Diabetic Neuropathy: Which Electrical Stimulation Method Really Works? New Meta-Analysis Provides the Answer
Painful diabetic peripheral neuropathy (DPN) is one of the most severe and debilitating complications of diabetes. Up to 60% patients with long-term diabetes experience chronic neuropathic pain, paresthesia, burning, numbness of the extremities, which significantly reduces the quality of life and disrupts sleep. Pharmacological treatments - antidepressants, anticonvulsants, opioids - often have a limited effect, especially in elderly patients, and can cause side effects. Against this background, non-invasive methods of stimulating the nervous system are attracting more and more attention.
A new systematic review and network meta-analysis published in the Journal of NeuroEngineering and Rehabilitation in 2025 provided the first comprehensive comparative evaluation of 10 non-invasive brain and peripheral nerve stimulation techniques aimed at reducing pain in DPN. The analysis included 15 randomized controlled trials involving 1,139 patients with an average age of 61.2 years. Outcomes assessed included pain level, sleep quality, overall quality of life, and treatment discontinuation rates.
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🔍 Stimulation methods: effectiveness, mechanisms of action and clinical applicability
The analysis covered two large groups: methods of stimulation of the brain and peripheral nerves.
✅ TENS - transcutaneous electrical nerve stimulation
TENS (Transcutaneous Electrical Nerve Stimulation) has become the most effective method in all key indicators. This technology involves placing electrodes on the skin above the affected area and delivering a weak pulsed current that stimulates the sensory nerves. This leads to:
•blockade of pain impulses at the level of the spinal cord (the “pain gate” mechanism),
•activation of descending antinociceptive pathways,
•release of endorphins and serotonin,
•improving local microcirculation.
Results:
•pain reduction: SMD = −1.67 (95% CI: −2.64 to −0.71),
•sleep improvement: SMD = −1.63 (95% CI: −2.27 to −0.99),
•the frequency of treatment refusals is not higher than in the control group.
TENS is a simple, safe, inexpensive and accessible method for outpatient or home use. It works especially well in courses lasting up to 12 weeks.
⚡ rTMS — repetitive transcranial magnetic stimulation
rTMS (Repetitive Transcranial Magnetic Stimulation) uses magnetic pulses delivered through a coil placed over a specific area of the brain. The best results were shown by stimulating the motor cortex (C3 point, left hemisphere) with a frequency of 10 Hz:
•improved quality of life: SMD = -2.16.
However, the method did not show statistically significant pain reduction or improvement in sleep. rTMS may be promising for patients with depression, anxiety, and sleep disturbances that often accompany DPN pain, but its effectiveness for pain relief is limited.
⚠️ Other stimulation methods
•tDCS (Transcranial Direct Current Stimulation) was found to be ineffective in reducing pain compared to placebo.
•PEMF (Pulsed Electromagnetic Field) and SEMF (Sinusoidal Electromagnetic Field) - methods using electromagnetic fields - did not show significant clinical improvement.
•FREMS (Frequency Rhythmic Electrical Modulated Stimulation) – a method of variable-modulated stimulation with a changing frequency – showed a positive effect in individual studies, but did not demonstrate consistent results in a meta-analysis.
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💡 What does this mean for practice?
The results of the analysis are unambiguous:
TENS is the most effective and clinically proven method of non-invasive pain therapy for DPN. It can be used:
•in an outpatient setting (in the physiotherapy room),
•at home (with doctor’s prescription and supervision),
•in patients who do not tolerate medications well,
•in complex therapy (in combination with medications and exercise therapy).
Brain stimulation methods (rTMS, tDCS) require equipment, personnel and logistics, which limits their use. However, they may be promising in the presence of concomitant neuropsychiatric symptoms. Other methods are experimental and require further study.
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📌 Conclusion
Pain in diabetic neuropathy is a serious clinical and social problem. Pharmacotherapy is not always effective and safe. In the context of the need to find affordable and minimally invasive solutions, TENS occupies a leading position among non-pharmacological approaches. This is a simple and scientifically proven method that can already be implemented in practice - both in physiotherapy departments and within the framework of chronic pain programs and diabetes offices.
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