Diabetic Neuropathy

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Dietary Changes


Recent study of vegan diet showed improvement in pain but did not show any benefit over B12 alone for pain. Mcgill questionnaire suggested it had less character though

Dm neuropathy.png

Diabetic Control


  • India study: [1]
 - 8 wk moderate exercise (40-60% maximal heart rate)
 - 30% improvement in pain and significant improvement in quality of life



B12 - px500

metformin lowers B12 levels

Vitamin D

  • Vitamin D deficency is twice as likely in cases of Diabetic neuropathy:[2] abstract here
  • recent article written on how reversal of vitamin D deficiency was associated with large improvement in diabetic neuropathy pain[3] free article here
-they suggest level under 30 ng/ml is a critically low level.
- 50,000 unit vitamin D weekly tripled subject's levels from 16 to 48 ng/ml {sold here as Osto-D2 50,000). I often use 50,000 weekly in high risk patients - that dose is non-toxic
- improved "dramatically with correction of the vitamin D deficiency"
  • They refer to a larger study of 51 type I diabetics with levels below 25 ng/ml - that develolped "a 50% decrease in pain scores with vitamin D repletion."[4] abstract here
  • vit D might help prevent diabetic neuropathy [5]
  • High Vit D protective against development of diabetes in metabolic syndrome cases[6] abstract here




Caudal D5W - The Sweet Caudal

Experimental procedure where 10 mls D5W (dilute sugar) is injected caudally The Sweet Caudal Epidural.Though there might be concerns about 10 mls going high enough, alternative treatments with 10 mls solution with steroid has been used for L5/S1 and L4/5 disc levels satisfactorily.[7].

This is given epidurally - which means must attempt to not go more than
2 cm up the caudal canal

Female member of CAOM (need name) mentioned at Toronto 2012 meeting she was having good results with diabetic neuropathy.

Intrathecal B12

A Study[8] gave 2,500 ug Methylcobalamin in 10 mls saline intrathecally several times a month. abstract here

- Cases used had intraspinal B12 levels the same level as controls
- effect appeared within hours to one week and lasted from several months to four years 

- injected through a 0.45 um-pore filter - total injections ranged from 1-8 with an average of 3.5 - many were also given 1,500 ug/day to take orally - 11 bad cases - most had retinopathy, 3 had diabetic gangrene - "most experienced a burning sensation in legs within several hours of injection" " The most striking effects common to all patients were the relief of heaviness in the legs and the return of sensation. These effects were apparent in less than one week after the injections and lasted from several months to as long as four years." - they felt intrathecal transport of oral B12 was poor and intrathecal injections gave better results. They felt intraspinal levels had an anesthetic effect. - no observed side effects - resulted in dramatic relief of symptoms in legs - burning, paresthesia, and heaviness - This article is supported by two previous Japanese articles[9] [10]

Question comes to mind is whether this combined with D5W could give additional benefit.


Lumbar sympathetic Blocks

- Severe Case Diabetic neuropathy treated 2012[11]

-Lumbar blocks - at L3 "12mL of 1% Lidocaine and 20mg Triamcinolone on each side".

- Results on pain are plotted but included Thoracic pain issues which were treated with T8 bilateral paravertebral sympathetic nerve block, "which was performed in the classic fashion, under fluoroscopic guidance. A solution of 1% Lidocaine 10mL and 20mg Triamcinolone was injected on each side."

- Stated got good sustained relief of leg pains from blocks.

- Plot of pains that unfortunately include thoracic pain readings which become more an issue as time went on:



On the whole relatively disappointing. A drop in VAS pain scale of 3 is considered life changing - They do not achieve that difference from placebo.

This leaves one to consider several obvious issues:

- Other mechanical issues are going to contribute to the pains and need treatment: 
     - back problems, particularly post-laminectomy and spinal stenosis, 
     - Inflammatory Issues Sacroiliac, hip, knee, ankle and foot
     - Tibialis posterior issues with its myofascial aches in lower legs, tendonitis at ankle,   and associated 
tarsal tunnel syndrome at ankle. - Myofascial knots - gluteal, piriformis, hamstings and quads, gastrocnemius and soleus, and so on - leading to question of "Didn't anybody bother to turn out the lights?" - (when considering residual myofascial pains
left behind despite other treatments) - The need for polypharmacy to achieve results - The wisdom to know what drug works best for certain types of pains and for what type of patient (eg. the poorly sleeping
or depressed one) - How poverty contributes to suffering by keeping certain medications beyond their reach - eg -ALA below is a herbal as successful as other meds, and in select non-cardiac subjects (get a cardiologist to clear?)-
, could work as well but would again cost near $200/month
NOTE - From various studies, Placebo averages out to give a 27% drop in pain level by self. However, one study[12] accepted
anything greater than 20% as better than placebo.
In a medscape article on Tapendadol, it was mentioned that the FDA requires at least a 1/10 point VAS difference
between active drug and placebo[13] medscape link here for those who register
Recent analysis[14] has found that placebo effect determines 62% of the clinical effect.
I try to maxify this effect by printing out a study showing the virtues of a particular drud/treatment.
If the patient has a relation that has done well on a particualr medication, that works well as well.


Below resuilts of Amitriptyline and Desipramine on DM neuropathy and their side effects[15] free article here

Amit desp placebo.PNG

Amitrip desimsideeff.PNG

In a gabapentin study, before the cross over (unreliable after), amitriptyline did not fare well at all [16]: abstract here

Amit gp.PNG

In some the results were similar to placebo: In a study comparing Amitriptyline to electretherapy[17], amitriptyl;ine did not get over the 27% drop anticipated by a placebo. : "With amitriptyline, the pain scores decreased significantly from 3.8 ±0.1 to 2.9 ± 0.2 (P < 0.01)" (that is a 24% drop). To be fair, 4 weeks might of not been enough time to get full benefits, and it looks like 50 mg is a suboptimal dose - though many would not be able to tolerate higher due to side effects.


Another study [18] abstract herecomparing woefully inadequate doses of Amitriptyline to woefully inadequate doses of gabapentin showed rather lackluster effects assuming placebo reduces pain by 20%. Amitriptyline average 16 mg vs gabapentin average 218 mg/day

What was most striking was the fact only half maintained on treatment in either group.


Ami pregab.PNG

A study comparing Amitriptyline to Maprotiline[19](latter unusage because crossed over from amitriptyline)again showed mediocre results:

Amitript75 ludiomelstudy.PNG

Another study compared Amitriptyline 50 mg to Lamotrigine[20] - the effect after cross over are difficult to understand - is there a a residual beneficial effect from the former treatments - this might make their results unreliable.

Amitri lamotri.PNG

Another study compared Amitriptyline and Duloxetine[21] free article here

-58 people, 14 weeks -working up to 50 mg Amitriptyline and 60 mg Duloxetine

Amit dulox.PNG

CONCLUSION: Most studies did not find a differnce of more than 1 with placebo making it not recognizable as a painkilling agent by FDA. The cuple of studies did find it 1.4 - 1.5 VAS better than placebo but this falls short of the 2 thought to be clinically relevant [need put ref].:



NO good - Results are so disappointing with the Crossed over fluoxetine group still having more pain than placebo.


Fluoxetine se.PNG


A Small study[22] http://www.ncbi.nlm.nih.gov/pubmed/15288411

Placebo dropped pain to about 4.8 and venlafaxine to 3.3 - that amounts to only at 1.5/10 VAS pain difference.
The drug was supposedly more tolerable yet had a 15% discontinuation rate. Keeping the drug dose to 75 mg was no better than placebo.

- 15% discontinuation rate


Venlafaxine se.PNG

a recent rodent study found venlafaxine augmented analgesic properties of morphine[23]

Other Anti-depressants Table comparing some TCA and SSRI drugs effectiveness [24]



Dose used in one study started with 300 mg tid for 7 weeks - "continued in stepwise fashion (up to five titration
increments with target doses of 1,200, 1,800, 2,400, 2,700, and 3,600 mg/day) for non-responders until there was a response or 3,600 mg/day was reached" (ref below).
- mean dose reached 1936 mg.

Gabapentin results appear dose related [25]

Effects: caption

Side effects: - 48% cases -4.7% withdrawal rate - Somnolence 20.1% dizziness 16.6% - other side effects mild

They also consider gabapentin's sleep aid as a benefit



Pregabalin Results, Pregabalin Side Effects, and its sleep effects:


Pregabalin se.PNG

Pregabalin sleep.PNG

- their comment: "Treatment with pregabalin was not associated with serious AEs such as orthostatic hypotension 
and other risks common in elderly patients and patients with cardiac arrhythmias as associated with some TCAs, or
with gastrointestinal effects seen with nonsteroidal anti-inflammatory drug (NSAID) use.There are no known
pharmacokinetic drug interactions."

- Felt that 600 mg was better if tolerated: "while 37/81 (46%) and 39/81 (48%) of patients in the 300- and 600-mg/day
groups achieved a >50% reduction in mean score from study baseline to endpoint, 22/81 (27%) of patients in the 600-mg/day group achieved
a >70% reduction in score compared with 13/81 (16%) in the 300-mg/day group. This observation was supported by the increased proportion
of patients on the 600 mg/day dosage (54/78, 69%) who rated themselves on the PGIC as much improved or very much improved compared
with patients receiving 300 mg/day (44/79, 56%)".

-Sleep aid is played up despite fact a little amitriptyline, trazadone, or gabapentin could achieve that:

Comparison of Duloxetine, Pregabalin and Gabapentin


- Pregabalin showed better sleep benefits


Gabapentin 300- 1800 (a low dose considering you can work up to 3,600 mg but that would probably take too long to reach)

Duloxetine 20-120 mg /day

Pregabalin 75 - 300 mg/day (a low dose since you can go up to 600 mg/day and one study on spinal neuropathic pain needed average 460 mg [28]) No significant difference in effectiveness between types at dose used - not great for duoxetine compared to half dose gabapentin

Preg gp dul1.PNG

Duo pg gp se.PNG


- Goldstein(2005) [29] - abtract here
- Cymbalta at 60 or 120 mg   
- "safe and well tolerated with less than 20 percent discontinuation due to adverse events"
- Helped the sharp, shotting, stabbing pains most
- They felt only 0.2% of effect was mood enhancement.
- expensive and may not be on drug plan 

Treatment Effects below; Side effects - nausea drowsiness/dizziness the big ones.




Carbamazepine[30] Double blind cross over all but the 2 rashes continued treatment pain types included following:


Unclear specifics but approximately 50% improvement; high incidence of neuralgic shooting pains in their group  might explain their benefits.

side effects:


authors felt except for the 2 rashes, the side effects wained after a week. I suspect at the time it was take it or nothing else there so most stuck to it. Getting thru a week of dizziness seems to much for most - need to start low with the 100 mg chewables.



Effects and Side Effects:


Tramadol se.PNG

Tramadol with Acetaminophen (Tramacet) -Effects and side effects

Tramadol acetamin.PNG

Tramadol aceet se.PNG


Placebo controlled trial with initial Open Laberl phase follwoed by double blind[32]

- Initiated at tapentadol ER 50 mg bid for 3 days 
- titrated to 100 mg bid for 3 days (minimum dose for study).
- then be titrated in 50 mg increments every 3 days 
- kept in the range of 100–250 mg bid
- could cut does by 50 mg bid as needed.



This barely makes the 1/10 VAS pain difference required to be a minimal effect.

Side effects:

Tapentadol se.PNG

Lack of side effectrs matched the lack of efficacy. They had highly significant differences only because they recruited over 500 patients for study


Oxycodone CR:[33]

Pain control is suspect because of high drop out rate (45%) potentially leaving only the best cases. Side Effects: - Constipation is the big one:


Oxycodone se.PNG

- 10/22 withdrew mostly from side effects.

_ They started with 10 mg Oxycodone CR BID and worked up weekly to 40 mg bid - subjects crossed over at 4 weeks.

- Oxycodone CR was recently delisted here due to addiction concerns. Escalating oxycodone CR use in Ontario corresponded to escalating death rates from opioids.

Another study on control release oxycodone [34]

-Only 19/82 withdrew
- started with 10 mg of control released twice daily and ramped up by one extra twice daily every 3 days
until 60 mg bid though could be decreased to acceptable level if side effects


Oxycodone2 se.PNG


Case study in a resistent subject highlighted how methadone could be used[35] free article here

- used following conversion from morphine - at 50-75% of conversion dose to start with. Methadone.PNG

If starting Opioid naive,:

-Start Opioid-naıve, frail, or elderly patients - 0.5–1 mg every 8 h;

-Normally start - 2.5–5 mg every 8 h.

-Breakthrough pain - at least 10–20% of daily dose given every 3–4 h PRN

-Night doses higher to deal with increased pain then

-Titration doses every 4–7 days,or reflecting braktrhough extra dosing

-Occasionally,use 6-h dosing in poor controlled

- side effect less than other opioids - if wait few days may go away. nausea, vomiting, constipation, sweating, itching, respiratory depression.

NSAID anti-inflammatory drugs

Both Ibuprofen 600 mg four times daily and Sulindac 200 mg twice daily were found to be better than placebo without affecting blood sugar or renal function.[36] abstract here

Alpha Lipoic Acid

Alpha Lipoic Acid

IV 600 mg/day best results (p<0.001):


- Dissolved in 250 mls saline  - infused: "once daily over two 5-day periods (Monday to Friday) 
and one 4-day period (Monday to Thursday) during 3 consecutive weeks."



Side Effects:

- 18.2% at 600 mg/day IV

headache (5/63) rare nausea/vomiting (seen at higher dose)

Unfortunately in this study, gains in neuropathy symptoms wained despite oral ALA 600 tid over subsequent 6 months
and were not different from placebo:

[38] Free full text

Oral ALA:

Multiple studies have shown benefits with just 600 mg/day for 5 weeks [39] http://www.hindawi.com/journals/ije/2012/456279/cta/


- "lack of tolerability did not differ between placebo and treatment groups."


- slightly more pricy than even pregabalin (above ref)
- Disconcertainly, heart rate and rhythm disorders over 4 years higher in ALA(6.9% ALA versus 2.7% placebo (P 0.047))[40]


95 cases[41] free article here

-double blind randomized control trial

- start 75 mg tid for one week, then 150 mg tid for one week; then 225 mg tid if suggested by weight - average dose was 150 tid = 450 mg/day


Results - scaled to 7/10 to start:


Side Effects- unless dose was pushed over average dose of 450 mg/day, side effects were higher in placebo.


Gastrointestinal and CNS symptoms appeared at higher doses.

A smaller earlier study - 16 cases treated with 10 mg/kg daily[42]

- randomized double bliind control crossover trial for 26 weeks

- mexiletine 150 mg first 3 days, 300 mg for next 3 days, then 10 mg/kg daily thereafter.

- 3/16 mild side effects - nausea, hiccups, tremor - two maintained on same dose; one reduced meds to 8 mg/kg

- dropped pains from 7 to 4.4 (scaled) -


Poor tolerance[43] - Only 112/214 completed study and side effectrs are listed below


Topiramate se.PNG

High Dose Dextromethorphan

DM ends up 24% better than placebo:[44]


Lamotrigine 2006 study[45]

-Start with 25 mg and gradually work up to 400 mg
- potentially life threatening rash can occur - did get 2/26 cases (at weeks 4-7)-  rashes in study - none serious
- no other significant side effects
- Potentially very useful in depression - particulary in bipolar subjects
- p<0.001


Lamotrigine se.PNG

Another study comparing amitriptyline and Lamotrigine[46]: They felt due to side effects, Lamotigine should be restricted to 25 mg BID.

Amitri lamotri.PNG

Sodium Valproate

48 Cases with type II DM[47] free article here

Their Exclusions: liver disease
pulmonary tuberculosis
thyroid disorders
vitamin deficiency
hereditary and paraneoplastic neuropathy
patients on steroid therapy

Dose - started on valproate mg od (presumably hs) for 1 week - looked at nausea/vomiting, nystagmus/ataxia - If Ok gradually worked up to 500 mg TID



Side Effects Included:

Valproate se.PNG

-Authors felt it was useful and well tolerated

Other Medications - ketamine

Overall conclusions

Treatment algorithms rely heavily on tricyclic antidepressants (shown to work poorly above, gabapentin and pregabalin. One of the lastest large sudies[48] abstract here used a better version of gabapentin up to 3600 and pregabalin at 300 mg/day. Results showed pregabalin did WORSE than placebo and high dose gabapentin NOT statistically better than placebo. People who rely on just medications for treatment of diabetic neuropathy are going to be in for a disappointment.

Gaba pregaba bad.PNG


Amitriptyline and Ketamine


Nitroglycerin patches

Initially it had been found that Isosorbide dinitrate spray was able to reduce diabetic foot pains[49]. 50% reported benefit. This product has been withdrawn from the market. attempt has been made to use nitroglycerin patches, though not submitted to placebo controlled trial[50]

Start with 5

Polyurethane Film

Opsite Flexifix Roll


Opsite has been found helpful in DM neuropathy[51] A recent article on subject[52] free article here stipulates optsite Flexifix rolls come in 5 and 10 cm widths and are 10 meters long. They can be wrapped around from toes up - usually to ankle though can go uptp knee. They state "Moleskin adhesive sheeting was added to the forefoot and heel contact areas on the plantar surface of the foot to increase the longevity of the film as walking on it can lead to breakdown of the material on the plantar surface." Excessive moisture inside leading to fungal infections and accumulation of shed skin are problems. The wrap is often left on 10 days and can get expensive. Moleskin adhesive pads are used to pad furniture and can be bought at a Dollar store or hardware store.

A second product is Lycra material fashioned into custom made stockings.


Third product is a stocking with some Lycra in it sold commercially as Swiss Venosan Legline 20


This product and how to measure and order is mentioned here on page 72: catalogue



Acupuncture for the treatment of chronic painful peripheral diabetic neuropathy: a long-term study B.B Abuaisha, J.B Costanzi, A.J.M Boulton Diabetes Research and Clinical Practice Volume 39, Issue 2, February 1998, Pages 115–121

6 courses classic acupunture over 10 weeks to both limbs

Acupuncture points: Liver 3 - web of the big toe


Spleen 6 - 4 fingers above the medial malleolus From:


Spleen 9 - upper tibia caption

Stomach 36 - approximating to the head of fibula From: 'Why Are You Doing That Point?’ Stomach 36 By Sara Calabro [1] States "located on the shin. It’s found about a hand length below the patella, just outside the prominent tibia bone (see picture below). Having this point needled often produces a strong sensation that sometimes travels down the leg."


"Standard references were consulted when choosing the acupuncture points. The precise points were confirmed by determining the position of the least skin resistance using a hand-held electrical conductance meter. Stainless steel disposable acupuncture needles (diameter 0.25 mm) are inserted into the skin to a depth of 3–4 mm. The first session was for 5 min and served to familiarize the patient with the acupuncture procedure while the rest of the sessions were for 20 min each. The second and third sessions were at weekly intervals. The fourth and fifth sessions were fortnightly. The sixth session was after 1 month. Thereafter, subsequent sessions took place when the patient felt the need for them, respectively."

Results - helped pain but did not help sleep

Acupuncture results.PNG

Acupuncture sleep.PNG

PENS Percutaneous Electical Nerve Stimulation (PENS)

Percutaneous Electrical Nerve Stimulation [53] appears to be westernized acupuncture - points are nearly identical but instead of acupuncture points they are described in terms of location to certain nerve trunks. When compared to acupuncture for postoperative pain, [54]abtract here some cases results are identical, some PENS better. PENS surg.PNG Near direct quotes:

"- standard, sterile, flexible solid 30-gauge, 1-inch acupuncture needles intramuscularly

- approximately 15–30-degree angles in points Sp6 and Sp8 bilaterally: - Sp6 at the posterior margin of the tibia, 3 units directly above the medial malleolus of the ankle, - Sp8 at the posterior margin of the tibia, 3 units below the inferior margin of the medial condyle of the tibia. (There are 13 units between the tip of the medial malleolus and the medial condoyle of the tibia.)Unit = fingerbreath - the needles were secured against the integument with medical tape and remained in place for the duration of the day until the second treatment 12 hours later, consistent with a morning and evening regimen on postoperative days 1 and 2. - The needles were removed at the end of each day by the nurse researchers." - Stimulation procedure - twice daily for 45-60 minutes - they did not directly say what frequency they used but since they varied pulse width up to 250 ms, one can assume it was near 4-5 hertz - pulse width was varied from 125-250 ms as such :"if the pulse width was set for the maximum output value (250ms), pulse width would decrease to 125 ms and then increase again to 250 ms in a period of 4 seconds. Thus, the nerve receptors would not become accustomed to the stimulation as quickly as would occur in a continuous mode."

For diabetic neruopathy they used following sites - look familiar?:


- "10 32-gauge (0.2 mm) stainless steel acupuncture-like needle probes (ITO, Tokyo, Japan) to a depth of 1–3 cm"
- stimulated at alternating frequencies of 15 and 30 Hz every 3 seconds
- maximum of 25 mamps res electrical stimulation
- biphasic square-wave pattern and a 
- pulse width of 0.5 ms in a continuous duty cycle.
- intensity  - highest tolerable level without muscle contractions
- 30 min three times a week for 3 wks

Results:- As can see 1/2 effectiveness gone within 1 week of no treatment so top ups would have to be at least weekly.

Pensrx last3.PNG

Intramuscular Stimulation

Other Needling

Treating Skin Sensitivity and Scars

Myofascial Release


Stocking /bodyu wraps

Treating Myofacial Pains

Massage techniques

Injection techniques

Treat Back Pain Issues

Spinal stenosis and Postlaminectomy issues NB


Intrathecal midazolam

MacKenzie therapy

Manual medicine techniques

Treat Joint Pains

OA hip

OA knee

Treat Feet

Diabetic foot

Intermetatarsal bursitis

Pes Planus

IV and Injectable


Lidocaine IV

Ketamine IV

Lidocaine and ketamine combined IV

Ketamine IM

Treat Restless Legs

Sleep Issues

disordered breathing

sleep apnea

Sleep study on Type 2 Diabetics[55] free article herefound sleep apnea common:

AHI 10+ - mild - may need CPAP - 48%

AHI 15+ definite - will need CPAP - 36% altogether = 29% females; 41% males

AHI 20 - severe - 29%

Another study[56]found sleep apena 2.8 times more likely in diabetics with neuropathy than those without abstract here. This means that in subjects with diabetic neuropathy, sleep apnea is more likely than not.Sleep apnea will encourage weight gain, encourage depression, and promote testosterone deficiency, all changes that will make DM neuropathy worse. (need ref) An epworth drowsiness scale should be done, and if >12 would indicate need for a sleep lab investigation.

Epworth home site:
How likely are you to doze off/fall asleep in the following circumstances?
0– never doze off
1 – Slight chance of dozing
2- moderate chance of dozing
3 – High chance of dozing

 Situation   -rate each from 0-3                                                                                                    

Sitting and Reading

Watching TV

Sitting inactive in a public place (e.g. a theater or meeting)

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after a lunch without alcohol

In a car, while stopped for a few minutes in the traffic

Score a total:

0-6 – good
7-8 – average
9-12 – abnormal
12+ - highly abnormal

Other sleep

Psychological Treatments

Cognitive Behavioural Therapy

Acceptance and Commitment

Mindfulness Meditation

Treatment Depression




SAD light

Physiotherapy Techniques

Sciatic nerve stretching and Hamstring Transverse Mobs

Poster IASP Montreal 2010 [57]

  • Sciatic nerve stretch treatments help diabetic peripheral neuropathy pain and vibration sense further confirming nerve entrapments in diabetes
  • Sciatic nerve stretches were done something like this:
  • Leg is brought up to 90 degrees with knee bent and then knee straightened - 5 times each - 5 sets

Scaitic nerve stretch DM.png

  • Then transverse sciatic nerve massage - adjacent to but not on sciatic nerve - five reps, 5 sets again (sorry re pic quality)

Hamstring transverse stretch.png

  • People were given 1 hour sessions, one weekly for 5 weeks – there was a control group as well

results: Sciatic hamstring DN.png

Wax therapy

Chinese article [58] http://en.cnki.com.cn/Article_en/CJFDTOTAL-XDJH200835006.htm abstract here

- daily wax therapy - 40 minutes daily for 4 weeks (not sure how to make it 40 min except by repeated dipping)
- control was daily injectable 500 ug B12 and 100 mg B1  therapy.
- no reactions to treatments
- significant difference on symptoms,signs (p = 0.05 and NCV (nerve conduction studies)(p = 0.005) between the 
two groups. This is surprising since
frequent B12 shots is associated with beneficial effects of pains. - Their conclusion - "Wax therapy has significant curative effects on diabetic peripheral neuropathy" WARNING - Chinese articles may suffer from a
mis-reporting to "respected doctor" issue. Some years ago, methylene blue injection into disc was reported as an excellent way to treat disc disease but
the Chinese study did not stand up to other reports.

Therabath commonly advertised:Need other sources


Canadian site: Canadian site for wax

Infrared (890 nm)gallium aluminum arsinide diode therapy

60 LED pads put below and above foot and on each side of calf above ankle for 40 minutes 3 times a week

Used a company that won't even list the cost of their pads so suggest get 850 nm LED IR Infrared Illuminator Light Lamp For CCTV Camera as long as you
can monitor units so they don't get too hot for skin (use at own risk!) Two units I can across on ebay:


Each unit is 35-50 dollars which I imagine is much less than the undisclosed amount on other site.

Results: Did not give results for placebo treatment pain levels except to say they were P<0.001 for 6 and 12 treatments. I scaled results to Pain VAS starting at 7
and put placebo where most studies have found the placebo response goes - here is what I found:


This would make results maybe VAS 1.3 better than placebo - which is comparible to what you get with some drugs.

Didn't work quite as well in subjects with numb feet.

About 1/2 reported improvement of sensation and balance.

They did not have any info on "durability" of treatment response though I would suspect weekly top-ups might be necessary.




Ultrasound and massage

Transcutaneous Electical Nerve Stimulation (TENS)


Study one:[59]free article here

- 4-70 hz - 4 ms pilse - to maximum comfort - 30 minutes daily - 4 pads - two above knee - medial and lateral quads

        - two below knee - fibular neck and 3 " below popliteal space in medial gastrocnemius

- 4 weeks



- If scaled to start at 7, dropped to 4.4/10

Study 2 - Turkish study with pad applied in back[60] free pdf clickable here The idea for using lumbar pads came from a physiotherapy case article[61] This early reference put their pads single channel (2 pads) 1.3 cm (1⁄2 in) lateral to the posterior superior iliac spine each side.

Present study - 80 hz; 30 minutes daily;  "Double channel TENS device ...with four electrodes was used. After skin cleaning and applying hydrophilic gel to the electrodes, the electrodes
were bilaterally applied 3 cm lateral to the vertebral column on the lumbo sacral region."



Study 3: - a long term study:[62]

- H wave machine with biphasic, exponentially decaying waveforms - 2-70 hz, 4 msec.; 4 pads - no info on usage time or positioning pads as just a home survey. 
- Followed for average 1.7 years
- Clamined a 2/10 mm drop in VAS on scale 0-10; this is not much better than the 1.9 anticipated from placebo
- However, suggested 70% were helped some and would have hardly stuck to it if it did not.

Trial with stocking electrodes 50 micoramp stimulated (small amount) 8 hours a night for 6 weeks did not fair better than control[63]

Spinal Stimulation

Diabetes Care. 2014 Sep 11. pii: DC_140684. [Epub ahead of print] Spinal Cord Stimulation and Pain Relief in Painful Diabetic Peripheral Neuropathy: A Prospective Two-Center Randomized Controlled Trial. Slangen R et al [2] RESULTS: Trial stimulation was successful in 77% of the SCS patients. Treatment success was observed in 59% of the SCS and in 7% of the BMT patients (P < 0.01). Pain relief during daytime and during nighttime was reported by 41 and 36% in the SCS group and 0 and 7% in the BMT group, respectively (P < 0.05). Pain and sleep were "(very) much improved" in 55 and 36% in the SCS group, whereas no changes were seen in the BMT group, respectively (P < 0.001 and P < 0.05). One SCS patient died because of a subdural hematoma.

CONCLUSIONS: Treatment success was shown in 59% of patients with PDPN who were treated with SCS over a 6-month period, although this treatment is not without risks.

Claudication Circulation Problems

Treat Tarsal Tunnel Syndrome

Innovative Techniques

Brain and spinal magnetic stimulation

Pulsed radiofrequency

Steroids in Diabetic Amyotriophy

Unproven Treatments


In experimental model of diabetic neuropathy[64] melatonin, alone or combined with nicotinamide (B3 derivative) ameliorated symptoms. Doses of melatonin were huge (3-10 mg/kg) where in an adult all I have ever used is max 12 mg at bedtime for sleep.

Epson salt soaks

Have on pateint who uses it for his neuropathy (not diabetic).

Warning was included in one patent application [65] free article herethat "epsom salts have been applied topically in low concentration as a wet soak, because a soak using a saturated epsom salt solution for longer than about fifteen minutes will likely cause local dermatitis" - so use of dilute warm soaks - Have no further info on its use - any comments?

Chi Machine

Rhythmically moves legs back and forth. Used to treat lymphedema but I have one patient with waldenstrom macroglobulinemia neuropathy that finds it removes 75% of his pain with a 20 minute use (testimonial is not proven though...)



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