Advocacy for Carbomedtherapy (Carbon Dioxide Therapy) in the Treatment of Diabetic Neuropathy

The carbon dioxide therapy is called Carbomedtherapy for diseases, and carboxytherapy for aesthetics. The CDT consists of transcutaneous injections of carbon dioxide [5-10]. This technic was first practiced, in 1932, by Dr Barrieu, at Royat-Chamalières, France. Initially the indications were purely vascular especially for Raynaud’s syndrome [11], arteriopathy of the lower limbs, leg ulcers, and of course, in the care of the diabetic foot.


Introduction
We are a medical center specializing in the care of the diabetic foot in Algeria for 10 years now. More than 95% of our patients suffer from severe Neuropathy. Treating Diabetic Neuropathy is a big challenge. More than 50% of diabetics worldwide are affected. Neuropathy is a consequence of microcirculatory damage in diabetics. The damage caused destroys the nerves. It is caused by the aggression of hyperglycemia [1][2][3][4]. The diagnosis is both clinical and paraclinical: ENMG.
Our experience covers more than 60,000 patients, 30% of whom have no wounds. The clinical examination finds the classic Neuropathy signs: tingling, numbness, cramping, pain, electric shock, loss of especially plantar sensitivity, sensitivity disorder otherwise. In the upper limbs, we look for lesions of the carpal tunnel, as well as lesions of the tarsal canal for the lower limbs. In addition, we note the degree of dryness of hyperkeratosis, the existence of a diabetic foot ulcer or a Charcot foot. Amyotrophy is correlated with the severity of the disorder. It can cause paralysis. We have noticed that the first neurological damage is the Oto-Rhino Laryngitis sphere-we noticed a decrease in hearing. The diastasis recti is a late sign and expresses the severity of Neuropathy.
So, for this fact and to relieve our patients, we first start by stabilizing the diabetes: • The Hb1Ac should be around 6, which we get easily by enforcing strict diet, hydration, physical activities and above all psychological support -awareness is an important factor.
• We correct the usual Vitamin D3 deficits after dosing.
• We stop all analgesic treatments because we see it as an overwhelming of our patients who reduce considerably their activities, gain weight, unbalance their diabetes to finally worsen their Neuropathy to the point of destroying everything and no longer feeling anything-Paralysis sets in. injections are transcutaneous and avoid well the vessels. We inject the surface of the 2 lower limbs, from the Scarpa triangle, around and on the wounds, and in the upper limbs in case of neuropathy. It is an outpatient practice.
The rhythm of the sessions will depend on the severity of the case: once a week, bimonthly, or monthly.

How does it work?
Hemoglobin molecules have 4 oxygen molecules at saturation. When we inject carbon dioxide, an exchange takes place between these oxygen molecules and those of CO 2 . This phenomenon is described as BOHR effect [12]. (Figure 1) We were able to record the instant nature of this exchange, by measuring PCO 2 and PO 2 , during a CO 2 injection. What we found was that the PCO 2 measurement curve has not been changed while the PO2 curve recorded an elevation.

What are the Contraindications?
As a precaution, women who are pregnant. By obligation, patients with an imbalance of tares, especially respiratory and cardiac; Patients who had a recent acute stroke; Patients with active cancers and active viral infections; finally, with anaerobic germ infections. These situations can be reversed, however.

What are the side effects?
They are benign and above all reversible. There are superficial micro-hematomas at the injection points, which can sometimes follow a session especially if the patient is frankly de-coagulated. They disappear quickly and are not painful. There is no risk of gas embolism. The CO 2 pressures delivered by this machine are adjusted to avoid this problem even during accidental injection. The risks of infection should not exist. It is a simple matter of hygiene.

Evolution under CDT treatment
The evolution under the CDT treatment follows a scheme described below • In the first place, the tingling disappears then the cramps-we believe that the correction of the Vit D3 rate is not unrelated to this. The pain gradually decreases as the CDT sessions progress. It is imperative to obtain a normal Hb1Ac level from the patient. Hyperglycemia is a real obstacle to healing by maintaining the perpetual attack of the nerves.
• The second parameter is ambulation, the resumption of which remains difficult when physical activity no longer exists. Exercises performed by a third party to combat stiffness and muscle atrophy are necessary. The use of a wheeled walker allows confidence to be restored for walking autonomy. We take into account the psychological problem linked to the fear that has settled in these patients with multiple histories of falls without counting the effects of the analgesic therapeutic withdrawal that we set up from the start of treatment.
• The recovery of especially plantar sensitivity is done from top to bottom from the Scarpa triangle to the sole of the foot. It manifests itself by the appearance of pain during the injections made during the different sessions.
• For carpal tunnel lesions, disappearance of pain and numbness allowing functional recovery.
• Before starting the CDT treatment sessions, an ENMG ⓪ of the four limbs is performed by an independent neurologist chosen by the patient. The control is done only after 12 to 24 sessions depending on the severity of the lesions. The sessions' rhythm varies from by-monthly to monthly. The improvement in electrical signs is recorded at one year. The disappearance of Neuropathy in moderate forms without muscle damage is done in one year. In severe forms, 2 to 3 years of treatment are necessary. It is imperative that the level of Hb1Ac stays around 6. The very few failures that we have noted are related to indiscipline and food anarchy. Patients come back regularly because the CDT treatment sessions make the pain disappear. In severe forms with muscle damage, we go through a more or less long stage of stagnation.
Currently, we are preparing 2 studies. First, getting ENMGs' results on a large number of patients. A 2 nd study, on the diastasis recti. Our work is unfortunately hampered by the COVID 19 pandemic.

Case Study
ENMGs below, performed by independent neurologist doctors. We keep all reports for future comparisons.  Conclusion: ENMG trace objectifying a spectacular improvement in the speeds of motor conduction (remyelinisation) to the lower limbs with a significant gain of the amplitudes but which remain below the norm. The VCS are diminished.
In total: Very good electrical evolution of diabetic neuropathy of the lower limbs with remyelinisation + + +. Normal trace to the upper limbs.
Conclusion: This ENMG exploration of the 04 members exploring the median, ulnar, sensitive and motor fibular tibial and objective F response: A discreet carpal tunnel on the right of moderate severity. Sensory-motor impairment (poly neuropathy of the axonal type at the level of the 2 lower limbs, sensitivomotor which may be part of a metabolic neuropathy of ancient appearance. Absence of denervation in the resting activity of the anterior leg muscles, twins internal of the 02 dimensions.

Lower limbs
SPE and SPI matrix latencies with normal VCM, reduced amplitude • Absent sensory potential of the sural nerve.
• F wave on the SPI nerve absent.
• H reflexes on the tibial nerve: weak amplitude.

Conclusion:
The EMG exploration to date reveals the persistence of electrophysiological signs in favor of a diffuse sensory motor neuropathy of essentially sensitive axonal type, probably diabetic.

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Motor latencies of the median and ulnar nerve, normal amplitudes and vcm.

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Sensory latencies of the median and ulnar nerve, normal amplitude and vcs.
• F wave on the median nerve of normal latency.

Lower limbs
SPE and SPI matrix latencies with normal vcm, reduced amplitude • Absent sensory potential of the sural nerve.
• F wave on the SPI nerve absent.
• H reflexes on the tibial nerve: present.

Conclusion:
The EMG exploration to date reveals the persistence of electrophysiological signs in favor of a diffuse sensory motor neuropathy of essentially sensitive axonal type, probably diabetic.

Conclusion
Little by little, a good number of our patients saw a significant decrease and even disappearance of the reported disorders of the Neuropathy, considerably improving their quality of life. From the wheelchair when they arrived first time at our center, the better static balance recovery with CDT treatments, allowed them to return to ambulation thereby increasing their autonomy. CDT is a simple and inexpensive technique that currently seems, to us, to be the only therapeutic alternative in the treatment of Diabetic Neuropathy. We have several studies underway and will publish them in the near future.