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1. TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION IN DIABETIC NEUROPATHY Sanjay Kalra, Bharti Kalra,
Bharti Hospital, Karnal
INDIA
bhartihospital@rediffmail.com
2. The first uses of electroanalgesia were recorded by Aristotle, Plinyand Plutarch, who reported application of electrical fish to pain sites.
4. 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.
5. 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).
6. 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).
7. 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.
9. 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.
10. 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)
11. 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)
13. TENS PARAMETERS WAVE FORMS
Biphasic (containing both + ve and –ve waveforms).
may be –
Square
Rectangular
Sinusoidal
Triangular /spiked
Selection depends on patient’s comfort.
14. 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)
15. 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)
16. 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.
19. 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
22. BASELINE CHARACTERISTICS
24. EXTENT OF NEUROPATHY: TENS GROUP
32. TENS GROUP/OXCARBAMAZEPINE GROUP
33. 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
34. 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
35. 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.
36. ACKNOWLEDGEMENTS STAFF AND PATIENTS
of
BHARTI HOSPITAL
KARNAL
MEMBERS
of
THE PEER GROUP
INDIA
37. Thank you