Non-Pharmacological Therapies in the Management of Painful Diabetic Neuropathy: A Literature Review

<b>Introduction:</b> Painful diabetic neuropathy (PDN) is a frequent diabetic complication with significant impact on the patient's daily life. However, available pharmacologic treatments lack efficiency leading to many therapeutic alternatives being tested. <b>Materials and methods:</b> The objective of this comprehensive narrative review is to summarize all relevant nonpharmacological therapies of PDN with emphasis on recommendations, indications, and risks. Mechanisms through which therapies alleviate pain were also described. <b>Results:</b> Four main categories of alternative treatments were found; respectively, exercise therapy, electric stimulation therapy, complementary and other physical therapies, and surgical therapy. Most therapies belong to physical therapies. While high frequency spinal cord stimulation has a class 1 recommendation, exercise therapy (including yoga), transcutaneous electrical nerve stimulation, and photobiomodulation also emerge as alternatives. Whole body vibration and surgical interventions had limited results due to small groups, while ozone therapy and dorsal root ganglion stimulation show pain improvement only in animal studies. Most traditional Chinese therapies had insufficient data, low quality studies, or questionable safety as important counterarguments. <b>Conclusions:</b> Despite the recurrent limitations given by insufficient standardization associated with therapy categories, a decent number of non-pharmacological treatments proved useful in PDN treatment by evading medicamentous side effects. The prototype remains high frequency spinal cord stimulation.