tDCS and Pain Associated With Diabetic Neuropathy

August 7, 2021 updated by: Mohammad Alwardat, University of Rome Tor Vergata

Effects of Transcranial Direct Current Stimulation (tDCS) on Pain Associated With Diabetic Neuropathy

The purpose of this study is to investigate the effects of anodal transcranial direct current stimulation (tDCS) on pain intensity associated with diabetic neuropathy. The investigators will conduct real tDCS or sham, over the left dorsolateral prefrontal cortex (DLPFC) during 6 separated days. They will evaluate pain intensity, sleep quality, quality of life and anxiety and depression symptoms via clinical validated scales.

The research question is whether tDCS can lessen neuropathic pain and improve sleep, psychological status and quality of life in patients with diabetic neuropathy.

It is hypothesized, that less neuropathic pain and improved sleep, psychological status and quality of life after the tDCS sessions.

Study Overview

Status

Recruiting

Conditions

Intervention / Treatment

Detailed Description

Background: Worldwide, the prevalence of diabetes mellitus (DM) and its chronic complications are reaching epidemic proportions. By 2045 DM expected to affect 629 million persons. Diabetic neuropathy is one of the most common complications of DM and is actually the set of heterogeneous clinical forms. Among diabetic neuropathies, generalized, focal or multifocal forms are distinguished. The most typical and most common form (up to 80% of cases is sensory-motor polyneuropathy. It has recently been redefined as a length-dependent symmetric sensory-motor polyneuropathy attributable to metabolic and microvascular alterations following exposure to chronic hyperglycemia and cardiovascular risk cofactors. Painful diabetic peripheral neuropathy (PDPN) may be considered a variant; about 15-25% of patients have painful diabetic polyneuropathy.

According to the definition of neuropathic pain of the International Association for the Study of Pain (IASP), PDPN is considered as asymmetric sensory-motor polyneuropathy chronic in which neuropathic pain has been present, for at least 3 months, as direct consequence abnormalities of the peripheral somatic-sensitive system following diabetic pathology. Sensory symptoms are more evident than motor symptoms; which is appear in the most distal portions of the limbs and progress proximally according to a "glove" or "sock" distribution associated with paresthesias and dysesthesias. The clinical symptoms are related to the type of nerve fiber involved and typically there are "positive" (tingling, burning, pain, allodynia) or "negative" sensory symptoms (loss of sensitivity, numbness). The involvement of small sensitive fibers causes a reduction in thermal sensitivity and pain and this, in turn, contributes to the deficits in tactile and proprioceptive sensitivity to increase the risk of a foot injury.

The PDPN is associated with negative repercussions on the quality of life (QoL), activities of daily livings, sleep disorders, and is the major determinant of depressive symptoms in patients with PDNP. In fact, depression and sleep disturbances play a negative prognostic role in the general and diabetic population, and sleep disturbances are associated with glycated hemoglobin levels higher than 0.35% in type 2 diabetes. The presence of PDPN determines an increase in the use of medical care and social costs, both directly related to treatments, and indirect secondary to the reduction of working capacity. The presence of chronic pain of any nature increases the risk of difficulties in the self-management of diabetes, in relation to taking therapy, physical activity, adherence to the diet, foot care and even glycemic self-monitoring.

Transcranial Direct Current Stimulation (tDCS) has shown promising results for the treatment of chronic pain in several types of diseases, being a good and non-invasive alternative to treat pain in PDPN patients. Also, based on studies that showed changes in the brain activity of chronic pain patients and on the difficulties faced to treat PDPN, there is a need to conduct clinical trials using new techniques, such as neuromodulation, to help these patients to control their pain. Therefore, tDCS emerges as a new tool to be coupled with other effective treatments already used for these patients.

The dorsolateral prefrontal cortex (DLPFC) is a functionally and structurally heterogeneous region as well as a key area of numerous brain networks involved in the processing of cognition effect. Numerous studies have shown that some chronic pain syndromes are associated with a reduction in the volume of the gray matter of DLPFC. Some studies show that pain relief manages to reverse these structural changes PDPN. Moreover, previous studies reported that DLPFC stimulation induces a significant analgesic and antidepressant effect.

Hypothesis: The investigators believe that neuromodulation by tDCS over the left DLPFC would decrease the pain intensity and improve the general quality of life in patients with PDPN.

Objectives: general PURPOSE Investigate if anodal tDCS over left DLPFC has analgesic effects in patients with PDPN.

Specifics purposes 1- Evaluate the tDCS effects over pain intensity; 2- Evaluate if tDCS has any effect on sleep quality, depression, anxiety, and quality of life.

Randomization: The subjects will be allocated consecutively to randomization as an intervention order using the tool from the randomization.com website (Dallal GE, http://www.randomization.com). The investigators will use the second generation suggested for crossover studies.

Data Collection Procedure: All subjects will be treated using two different interventions (groups respecting the washout period of six weeks to avoid residual effects. The intervention order will be determined by randomization per group of interventions. Subjects will be contacted by phone and asked if they want to participate in the study. Those who wish to participate and qualify according to the selection criteria after completing the pre-screening questionnaire will be scheduled after reading and signing the consent form (2 copies). During the second visit, all clinical and neurological assessments will be performed before and after tDCS stimulation phase. Each patient will be clinically and neurologically assessed before and after the stimulation, allowing data to be collected 4 times (T0, T1, T2, and T3).

tDCS protocol: Group Real tDCS: The participant will receive anodal tDCS over the left DLPFC and the reference electrode will place over the right forearm. The stimulation intensity will be 2mA DC delivered for 20 min (30 s step-up ramp, 30 s step-down ramp), repeated six times, during two weeks (Mon, Wed, Frid).

Group sham tDCS: Identical to the real tDCS, except the participants will only receive the initial 30 seconds of ramp-up, after which the current will be set to 0 for the remainder of the 20 minutes.

Study Type

Interventional

Enrollment (Anticipated)

20

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Contact Backup

Study Locations

  • Italy
    • Lazio
      • Roma, Lazio, Italy, 00133
        • Recruiting
        • Prof. Silvia Natoli
        • Contact:
        • Contact:
        • Principal Investigator:
          • Antonio Pisani, MD, PhD
        • Principal Investigator:
          • Vincenza Spallone, MD. PhD
        • Principal Investigator:
          • Siliva Natoli, MD, PhD

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years to 65 years (ADULT, OLDER_ADULT)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  • Patient diagnosed with painful diabetic peripheral neuropathy (PDPN) components with DN4 score ≥ 4/10, and chronic pain with an intensity of at least VAS> 4/10.
  • Onset of neuropathic PDPN pain for at least 6 months.
  • Pain intensity as measured by VAS> 4/10 in the week preceding inclusion in the study.
  • drug-resistant patients who have no pain reduction of 50% or an improvement of at least 2 points in the Patient Global Impression of Change, having used all the classes of drugs indicated as a first, second or third line.
  • Absence of glycemic de-compensation with HbA1c values <9% in the previous 6 months.
  • Stability of glycemic control with changes in HbA1c in the last 6 months of less than 2%.

Exclusion Criteria

  • Neurological comorbidities.
  • Presence of contraindications to the use of electrotherapy (pacemaker, epilepsy, etc ...).
  • Pregnancy.
  • Previous neurosurgical interventions.
  • psychiatric conditions.
  • Cognitive impairments ( Mini-Mental Status exam (MMSE) <24).
  • Presence of red flags for pain: tumors, spine fractures, non-neuropathic pain difficult to distinguish from that of the PDPN, neuropathic pain from a cause other than the PDPN.
  • Severe comorbidities such as advanced renal failure, heart failure, respiratory failure.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: TREATMENT
  • Allocation: RANDOMIZED
  • Interventional Model: CROSSOVER
  • Masking: DOUBLE

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
ACTIVE_COMPARATOR: Real tDCS
The participant will receive anodal tDCS for 20 min at an intensity of 2 mA while seated comfortably and quietly in a room. The intensity will start at 0 mA and will be incrementally increased to 2mA over the initial 30 seconds. At the 19:30 minute time point, the current will gradually be reduced from 2 mA to 0 mA.
Device: transcranial direct current stimulation
Transcranial direct current stimulation (tDCS) is a noninvasive technique of neuronal modulation that has been used in different neurological conditions, neuropathic pain.
SHAM_COMPARATOR: Sham tDCS
Identical to the real tDCS, except the participants will only receive the initial 30 seconds of ramp-up, after which the current will be set to 0 for the remainder of the 20 minutes.
Device: transcranial direct current stimulation
Transcranial direct current stimulation (tDCS) is a noninvasive technique of neuronal modulation that has been used in different neurological conditions, neuropathic pain.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Changes in Pain severity
Time Frame: Measured at baseline and immediately after the intervention
Changes in Pain severity will be measured by Brief Pain Inventory (BPI) to determine the effect of anodal Transcranial direct current stimulation (tDCS) in reducing pain of subjects with pain associated with diabetic neuropathy.
Measured at baseline and immediately after the intervention

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Changes in Depression severity
Time Frame: Measured at baseline and immediately after the intervention
Changes in depression severity will be measured by Hamilton Depression scale (HAM-D) to determine the effect of anodal Transcranial direct current stimulation (tDCS) in reducing depression severity of subjects with pain associated with diabetic neuropathy.
Measured at baseline and immediately after the intervention
Changes in Anxiety severity
Time Frame: Measured at baseline and immediately after the intervention
Changes in Anxiety severity will be measured by Hamilton Anxiety scale (HAM-A) to determine the effect of anodal Transcranial direct current stimulation (tDCS) in reducing anxiety severity of subjects with pain associated with diabetic neuropathy.
Measured at baseline and immediately after the intervention
Changes in sleep quality
Time Frame: Measured at baseline and immediately after the intervention
Changes in Sleep quality will be measured by Pittsburgh sleep quality index (PSQI) to determine the effect of anodal Transcranial direct current stimulation (tDCS) in improving sleep quality of subjects with pain associated with diabetic neuropathy.
Measured at baseline and immediately after the intervention
Changes in Quality of Life
Time Frame: Measured at baseline and immediately after the intervention
Changes in quality of life will be measured by SF-36 to determine the effect of anodal Transcranial direct current stimulation (tDCS) in improving quality of life of subjects with pain associated with diabetic neuropathy.
Measured at baseline and immediately after the intervention
Changes in Pain related to disability
Time Frame: Measured at baseline and immediately after the intervention
The investigators will use the Pain Disability Index (PDI) to assess changes in pain related to disability.
Measured at baseline and immediately after the intervention
Changes in Pain Catastrophizing
Time Frame: Measured at baseline and immediately after the intervention
The investigators will use the Pain Catastrophizing Scale (PCS) to assess changes in pain Catastrophizing.
Measured at baseline and immediately after the intervention
Changes in Neuropathic Pain Symptom
Time Frame: Measured at baseline and immediately after the intervention
Changes in neuropathic pain symptoms will be measured by Neuropathic Pain Symptom Inventory (NPSI) to determine the effect of anodal Transcranial direct current stimulation (tDCS) in improving and/or reducing neuropathic pain symptom of subjects with pain associated with diabetic neuropathy.
Measured at baseline and immediately after the intervention

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

University of Rome Tor Vergata

Investigators

  • Study Director: Slivia Natoli, MD, PhD, Department of Clinical Science and Translational Medicine, University of Rome Tor Vergata, 00133 Rome, Italy.

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (ACTUAL)

June 1, 2020

Primary Completion (ANTICIPATED)

June 6, 2022

Study Completion (ANTICIPATED)

September 1, 2022

Study Registration Dates

First Submitted

March 3, 2020

First Submitted That Met QC Criteria

March 9, 2020

First Posted (ACTUAL)

March 12, 2020

Study Record Updates

Last Update Posted (ACTUAL)

August 10, 2021

Last Update Submitted That Met QC Criteria

August 7, 2021

Last Verified

August 1, 2021

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • University of Rome Tor Vergata

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

Clinical Trials on Diabetic Neuropathies

Clinical Trials on transcranial direct current stimulation

Search Similar Trials

Sponsors and Collaborators

Medical Conditions

Drug Interventions

CROs by country

CROs in Japan

Conditions

Rare Diseases

Drug Interventions

Dietary Supplements

Sponsor/Collaborators

Locations

3
Subscribe