Effect of TENS on Sensory Parameters in Diabetic Polyneuropathy

Diabetic Neuropathies, Diabetic Neuropathy, Painful, Peripheral Nervous System Diseases

Diabetic polyneuropathy is a common complication of diabetes that damages the nerves of the feet and legs. Besides causing pain, it gradually reduces the ability to feel light touch on the sole of the foot. This loss of protective sensation is important because it removes the warning signal that normally prevents unnoticed injuries, which can lead to foot ulcers. Transcutaneous electrical nerve stimulation (TENS) is a non-drug treatment that delivers mild electrical currents through the skin using surface electrodes. It is inexpensive, widely available, and generally well tolerated. Most previous studies of TENS in diabetic polyneuropathy have looked at whether it relieves pain. Far less is known about whether it affects touch sensation, and whether the frequency of the stimulation matters. This study compares three groups of patients with long-standing diabetic polyneuropathy. One group receives high-frequency TENS (100 Hz), one receives low-frequency TENS (5 Hz), and one receives sham stimulation at an intensity too low to have a treatment effect. Treatment is given five days a week for eight weeks, with electrodes placed on the calf and the sole of the foot. The main measure is the lightest touch a participant can feel on the big toe, tested with Semmes-Weinstein monofilaments before and after the eight-week period. Additional measures include electrical and pressure pain thresholds and questionnaires on pain, mood, and quality of life. Participants and the researchers performing the assessments do not know which group each participant is in.

BACKGROUND AND RATIONALE Distal symmetric polyneuropathy is the most common chronic complication of diabetes and the principal cause of the sensory loss that precedes foot ulceration. Current management is directed almost entirely at symptomatic control of neuropathic pain and is not expected to modify sensory function. Transcutaneous electrical nerve stimulation (TENS) has been studied in this population, but trials have used pain intensity or composite symptom scores as endpoints, and cutaneous sensory function has rarely been treated as a prespecified outcome. Stimulation frequency provides a mechanistic rationale for outcomes that may differ in kind. Conventional high-frequency, sensory-intensity TENS preferentially recruits large-diameter, low-threshold A-beta afferents, whereas low-frequency, higher-intensity stimulation is generally attributed to endogenous opioid-mediated descending inhibition. The A-beta population engaged by the former is the same population that mediates detection of weak mechanical stimuli and that monofilament testing assesses. Converging evidence from the repetitive sensory stimulation literature indicates that prolonged, passive peripheral input can lower tactile thresholds through long-term-potentiation-like mechanisms, with a frequency dependence paralleling the induction of synaptic potentiation and depression. DESIGN Single-centre, randomised, double-blind, sham-controlled, parallel-group trial with three arms allocated in a 1:1:1 ratio. Participants were recruited from the Endocrinology and Metabolism outpatient clinic of Akdeniz University Faculty of Medicine; assessments were performed at the Akdeniz University Sports Sciences Research and Application Centre. ALLOCATION AND BLINDING Allocation was performed by a lot-drawing procedure after written informed consent and before baseline assessment. Simple randomisation was used, without blocking or stratification. Participants and outcome assessors were blinded to group assignment. The sham arm followed an identical procedure at a sub-therapeutic intensity, so participants were unaware of whether they received active or sham stimulation. All sensory, nociceptive, and questionnaire-based assessments were performed by evaluators blinded to allocation. INTERVENTIONS TENS was delivered with a dual-channel PRIMERA TENS/NMES stimulator (DJO, LLC, USA) using standard 2-inch self-adhesive electrodes, one placed on the calf and one on the plantar surface of the foot. A zero-direct-current, asymmetric biphasic rectangular waveform was used. Intensity was individually adjusted to each participant's sensory tolerance and maintained at a comfortable level throughout each session. Sessions were delivered five days per week for eight weeks in all arms. ASSESSMENTS Assessments were performed at baseline and repeated in the week following the eight-week programme. The primary outcome was the tactile detection threshold at the plantar surface of the great toe, measured with Semmes-Weinstein monofilaments (index 1.65-6.65), with the corresponding buckling force recorded in grams; a higher value indicates a more impaired threshold. All monofilament measurements were obtained by a single blinded investigator. Secondary outcomes were exploratory and comprised electrical pain detection and tolerance thresholds obtained by transcutaneous sural nerve stimulation using an ascending method of limits; the nociceptive flexion reflex recorded by surface electromyography from the short head of the biceps femoris; pressure pain threshold and tolerance measured by digital algometry at the dominant forearm and leg; and patient-reported measures of neuropathic pain, pain quality, depressive symptoms, and quality of life. STATISTICAL APPROACH Non-parametric methods were planned throughout because of small, unequal group sizes and the expected right-skew of several sensory variables. Continuous variables are summarised as median with interquartile range. Within-group change was tested with the Wilcoxon signed-rank test and between-group differences at post-treatment with the Kruskal-Wallis test, followed for the primary outcome by prespecified Mann-Whitney contrasts of each active arm against sham. Benjamini-Hochberg false-discovery-rate correction was applied across the exploratory secondary family.

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