Case Study
November 9, 2022

Electrical stimulation for diabetic foot ulcers and neuropathy | Case Study

Dr Irem Tezer Ates
Published on: 
November 9, 2022
NuroKor Team
Published on: 
November 9, 2022

Electrical stimulation for diabetic foot ulcers and neuropathy | Case Study

Diabetic foot ulcers are the main cause of foot amputations, being responsible for 80% of cases. These ulcers are the result of wounds on the feet that fail to heal and often become infected, and stem from peripheral neuropathy (the loss of feeling in your extremities) and circulation problems, both of which are complications from diabetes.

These are challenging to treat and can have serious impacts on quality of life and life expectancy. Dr Irem Tezer Ates, NuroKor’s Medical Science Director, presented at the European Wound Management Association on how electrical stimulation, or electrotherapy, can be effective for treating peripheral neuropathy, preventing diabetic ulcers and increasing overall quality of health.

Before we examine the case study that she presented, we’ll first look at the background to diabetic foot ulcers, how neuropathy and other complications feature, and current treatment methods.

How diabetic ulcers form (and lead to amputations)

For diabetes patients, ulcers most commonly form on the feet and peripheral neuropathy is the main reason. This may sound strange, but think about the times when you have worn shoes that don’t quite fit properly - after a few minutes of walking around, you can probably feel them rubbing your heel or little toe. If this goes on for too long, perhaps they felt fine in the shop and you cannot change them until later, then a blister might form. You’ll likely recognise this and make changes, maybe finding a plaster or resting.

Someone checking their blood sugar levels
Regularly checking blood sugar levels is essential for diabetics

However, for people with peripheral neuropathy, it is very common to not feel the pain (or at least for it to be negligible), so they keep doing what created the blister in the first place. The blister might form, burst and then not be adequately protected, creating an opportunity for infection. 

If the lack of sensation were the only problem, then it might not go too much further. But diabetes can also affect the circulation, particularly in the legs and feet, through the build up of blockages (plaques) in the blood vessels. Several of the stages of healing rely on cells and nutrients being transported to damaged areas by the blood. If circulation is impeded, then these vital resources cannot reach the wound and it can take a long time to heal - or sometimes not heal at all. From here, it’s not too difficult for a blister to become an ulcer.

Poor circulation not only increases the risk of infection by the wound remaining open for longer, but also makes it harder for your body to fight infection in an area with limited circulation because the immune system’s response is hindered as well. If white blood cells cannot reach the area via the blood, then infection will spread.

An added complication is that peripheral neuropathy can not only affect the ability to feel pain, but can make moving and walking more difficult - some people more easily trip and fall and become reluctant to walk. This in turn can make the situation worse, as moving about less can negatively impact circulation.

Ultimately, poor circulation is what leads to tissue in the area dying and gangrene setting in. Once it gets this far, removing dead tissue or amputation are the most common ends.

Current prevention and treatment of diabetic foot ulcers and peripheral neuropathy

Unfortunately, there is no cure for diabetes itself, the disease can only be managed through lifestyle changes and taking drugs, including insulin. The same applies to neuropathy, which can only be slowed or prevented, although ulcers can be treated.

Someone touching their foot
Checking your feet regularly for signs of injury can help catch ulcers early

There are some shared measures that you can take to reduce the risk of neuropathy and diabetic foot ulcers, which are broadly the same as the lifestyle changes that are recommended for diabetes: controlling blood sugar levels through diet, exercising (but remembering to monitor blood sugar levels), and not smoking. These reduce the damage to nerves that leads to peripheral neuropathy and can help maintain good circulation, in turn lowering the risk of foot ulcers.

Of course, washing your feet and not wearing shoes that give you blisters - though you may not recognise if the shoes are causing them at first - are sensible measures to take to prevent ulcers. Checking your feet regularly and also having them inspected when you see your doctor is also important to catch early signs of damage.

If a wound does appear on your foot, see your doctor immediately, they will likely bandage the area, advise you to rest or at least reduce pressure on the foot, and may also prescribe some medication. The majority of non-infected foot ulcers heal without surgery, but sometimes it will be necessary.

Before it gets to the stage of amputation, other surgery options include attempting to improve circulation to affected areas, either with a bypass or a stent. There are several risks with these types of operations for diabetics, including that the blood vessels may just become blocked again. Overall, patients with diabetes are more likely to need amputation later on after a leg bypass than non-diabetics (1).

Aside from foot ulcers, the main symptom that stems from peripheral neuropathy is pain, which is usually managed with drugs.

The benefits of electrical stimulation

Understanding the background to diabetic ulcers and their treatment is necessary to see the full potential that electrical stimulation has as part of their prevention and management.

Although there are many benefits of electrical stimulation, the ones most relevant for diabetic ulcers and peripheral neuropathy are the ability to manage pain, aid circulation, combat neuropathy and even to have an antibacterial effect (2).

The case study we are focusing on in this article does not cover the full scope of how electrical stimulation can benefit diabetes. For a more complete look, read our White Paper Diabetes Treatments and the Role of Electrotherapy. Some of the main points that it covers are that certain types of electrical stimulation can reduce the need for additional insulin in type 2 diabetes, as well as helping to control blood glucose levels and improve fitness.

Electrical stimulation for diabetes complications - a case study

Thermal imaging of someone's legs while the NuroKor Lifetech mitouch is attached
Thermal imaging can show activity and circulation

Aim: To assess the effectiveness of electrical stimulation in treating diabetes complications.

Participant: A 77-year-old man, who had suffered from diabetes for 25 years, hypertension for 40 years, hypercholesterolemia for 30 years. He has diabetic nephropathy (kidney problems), retinopathy (eye problems), neuropathy, and problems with the blood vessels in his legs and heart. He led a sedentary life after leaving his job, which only increased during COVID lockdowns and his neuropathy and circulation problems deteriorated during this time.

He had critical blockages of blood vessels in his legs but refused a peripheral bypass stent operation due to the risk and low rate of success.

Methodology: Using a NuroKor Lifetech device, electrical stimulation was delivered to the patient’s legs, initially with his doctor’s assistance and later by himself. The patient’s symptoms were also monitored: monofilament tests (used to test for nerve damage) were performed before and after the treatment; blood sugar, pressure and pulse were measured three times per day; and thermal imaging was used to monitor localised circulation increases.

Results: The thermal camera showed increased activity in the area where the electrical stimulation was applied, and there was also increased circulation for a few hours afterwards. The monofilament tests also showed an improvement in the patient’s neuropathy and he even said that he started to feel the electrical stimulation more in the later stages of treatment. The other measures were all within the normal limits.

Thermal imaging of someone's legs
Thermal imaging showing an increase in circulation after electrical stimulation

What do these results mean?

What stands out most at first glance is that not only did the patient’s circulation improve, but so did the feeling in his legs. When we consider that these are two of the most significant risk factors for diabetic ulcers and whether they require more invasive treatment, this is an exceptional outcome.

Beyond the obvious medical benefits of reducing the risk of diabetic ulcers, the patient’s quality of life was also improved. Improving feeling in his legs enabled him to be more confident in his ability to walk, which was further supplemented by the pain management that electrical stimulation can also provide. In the end, he said that he was more confident in his daily activities and able to walk further and for longer. He will be able to maintain this by continuing to use NuroKor technology at home, which is possible thanks to the easy-to-use nature of the devices that our technology is delivered with.

This patient’s case is particularly encouraging because not only does it show electrical stimulation to be an effective treatment method, but also highlights how it can be used in situations where other methods are not feasible. This man would likely have had a low success rate with an operation, but here, a non-invasive treatment has improved his condition.

Although it was not measured here with this patient, electrical stimulation has been shown to have beneficial effects in wound healing (3) and to have an antibacterial effect as mentioned earlier.

The future of diabetes treatment

Diabetes is a chronic disease that affects roughly 415 million people around the world. With no cure, this has a significant cost to health services everywhere. In the UK, where there are around 4 million sufferers, the cost to the NHS is roughly £10 billion - 10% of its entire budget. 

Healthcare around the world is increasingly taking a preventative outlook towards many conditions. The NHS Long Term Plan is looking for ways to support people to live independently in their own homes and to minimise the number of surgeries. Electrical stimulation fits right into this future plan as a treatment method with clear potential for positive outcomes that can be used in the comfort of people’s own homes and with little or no oversight from healthcare professionals. 

Bearing in mind the cost of diabetes to health services and the impact it can have on individuals, we see great potential for electrical stimulation in helping people manage their diabetes, neuropathy and reducing the risk of diabetic foot ulcers and other complications.

However, it is not just diabetes and its complications that electrical stimulation is an effective treatment for.

Treating other conditions with electrical stimulation

Dr Tezer Ates has examined the use of electrical stimulation in a range of conditions, not just diabetic foot ulcers. She has studied its use for reducing the risk of venous thromboembolism and reducing swelling in the legs, as well as how electrical stimulation can help with menstrual pain.

Hands with non-healing ischemic ulcers
Before treatment on the left, after treatment on the right

As a final indicator of the effectiveness of electrical stimulation for treating non-healing injuries, another case that was presented to a conference featured a patient with non-healing ischemic (meaning lack of blood supply) hand wounds. After 40 sessions of electrical stimulation as an adjuvant treatment (20 minutes per session, six days per week), the wounds healed completely, as well as the stimulation providing pain relief (4).

About NuroKor

Founded in 2018, NuroKor is a company committed to the development of bioelectronic technologies. NuroKor develops and formulates programmable bioelectronic software for clinical and therapeutic applications, in a range of easy to use, wearable devices. It provides the highest-quality products, delivering personalised pain relief and recovery support and rehabilitation to patients.

References

  1. Malmstedt, Jonas & Leander, Karin & Wahlberg, Eric & Karlström, Lars & Alfredsson, Lars & Swedenborg, Jesper. (2008). Outcome After Leg Bypass Surgery for Critical Limb Ischemia Is Poor in Patients With Diabetes A population-based cohort study. Diabetes care. 31. 887-92. 10.2337/dc07-2424. 
  2. Asadi MR, Torkaman G. Bacterial Inhibition by Electrical Stimulation. Adv Wound Care (New Rochelle). 2014;3(2):91-97. doi:10.1089/wound.2012.0410
  3. Ud-Din S, Bayat A. Electrical Stimulation and Cutaneous Wound Healing: A Review of Clinical Evidence. Healthcare (Basel). 2014;2(4):445-467. Published 2014 Oct 27. doi:10.3390/healthcare2040445
  4. Tezer Irem, Fabricius Christian, 42nd Annual Scientific Meeting of the European Underwater & Baromedical Society, (EUBS) 2015, Hyperbaric oxygen and electrical stimulation treatment of systemic sclerosis non healing ulcers: a case report