TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION IN PAEDIATRIC TYPE 1 DIABETIC PATIENTS WITH PAINFUL NEUROPATHY

Sanjay Kalra, Bharti Kalra,Bharti Hospital, Karnal INDIAbhartihospital@rediffmail.com

The first uses of electroanalgesia were recorded by Aristotle, Pliny and Plutarch,

who reported application of electrical fish to pain sites.

BACKGROUND

Neuropathy is a common complication of diabetes.

Painful neuropathy (PN) is gradually being recognized

as a significant cause of morbidity in children with

diabetes. (Abad F et al, 2002; Karsidag S et al, 2004; Hamilton J et

al,2004)

Many drugs are available to manage PN, but all have

limited application in paediatric population.

BACKGROUND

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).

PRESENT STATUS

Few reports are available, however, on the use of

TENS in diabetic painful neuropathy (Kalra et al 2006,

Alvaro M et al, 1999)

No reports are available on effect of TENS in

paediatric diabetes.

PRESENT STATUS

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.

STUDY DESIGN

Single blind, randomized, prospective, single centre

study at Bharti Hospital, Karnal.

Children aged < 18 yrs, with type 1 diabetes, with

lower limb pain > 1 month, not explainable by other

reasons

Rickets was excluded

PATIENT POPULATION

15 patients in group I : oxcarbamazepine 150 mg b d x 3

weeks and five o d/ EOD sittings of 15 min using sham

electrodes with no stimulation.

15 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)

STUDY DESIGN

Glycemic control: Insulin

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.

Validated questionnaires used to assess health distress,

physician communication and disease intrusion.

STUDY DESIGN

Pain severity assessed by visual analog scale

Validated questionnaires used to assess health

distress, physician communication and disease

intrusion.

Administered at baseline and at 4 weeks

TENS duration: 5 sittings over 5 or 10 days

TENS PARAMETERS

WAVE FORMS

Biphasic (containing both + ve and –ve waveforms).

may be –

Square

Rectangular

Sinusoidal

Triangular /spiked

Selection depends on patient’s comfort.

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 /2-10 Hz

• PULSE WIDTH / DURATION

50 -400 µs (100-200 µs)

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)

Group Oxcarbamazepine TENS

Age (years) 12.60 ± 6.40 11.11 ± 6.88

Gender (male/female)

9/6 12/3

Duration of diabetes (years)

1.86 ± 1.12 1.86 ± 1.21

HbA1c (%) 8.48 ± 0.63 8.62 ± 0.91

bl glucose fastingbaseline3 weeks

148.1 ± 48.2 mg%112.2 ± 21.9 mg %

161.6 ± 48.3 mg %109.5 ± 23.5 mg%

BASELINE CHARACTERISTICS

Symptom TENS GROUP OXCARB GROUP

burning 2 3

tingling/ ants crawling

1 1

lancinating 1 1

deep pain 8 6

restless legs 3 3

Allodynia 0 1

CHARACTER OF PAIN

0

1

2

3

4

5

6

7

8

B T L DP RL A

TENS GROUPCONTROL GROUP

B=burningT=tinglingL=lancinatingDP=deep painRL=restless legsA=allodynia

Results Pain scores reduced significantly in both

groups, but much more so in the TENS group (from 4.60 ± 0.54 to 2.40 ± 0.54) than the sham electrodes + oxcarbamazepine group (from 4.40 ± 0.54 to 3.60 ± 0.54).

A significant change was seen in health distress and disease intrusion scores in the TENS group

IMPROVEMENT IN PAIN SCORES

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

PRE- POST-

TENS GROUP CONTROL GROUP

Symptom TENS GROUPimprovement

(pain score)

OXCARB GROUPimprovement

(pain score)

burning 2.50 ± 0.70 1.12 ± 0.33

tingling/ ants crawling

4.00 ± 0.00 2.00 ± 0.00

lancinating 3.00 ± 0.00 1.00 ± 0.00

deep pain 2.00 ± 0.00 0.00 ± 0.00

restless legs 2.50 ± 0.00 1.00 ± 0.00

Allodynia - 1.00 ± 0.00

IMPROVEMENT IN PAIN SCORES

0

0.5

1

1.5

2

2.5

3

3.5

4

B T L DP RLS A

TENS GROUPCONTROL GROUP

B=burningT=tinglingL=lancinatingDP=deep painRL=restless legsA=allodynia

DOSE

The dose of TENS used varied from 5.5 to 9.0 Hz on the initial day to 3.5 to 5.5 Hz on the last sitting. The dose varied insignificantly for different symptoms

The difference in pain relief was maintained after 4 weeks, even though the TENS sittings had stopped

Improvement in

Physician communication score : 1.43 ± 1.19 to 3.93 ± 0.86 over one month of therapy in all subjects.

Disease intrusion: 2.25 ± 0.63 to 1.08 ± 0.39.

Health distress score: 3.20 ± 0.82 to 1.35 ± 0.47

INPROVEMENT IN PSYCHOLOGICAL PARAMETERS

0

0.5

1

1.5

2

2.5

3

3.5

4

PCS DI HDS

PRE-POST-

PCS= Physician communication score , DI= disease intrusion, HDS=health distress score

DISCUSSION

Till date no study has tried to assess effect of TENS in

paediatric type 1 diabetes patients.

The efficacy and efficiency of TENS as a therapeutic

modality in children with diabetes and painful

neuropathy is worthy of more extensive study.

Thank you