Comparison Electrical Stimulation and Passive Stretching

for Blood Glucose Control Type 2 Diabetes Mellitus

Patients
Rika Wahyuni Arsianti1,a), Dewy Haryanti Parman2,b), Hendy Lesmana2.c)
1
Department of Electrical Engineering, University of Borneo Tarakan, Tarakan
Jl. Amal Lama No.1 Kampus UBT, Tarakan
2
Department of Nurse Science, University of Borneo Tarakan, Tarakan
a) rkwahyuni@gmail.com
b) dewy_fik@yahoo.com
c) hendylesmana13@gmail.com

Abstract. Physical exercise is one of the cornerstones for management and treatment type 2 diabetes mellitus. But
not all people are able to perform physical exercise because of their physical limitation condition. The strategy for
those people in this study is electrical stimulation and passive stretching. The aim of this study is to find out the
effect of electrical stimulation and passive stretching to lowering blood glucose level. 20 subjects is divided into
electrical stimulation and passive stretching group. The provision of electrical stimulation on lower extremities
muscles for 30 minutes for electrical stimulation group (N=10). And other underwent passive stretching for 30
minutes (N=10). The result shows that blood glucose level is decrease from 192.9 ± 10.7087 mg/dL to 165.3 ±
10.527 mg/dL for electrical stimulation intervention group while for the passive stretching group the blood glucose
decrease from 153 ± 12.468 mg/dL to 136.1 ± 12.346 mg/dL. Both electrical stimulation and passive stretching are
effective to lowering blood glucose level and can be proposed for those people restricted to perform exercise .
Keywords: blood glucose, electrical stimulation, exercise, lower extremities, passive stretching

INTRODUCTION

Physical exercise has the main role for the management and treatment for type 2
diabetes mellitus (T2DM) to blood glucose control. In T2DM insulin is present but it does not
function efficiently to stimulate glucose uptake into cells so called insulin resistance [1]. The
contraction muscle doesn’t need insulin to stimulate glucose into cells because the insulin
receptor was increased when muscle activated [2]. This is the main reason for T2DM to
perform physical exercise. T2DM without proper treatment can cause serious long-term
complications such as macro vascular and micro vascular disease. But not all T2DM are able
to perform physical exercise. This is due to a very weak physical condition such as very old
patients, lower limb amputation, disability or bedridden state because of chronic illness.
Therefore the new strategy is needed to blood glucose control for T2DM patients who are
unable to perform physical exercise. The intensity of physical exercise is adjusted to age and
physical fitness of the T2DM patients. But it is quite different to determine the intensity of
physical exercise for those T2DM patients. The treatment management of physical exercise
for elderly patients is choosing the activity that suitable for physic and psychics of elderly
patients. In this study we propose Electrical Stimulation (ES) and passive stretching to blood
glucose control. The aim of this study is to compare electrical stimulation and passive
stretching to blood glucose control.
In our previous study we use ES to replace physical exercise for T2DM. The result
shows that electrical stimulation is able to lower blood glucose level significantly. ES
delivered a low current to muscle through surface electrode that causes muscle contraction.
To produce muscle contraction the signal from electrical stimulation must have the same
characteristic to Central Nervous System. The parameter of ES is adjusted to the aim of the
provision ES to achieve the optimal result and prevent fatigue. The parameters of ES are
consist of frequency, duration, duty cycle, intensity/amplitude, pulse pattern, program
duration and muscle group activated [3]. The parameter of ES has to consider the patients
safety and the aim of the provision ES.
The frequency is determined to the aim of the provision of ES. For clinical
application, the 20 – 50 Hz is commonly used to achieve the optimal result [4, 5]. Pulse
duration influence the muscle contraction. The wider pulse duration the bigger muscle
contraction is produced. If the ES is used to produce muscle contraction in subcutaneous
tissue to secondary tissue the duration must be set wider [6]. The study of variety of duration
width 50, 200, 500 and 1000 µs at 20 Hz frequency at soleus muscle shows that the wider
pulse duration will generate the stronger muscle contraction in plantar flexion [7]. Duty cycle
shows the ration on and off signal from ES device. For clinical application the widely used of
duty cycle is 70%, but the ratio can be changed in accordance with the purpose of the
provision of ES [6]. In this study we use 20 Hz of frequency, 200 µs of pulse duration, 50%
duty cycle. The maximum amplitude and maximum current respectively is 80 V 60 mA. The
exercise program duration in this study is 30 minutes, 3 times a week for 4 week [8]. The
intervention ES will be given to lower extremities muscles.
The other strategy for elderly T2DM patients in this study is passive stretching.
Physical exercise should be adjusted to age and physical fitness condition [9]. Management
exercise for elderly T2DM patients is adjusted to the ability of their physical. Stretching is the
possible alternative for elderly and people with a very weak condition. The study conducted
by Nelson state that stretching for 20-40 minutes every day has the same metabolism to rate
estimated walking exercise 40 meter/minute [10]. Passive stretching is exercise within a
person’s muscle through action performed by an outside source. Passive stretching is able to
perform in seat and lying position. Every stretched position is held for 30 seconds and
repeated for 4 times except for the right and left side stretch movement just 2 times
repetitions [10].
Passive stretching on muscle will increase the adenosine monofosfat kinase (AMPK)
that facilitated glucose transport (GLUT 4). The GLUT4 is main factor to determine the
maximal transportation of glucose to skeletal muscle [11]. Sukamoto in his study state that
kinase β protein is stimulated by perform passive exercise to the glucose uptake [12].

METHODS

The study design was pre-post experimental study. The participants are clinically
diagnosed type 2 diabetes mellitus without complication. The inclusion criteria are men and
women ≥ 55 years old, random blood glucose 100 mg/dL ≤ x ≤ 250 mg/dL, willing to sign
the inform concent. The exclusion criteria are type 2 diabetes mellitus with hypertension,
cardiovascular, had any kind of lower limb contracture. The drop out criteria is participant
who unable to complete the study. Subjects is divided into group A (N=10) underwent 30
minutes electrical stimulation on lower limb muscles and group B (N=10) underwent 30
minutes passive stretching supervised by the therapist. The study was approved by Ethical
Committee from Udayana University No.383/UN.13.2/KEP/2016.
Subjects are informed about the aim and procedures of the study. The blood glucose
samples were determined before and after intervention in both groups. The frequency of
intervention is 30 minutes, 3 times a week for 4 week. The first experimental set up for
electrical stimulation intervention (group A) is the placement of surface electrode on vastus
and harmstring muscles. The electrical stimulation is only on lower extremities. The subjects
sitting relax for 30 minutes while the provision electrical stimulation. For the passive
stretching group (group B) is refer to Nelson [10]: Seated knee flexor (bilateral); Seated knee
flexor-hip adductor (bilateral); Seated shoulder lateral flexor (bilateral); Supine hip flexor-
knee extensor (unilateral). Seated hip external rotators, extensor (unilateral); Seated shoulder
extensors, adductors, retractors (unilateral). Supine knee flexor-plantar flexor (unilateral);
Prone hip flexor (unilateral); Seated shoulder flexors, depressors (bilateral); Seated shoulder
and elbow flexors (unilateral). Every stretch is held for 30 minutes and 4 times repetitions
except the movement on right and left side just 2 repetitions.
The blood sample from both group will be statistical analyzed using pair T-test. The
normal data test using Saphiro-Wilk. Data will express by Mean ± Standard Error.

RESULT AND DISCUSSION

The normality data test using Saphiro-Wilk for electrical stimulation and passive
stretching group respectively are p = 0.959 and p = 0.569. The p-value > 0.05. It means the
data is normal distribution for both groups. The result for electrical stimulation is shown in
figure 1.

200
*

150
mg/dL

100

50

0
Pre-Exp Post-Exp

Electrical Stimulation

Figure 1. The blood glucose level before and after electrical stimulation intervention
*) significantly different before ES (p<0.001)

The baseline blood glucose level for electrical stimulation is 192.9 ± 10.7087 mg/dL
The subjects in this group underwent electrical stimulation intervention 30 minutes, 3 times a
week for 4 week. The result from statistical analysis shows that the decrement of blood
glucose level to 165.3 ± 10.527 mg/dL. The difference from the baseline to last session is
27.6 mg/dL. This result is significantly decrease from the baseline with t =6.720 and p ≤
0.001.
 The baseline blood glucose level in passive stretching group is 153 ± 12.468 mg/dL.
After 4 weeks underwent passive stretching the blood glucose level decrease to 136.1 ±
12.346 mg/dL. The decrement of blood glucose level is significant (t=68.840 , p ≤0.001). The
result of passive stretching intervention is shown at figure 2.

200

*
150
mg/dL

100

50

0
Pre-Exp Post-Exp

Passive Stretching

Figure 2. The blood glucose level before and after Passive stretching intervention *) significantly different
before passive stretching(p<0.001)

Electrical Stimulation and Passive Stretching is used to generate muscle contraction to

lowering blood glucose level. In T2DM patients, insulin-stimulated glucose uptake in skeletal
muscle is impaired. Therefore the exercise is needed to stimulated glucose uptake to lowering
blood glucose to normal level or at near normal level [13]. Both insulin and exercise increase
skeletal muscle glucose uptake by translocation of glucose transporter 4 (GLUT4), the
predominant GLUT in muscle, from an intracellular location to the plasma membrane. The
study conducted by [85] state that mice that lack insulin receptors in skeletal muscle can be
achieved normal blood glucose level through exercise [14]. The study clearly demonstrated
that exercise is able to blood glucose control. In hyper-insulinemic condition the tissue
mediated the whole body glucose homeostasis and the glucose disposal 70-75% is supported
by skeletal muscle by exercise [15].
Glycogen is the molecular form of carbohydrates stored in humans and up to 80% is
stored in skeletal muscle [16]. The glucose uptake correlated with glycogen breakdown when
muscles were stimulated at different intensities [17]. The glycogen breakdown can be
achieved after prolonged exercise, but high intensity also decreases the content of glycogen
[18]. The glycogen utilization is low or absent in skeletal muscle at rest. [19]. There is
significant different rate of carbohydrate oxidation between well-trained person compare to
untrained person. It depends on exercise intensity. During exercise above 70% the major
carbohydrate source is muscle glycogen [19]. The glycogen content of stretched muscles
decreases in compared to unstretch muscles [20].
Both ES and Stretched is directly related with metabolism. According to N.F Clinch
state that stretch response is able to increase the rate of heat production. Stretch response is
associated with appearance tension in the sarcolemma [21]. The metabolism of a muscle is
related with stretch demonstrated by heat and oxygen consumption [22]. Taku Hamada state
that electrical stimulation for 20 minutes enhances energy consumption, carbohydrate
oxidation and whole body glucose uptake at low intensity of exercise [23].
The result of this study shows that both ES and passive stretching are able to lowering
blood glucose significantly. But blood glucose level is lower in ES compared to passive
stretching. Electrical stimulation induced muscle contractions imposed a specific recruitment
pattern depending on location of depolarized motor units within muscle [24]. The metabolic
demand for force development in ES is higher than voluntary contraction [25]. The provision
of ES on quadriceps muscles found that the rates of glycolysis in contracted muscles were
higher in type II fibres than type I fibres [26]. Hamada state that differential metabolic
response could be primarily due to a large activation of glycolytic type II fibres by ES.[23].
In the previous study 20 Hz of frequency is used on quadriceps muscles to activated knee
extension and knee flexion to obtain target angle [27]. Kebaetse state frequency lower than
16 Hz is not enough to produce muscle contraction on quadriceps muscle to achieved target
400 [28]. The higher frequency will produce the bigger muscle contraction. However, high
frequencies can leads to fatique or discomfort to subjects [4].
There is significant blood glucose decrease for passive stretching group. The benefit of
passive stretching is no physical stress accrues in case of aerobic exercise and resisted
exercise [29]. The other benefits is passive stretching requires a little effort for those with a
very weak physical condition. Passive stretching increase glucose transport in muscle with
direct relation with the force generated during the stretch [30]. However stretching may
possibly cause discomfort and pain during the stretch. Therefore the passive stretching used
in this study condition was not ‘eased off’ to the point of no discomfort [10].

CONCLUSIONS

Both electrical stimulation and passive stretching can be used to control blood glucose level
for those sedentary patients because of chronic illness, people who have limitation to perform
exercise and people with a lack of motivation to exercise. The result shows that electrical
stimulation is more effective than passive stretching to lowering blood glucose level.
Exercise is one of cornerstone for diabetes mellitus type 2 management and treatment to
control blood glucose level. This is can reduce a substantial financial saving. T2DM patients
with blood glucose controlled prevent or delay the onset of diabetes mellitus complication.

ACKNOWLEDGEMNTS

The authors thank the subject for participation in this study. And the authors express sincere
thanks to Erry Purnomo for the guidance and motivation to do the research

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