Prac 2000; 47: 123–128.
- Jung SJ, Pfeifer MA. Persons with diabetes and neuropathic symptoms have poor psychosocial adjustments. Diabetes 1986; 35 Suppl: 123.
- Uccioli L, Giacomini PG, Monticone G. Body sway in diabetic neuropathy. Diabetes Care 1995; 18: 339–344.
- Matjacić Z, Zupan A. Effects of dynamic balance training during standing and stepping in patients with hereditary sensory motor neuropathy. Disabil Rehabil 2006; 28: 1455–1459.
- Balducci S, Iacobellis G, Parisi L, Di Biase N, Calandriello E, Leonetti F, et al. Exercise training can modify the natural history of diabetic peripheral neuropathy. J Diabetes Complications 2006; 20: 216–223.
- Cheer K, Shearman C, Jude EB. Managing complications of the diabetic foot. BMJ 2009; 339: 1304–1307.
- Boulton AJ, Hardisty CA, Betts RP, Franks CI, Worth RC, Ward JD, et al. Dynamic foot pressure and other studies as diagnostic and management aids in diabetic neuropathy. Diabetes Care 1983; 6: 26–33.
- Abouaesha F, van Schie CH, Griffths GD, Young RJ, Boulton AJ. Plantar tissue thickness is related to peak plantar pressure in the high-risk diabetic foot. Diabetes Care 2001; 24: 1270–1274.
- Brink T. Induration of the diabetic foot pad: another risk factor for recurrent neuropathic plantar ulcers. Biomed Technik 1995; 40: 205–209.
- Boulton AJ, Malik RA, Arrezo JC, Sosenko JM. Diabetic somatic neuropathies. Diabetes Care 2004; 27: 1458–1486.
- Tooke JE. Perspectives in diabetes: microvascular function in human diabetes, a physiological perspective. Diabetes 1995; 44: 721–726.
- Malik RA, Newrick PG, Sharma AK, Jennings A, Ah-See AK, Mayhew TM, et al. Microangiopathy in human diabetic neuropathy: relationship between capillary abnormalities and the severity of neuropathy. Diabetologia 1989; 32: 92–102.
- Fisher MA, Langbein WE, Collins EG, Williams K, Corzine L. Physiological improvements with moderate exercise in type II diabetic neuropathy. Electromyogr Clin Neurophysiol 2007; 47: 23–28.
- Gilcreast DM, Stotts NA, Froelicher ES, Baker LL, Moss KM. Effect of electrical stimulation on foot skin perfusion in persons with or at risk for diabetic foot ulcers. Wound Repair Regen 1998; 6: 434–441.
- Kaada B. Vasodilation induced by transcutaneous nerve stimulation in peripheral ischemia: Raynaud’s phenomenon and diabetic polyneuropathy. Eur Heart J 1982; 3: 303–314.
- Jacobs MJ, Jorning PJ, Joshi SR, Kitslaar PJ, Slaaf DW, Reneman RS. Epidural spinal cord electrical stimulation improves microvascular blood flow in severe limb ischemia. Ann Surg 1988; 207: 179–183.
- Martin TP, Stein RB, Hoeppner PH, Reid DC. Influence of electrical stimulation on the morphological and metabolic properties of paralyzed muscle. J Appl Physiol 1992; 72: 1401–1406.
- Walker J. Relief from chronic pain by low power laser irradiation. Neurosci Lett 1983; 43: 339–344.
- Passarella S. He-Ne laser irradiation of isolated mitochondria. J Photochem Photobiol B 1989; 3: 642–643.
- Yamamoto H, Ozaki A, Iguchi N, Kinoshita S. Antinociceptive effects of laser irradiation of Hoku point in rats. Pain Clin 1988; 8: 43–48.
- Ailioaie C, Lupusoru-Ailioaie LM. Beneficial effects of laser therapy in the early stages of rheumatoid arthritis onset. Laser Ther 1999; 11: 79–87.
- Watkins ES, Koeze TH. Spinal cord stimulation and pain relief. BMJ 1993; 307; 462.
- Mima T, Oga T, Rothwell J, Satow T, Yamamoto J, Toma K, et al. Short-term high frequency transcutaneous electrical nerve stimulation decreases human motor cortex excitability. Neurosci Lett 2004; 355: 85–88.
- Kumar D, Marshall HJ. Diabetic peripheral neuropathy: amelioration of pain with transcutaneous electrostimulation. Diabetes Care 1997; 20: 1702–1705.
- Kumar D, Alvaro MS, Julka IS, Marshall HJ. Diabetic peripheral neuropathy. Effectiveness of electrotherapy and amitriptyline for symptomatic relief. Diabetes Care 1998; 21: 1322–1325.
- Julka IS, Alvaro M, Kumar D. Beneficial effects of electrical stimulation on neuropathic symptoms in diabetes patients. J Foot Ankle Surg 1998; 37: 191–194.
- Alvaro M, Kumar D, Julka IS. Transcutaneous electrostimulation: emerging treatment for diabetic neuropathic pain. Diabetes Technol Ther 1999; 1: 77–80.
- Forst T, Nguyen M, Forst S, Disselhoff B, Pohlmann T, Pfützner A. Impact of low frequency transcutaneous electrical nerve stimulation on symptomatic diabetic neuropathy using the new Salutaris device. Diabetes Nutr Metab 2004; 17: 163–168.
- Armstrong DG, Lavery LA, Fleischli JG, Gilham KA. Is electrical stimulation effective in reducing neuropathic pain in patients with diabetes? J Foot Ankle Surg 1997; 36: 260–263.
- Oyibo SO, Breislin K, Boulton AJ. Electrical stimulation therapy through stocking electrodes for painful diabetic neuropathy: a double blind, controlled crossover study. Diabet Med 2004; 21: 940–944.
- Weintraub MI, Cole SP. Pulsed magnetic field therapy in refractory neuropathic pain secondary to peripheral neuropathy: electrodiagnostic parameters – pilot study. Neurorehabil Neural Repair 2004; 18: 42–46.
- Musaev AV, Guseinova SG, Imamverdieva SS. The use of pulsed electromagnetic fields with complex modulation in the treatment of patients with diabetic polyneuropathy. Neurosci Behav Physiol 2003; 33: 745–752.
- Wróbel MP, Szymborska-Kajanek A, Wystrychowski G, Biniszkiewicz T, Sieroń-Stołtny K, Sieroń A, et al. Impact of low frequency pulsed magnetic fields on pain intensity, quality of life and sleep disturbances in patients with painful diabetic polyneuropathy. Diabetes Metab 2008; 34: 349–354.
- Weintraub MI, Herrmann DN, Smith AG, Backonja MM, Cole SP. Pulsed electromagnetic fields to reduce diabetic neuropathic pain and stimulate neuronal repair: a randomized controlled trial. Arch Phys Med Rehabil 2009; 90: 1102–1109.
- Weintraub MI, Wolfe GI, Barohn RA, Cole SP, Parry GJ, Hayat G, et al. Static magnetic field therapy for symptomatic diabetic neuropathy: a randomized, double-blind, placebo-controlled trial. Arch Phys Med Rehabil 2003; 84: 736–746.
- Reichstein L, Labrenz S, Ziegler D, Martin S. Effective treatment of symptomatic diabetic polyneuropathy by high-frequency external muscle stimulation. Diabetologia 2005; 48: 824–828.
- Klassen A, Di Iorio B, Guastaferro P, Bahner U, Heidland A, De Santo N. High-tone external muscle stimulation in end-stage renal disease: effects on symptomatic diabetic and uremic peripheral neuropathy. J Ren Nutr 2008; 18: 46–51.
- Humpert PM, Morcos M, Oikonomou D, Schaefer K, Hamann A, Bierhaus A, et al. External electric muscle stimulation improves burning sensations and sleeping disturbances in patients with type 2 diabetes and symptomatic neuropathy. Pain Med 2009; 10: 413–419.
- Bosi E, Conti M, Vermigli C, Cazzetta G, Peretti E. Effectiveness of frequency-modulated electromagnetic neural stimulation in the treatment of painful diabetic neuropathy. Diabetologia 2005; 48: 817–823.
- Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, et al. Grading quality of evidence and strength of recommendations. BMJ 2004; 328: 1490–1498.
- Furlan AD, Pennick V, Bombardier C, van Tulder M. 2009 updated method guidelines for systematic reviews in the Cochrane Back Review Group. Spine 2009; 34: 1929-1941.
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