Existing evidence of tSCS emphasizes pain relief and overlooks other functional parameters such as sensory enhancement, lower limb flexibility, and sustained improvements in physical activity and QoL.
Combined effects of tSCS and AR training on lower limb flexibility, vibration sense, QoL, and physical activity in patients with diabetic neuropathy. This dual approach has the potential to deliver a comprehensive strategy for managing DPN, which is low-cost, safe, and a more accessible solution for diabetic patients in Pakistan and around the world.
More than or equals to 4 scores on Douleur Neuropathique 4 Questionnaire (DN4)
More than or equals to 6 Hz at Neurothesiometer
Cognitively compromised (MOCA score ≤ 26/30)
Metallic implants at skull
Shunting
Skin allergy
Parallel
Transcutaneous spinal cord stimulation Group
Other interventionTranscutaneous spinal cord stimulation will be administered non-invasively using surface electrodes placed over the D12-L1 spinal segment. Stimulation will be delivered using the Soterix 1×1 Transcutaneous Electrical Stimulation (TES) unit. Stimulation will be applied at a frequency range of 30 Hz. The pulse duration is 1 ms, and the intensity will be set at 2 mA. A ramp-up and ramp-down time of 30 seconds will be used to enhance participant comfort during the start and end of each stimulation session, following standardized electrode placement and safety protocols. The stimulation will be delivered in a comfortable sitting or lying position
Augmented reality
Other interventionAR-based rehabilitation will involve interactive balance and coordination tasks performed in a virtual environment all while receiving real-time visual feedback to guide movement accuracy and postural control. The main training block will comprise exercises focusing on hip flexion, hip abduction, knee flexion, and lateral weight shifting. Each module will be performed for 5-8 minutes, with short rest intervals between tasks.
International Physical Activity Questionnaire
The IPAQ assesses physical activity across four domains: work, transport, domestic, and recreation time. It includes 27 items and collects data on frequency and duration of physical activity at three intensity levels; high, moderate, and low. The IPAQ has Test-retest reliability ICC = 0.80. the score is calculated by converting activity into MET-minutes/week. Low activity: \< 600 MET-min/week, Moderate activity: 600-3000 MET-min/week and High activity: \> 3000 MET-min/week. Outcome will be measured at Baseline then Week 1 and then week 5
Diabetes Quality of Life Questionnaire
The Diabetes Quality of Life (D-QoL) questionnaire is a disease-specific instrument originally developed for the diabetes control and complications trial (DCCT) to assess the quality of life in individuals with diabetes mellitus. It has 46 items divided into three main domains: satisfaction, impact, and worry. Each item is rated on a likert scale, with higher scores indicating greater impact, or concern. The tool assesses the individual's perception of how diabetes affects various aspects of life, including daily activities, social functioning, and emotional well-being. The D-QoL has demonstrated strong reliability and validity, with internal consistency ranging from 0.73 to 0.94 for its subscales. Outcome will be measured at Baseline then Week 1 and then week 5
Neurothesiometer
The neurothesiometer is a non-invasive and reliable device for assessing vibration perception threshold (VPT). The neurothesiometer demonstrated excellent intra-class correlation coefficients (ICCs) exceeding 0.90, highlighting its consistency. The cut off value of ≥ 6hz indicates presence of neuropathy. This tool is beneficial in clinical settings due to its ease of use, objective quantification, and ability to detect subclinical neuropathy. The neurothesiometer offers superior standardization, making it a preferred method for evaluating protective sensation and vibration loss in diabetic populations. Outcome will be measured at Baseline then Week 1 and then week 5
Sit and reach test
The sit-and-reach test is a widely used tool for assessing lower limb flexibility. The test demonstrates excellent reliability, with intra-class correlation coefficients (ICCs) ranging from 0.92 to 0.99, indicating strong consistency in repeated measures. Scoring is based on distances recorded in inches or centimeters, higher values indicate better flexibility. It is simple to administer, cost-effective, making it a reliable method for flexibility assessment in healthy adult populations. Outcome will be measured at Baseline then Week 1 and then week 5
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