Protocol for the treatment of diabetic peripheral neuropathy

About Diabetic Neuropathy

Metabolic disease, like diabetes meillitus (DM), is a condition that can cause neuropathy and is estimated to affect 415 million adults worldwide2. Neuropathy caused by DM is known as diabetic neuropathy (DN). DN is caused by diabetic microvascular injury of the small blood vessels that supply nerves in addition to macrovascular conditions3.

Diabetes mellitus (DM) (Type 1 and Type 2) is associated with chronic sequelae and 50% of people develop polyneuropathy.4 This may manifest in the upper limbs (hands) and or lower limbs such as calves and feet.

The symptoms of DN can be grouped into non-painful indications, such as dysesthesia (abnormal sense of touch), tingling and itching, and negative symptoms like numbness, muscle weakness, and difficulty with balance. However, 25% of people with DN also develop neuropathic pain and these symptoms include those described above for non-painful DN, but with additional “burning,” “electric shocks,” “stabbing,” and “pins and needles”5.

Diabetic neuropathy affects all peripheral nerves including sensory and motor nerves, including more rarely, the autonomic nervous system. A patient can have sensorimotor and autonomic neuropathy or any other combination6.

Treatment Protocol for DN of lower limbs 

  1. The most important aspect of any treatment with NMS460 is to identify the correct nerve supply to the particular region.
  2. Due to increased sensitivity in some patients in the peripheral region like the feet, it is suggested to initially commence NMS460 treatment at the most proximal region of the nerve supplying the foot ie. the sciatic nerve at the posterior knee crease before bifurcation into common fibular and tibial nerves. Refer to Figure 1.
  3. Commence treatment as per the Quick Treatment guide.
  4. The associated fasciculation will involve a contraction of the entire calf and foot muscles.
  5. Place the treatment probe at the right sciatic nerve (as indicated in Figure 1) and the reference electrode on the opposite left hamstring or posterior thigh above the sciatic nerve region.
  6. If the nerve in the right leg is severely affected by the DM, nerve conduction may be reduced and a higher current intensity may be required to activate the nerve sufficiently. The patient will indicate when the current is at a comfortable level and may even suggest that he/she can feel the current translate into the calf or foot, signalling a successful treatment target.
  7. Repeat steps for the opposite leg as above.
  8. As the pain recedes individual nerve branches may remain symptomatic. Provided that the treatment described above does not aggravate or increase sensitivity, these areas may respond favourably to a local application of the current.Such nerve branches may include: the Lateral Nerve Branches and Medial Nerve Branches.Lateral Nerve Branches include the common fibular, superficial fibular, deep fibular, branches to fibularis longus and fibularis brevis, lateral cutaneous nerve of the calf and lateral plantar. Medial Nerve Branches include the tibial, sural nerve, saphenous nerve, calcaneal branch of tibial, medial plantar. Refer to Figure 2.
  9. When specific nerve branches are treated the reference electrode may remain in the original place on the opposite leg or if more convenient for treatment, this electrode may be moved more distally to a fleshy area in the calf.

Duration of treatment

The first treatment may be applied for 5 mins on each nerve site. Some chronic pain patients are hypersensitive due to sensitization of nerve endings and an even shorter period of treatment may be required initially (1 to 2 minutes).

The treatment duration can be extended up to 10 minutes depending on the severity of the condition and if the initial treatment caused no irritation.

Number of treatments

Three treatments will usually demonstrate significant changes in either pain, dysaesthesia or paraesthesia. However, it is recommended to continue with the treatment until resolution or best treatment effects are obtained for the specific patient.

Frequency of treatments

It’s recommended to do 1 to 2 weekly treatments, depending on the degree of pain or neuropathic symptoms on the DN4 test (less than 4 out of 10).7,8 This specific test is known as the doleur neuropathique 4 test and is designed to detect neuropathic pain.

If the patient responds to this treatment then 3 to 6 ‘top up’ treatments can be performed at 3 to 6 monthly intervals.

Pilot Study

The first report about treating DN with Xavant’s pulsed radio frequency technology was conducted with a device known as the Stimpod NMS300 (also marketed as Neurotrace III) by Gorozeniuk and Kothari at the St Thomas Pain Management Clinic in the United Kingdom. In this report, 34 eligible patients with DN were treated for 5 mins bilaterally on the sciatic nerve posterolaterally at the knee crease. Patients were given this treatment once weekly for 3 weeks only.

Results

In 19 patients the visual analogue scale (VAS) was reduced to 0/10 at the end of the 5-minute treatment, demonstrating a 100% improvement. The VAS scores decreased by 90% in four, 63% in another four and 50% in four more patients. Remaining three cases had their VAS score reduced by 25%, 20% and 15% respectively. In four patients with complex regional pain syndrome (CRPS), vascular changes were observed at the end of the procedure.

These results were taken into consideration when treating patients with neuropathic pain and symptoms from many different etiologies, including CPRS.

The NMS460 has also been successfully used to treat neuropraxias like Bell’s palsy and axonal degeneration as evidenced by damage to the peroneal nerve from injury (clinical evidence). This may have positive effects on diabetic peripheral neuropathy by improving nerve conduction and therefore strengthening muscles.

This information may provide the reasoning behind the effects that are observed in non-painful DN where symptoms like tingling, itching, numbness and abnormal sense of touch may improve.

Figure 1.

Figure 2.

About the author

Professor Phyllis Berger is Adjunct Professor at the School of Therapeutic Sciences, Faculty of Health Sciences at the Department of Physiotherapy at the University of the Witwatersrand. She holds a BSc Physiotherapy degree and is also the Chairperson of the Acupuncture Group South African Society of Physiotherapy.

Professor Berger has been using the Stimpod NMS 460’s non-interventional pulsed radio frequency technology for the treatment of neuropathic pain and symptoms emanating from different aetiologies since 2009. Prof Berger has also used the Stimpod for neurogenic conditions caused by degeneration, inflammation or injury to nerve tissue.

References

  1. Finnerup NB, Haroutounian S, Kamerman P, Baron R, Bennett DL, Bouhassira D, Cruccu G, Freeman R, Hansson P, Nurmikko T, Raja SN, Rice AS, Serra J, Smith BH, Treede RD, Jensen TS. Neuropathic pain: an updated grading system for research and clinical practice. PAIN 2016;157:1599–606.
  2. International Diabetes Federation. IDF Diabetes Atlas, 7th ed. Brussels: International Diabetes Federation, 2015. Available at: http://www.diabetesatlas.org. Accessed August 9, 2016
  3. Diabetic neuropathy Wikipedia
  4. Tölle T, Xu X, Sadosky AB. Painful diabetic neuropathy: a cross-sectional survey of health state impairment and treatment patterns. J Diabetes Complications 2006;20:26–33.
  5. van Hecke O, Austin SK, Khan RA, Smith BH, Torrance N. Neuropathic pain in the general population: a systematic review of epidemiological studies. PAIN 2014;155:654–62.
  6. Diabetic neuropathy Wikipedia.
  7. Bouhassira D, Attal N, Alchaar H, et al. “Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4).” Pain 114.1-2 (2005): 29-36
  8. D’Amato C, Morganti R, Greco C, Di Gennaro F, Cacciotti L, Longo S, Mataluni G, Lauro D, Marfia GA, Spallone V. Diabetic peripheral neuropathic pain is a stronger predictor of depression than other diabetic complications and comorbidities. Diab Vasc Dis Res 2016;13:418–28.