TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION IN PAEDIATRIC TYPE 1 DIABETIC PATIENTS WITH PAINFUL...
Transcript of TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION IN PAEDIATRIC TYPE 1 DIABETIC PATIENTS WITH PAINFUL...
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION IN PAEDIATRIC TYPE 1 DIABETIC PATIENTS WITH PAINFUL NEUROPATHY
Sanjay Kalra, Bharti Kalra,Bharti Hospital, Karnal [email protected]
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