Stimulation therapies

Transcutaneous electrical nerve stimulation (TENS) was used in a 4-week, single-blind study that randomized 31 patients with type 2 diabetes and symptoms and signs of peripheral neuropathy, to receive either active electrotherapy or sham therapy [98]. Patients in the active group had a 52% reduction in pain compared with 27% in controls. In another study, 54 patients with diabetes who were using a TENS device were identified, and the patients' symptoms prior to and following electrotherapy were assessed [99]. Forty-one (76%) patients reported a mean 44% subjective improvement in their neuropathic pain with TENS electrotherapy, which they had continued to use as an adjunct to their conventional analgesic drugs for a mean of 1.7 years. In another small (n = 26), single-blind study TENS was also shown to be a useful adjunctive modality when combined with a pharmacologic agent such as amitriptyl-ine, to augment symptomatic pain relief [100].

The value of percutaneous electrical nerve stimulation (PENS) in painful diabetic neuropathy was assessed in one short-term sham-controlled crossover study which randomized 50 patients to receive either active PENS or sham PENS (acupuncture only) [101]. Patients who received active therapy showed a significant reduction in pain scores.

The effects of traditional acupuncture in CPDN were studied in one uncontrolled trial [102]. Forty-six patients (of whom more than half were on standard medical treatment for painful neuropathy) received up to six courses of classic acupuncture analgesia over 10 weeks; over 75% noted an improvement in pain symptoms. The patients were followed up for a period that ranged from 18 to 52 weeks during which time only 8/34 needed further acupuncture.

Electrical spinal cord stimulation (ESCS) involves the delivery of a low-voltage electrical current to the dorsal structures of the spinal cord in order to reduce pain perception. In a small study, ESCS has been shown to be effective and safe in the treatment of severe, resistant, painful neuropathy, confirming its place in the contemporary management of chronic intractable pain when all other conventional treatment strategies have failed [103]; the beneficial effects can last many years [104] and the majority of complications are of a technical nature and tend to occur during the first 6 months of implantation.

The mechanisms behind the pain-relieving effects of ESCS are still obscure. Although these data do support a role for electrotherapy in the symptomatic treatment of CPDN, there are obvious deficiencies as it is not possible to perform conventional double-blind studies because of failure to "blind" the patients to the electrical sensation when active and sham therapies are applied. The studies also tend to be small and/or of short duration. However, the lack of significant reported or observed side effects from these electroanalgesic therapies appears encouraging. ESCS is an expensive procedure and is suitable only for selective cases of CPDN when managed in specialist centers where the necessary expertise and facilities are available.

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