Diabetic neuropathy is a prevailing, disabling disorder that impacts many individuals both young and old. The individuals affected by this disorder experience daily symptoms such as numbness, tingling, pins and needles sensations, burning, sexual dysfunction, skin ulcers, slow reflexes, uncontrolled heart rates, digestive problems, poor bladder control, and loss of independence. High levels of blood sugar-hyperglycemia, or uncontrolled blood sugars alternating from an extreme high to an extreme low, damage the molecular processes on a cellular level injuring the nervous system. Diabetic neuropathy is prevalent in the peripheries, autonomic nervous system, radiculoplexus, and individual nerves known as mononeuropathy.
Day to day, hour to hour, and minute to minute, these individuals battle with excruciating and debilitating pain, and regrettably, there remains absolutely no cure. In an effort to alleviate this severe pain, normalizing blood sugars with glucose control and pain management with medicine are two approaches to maintain and control the symptoms. However, there is no halting the disorder. Lifestyle modifications including daily exercise, low-fat diet, and eliminating stress are three ways to reduce the symptoms of diabetic neuropathy. There has been extensive research regarding the drugs that people are taking to manage this pain. The first line drugs include antidepressants and anticonvulsants. Sleep disturbances, migraine headaches, weight gain, suicide, and sexual dysfunction have been linked to adverse effects of both of these types of medications.
Traditional Chinese needling and Japanese acupuncture are both newly discovered topics of research concerning the treatment and management of diabetic neuropathy. The decreased pain and reported increase in symptoms have proven this approach to be positive in managing this disorder. It is important for healthcare providers to find the most effective way for helping people with diabetic neuropathy manage the day to day disability that comes with the diagnosis.
P-In patients with diabetic neuropathy,
I-are those whose nurses have advocated for acupuncture
C-compared with patients who take medication,
O- more likely to express decrease in chronic pain?
“Patients with neuropathic pain (NP) are challenging to manage and evidenced-based clinical recommendations for pharmacologic management are needed” (Dworkin et al, 2007). The previous quote was from a journal article titled “Pharmacologic Management of Neuropathic Pain: Evidenced-based Recommendation”. This systematic review using randomized control trials, a placebo group, and double-blind studies of drugs, evaluated different pharmacologic approaches in trying to find first line treatment to manage diabetic neuropathy. (Dworkin et al, 2007). On the evidence hierarchy of research, this sits as the highest rank at level one (LoBiondo-Wood & Haber, 2014, p.13). A total of 237 individuals were selected based on status of diabetic neuropathy and age. One group received a placebo pill, and the other group received a variety of different drugs including antidepressants, anticonvulsants, topical lidocaine, opioid analgesics, tramadol, and antiepileptic drugs. (Dworkin et al, 2007). The results concluded that the treatment of neuropathic pain is currently a “trial-and-error” process. (Dworkin et al, 2007). “Evidence based recommendations have recently been updated for the pharmacotherapy of neuropathic pain including that the first line treatment was found to be antidepressants and anticonvulsants” (Dworkin et al, 2007). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) scale used to rate the quality of evidence and strength of the drugs was given to the participants of the study. (Dworkin et al, 2007). Throughout this research, even though first-line drugs were discovered, the results showed that not one specific drug resolved the pain associated with the disease. Instead, the drugs blocked the pain for a short amount of time and brought other demeaning side effects such as nausea, vomiting, feeling of misplacement, weakness, and fatigue. (Dworkin et al, 2007). More research regarding each specific drug as a whole, and its mechanism of action would make this a strong study overall.
Acupuncture has also become an option for patients to alleviate the pain of diabetic neuropathy. Acupuncture has three primary effects: pain relief, reduction of inflammation, and restoration of homeostasis. Through the use of fine needles, acupuncture promotes blood flow, stimulates the body’s built-in healing mechanisms, and releases natural painkillers. (Physiology of Acupuncture, 2016). When the needle is inserted into the part impacted by pain, a signal is sent through the nervous system to the brain where endorphins, norepinephrine, and enkephalin are released. The shortened muscles are able to relax, and the overall stress of the patient is reduced. (Physiology of Acupuncture, 2016). The promotion of blood flow is significant because “everything the body needs to heal is in the blood. Oxygen, nutrients, immunity, hormones, analgesics, and anti-inflammatory mechanisms are stored here and need to be at the site of injury in order for healing to take place” (Physiology of Acupuncture, 2016).
Beginning in 1998, the treatment for diabetic neuropathy was explored through the implementation of acupuncture. Working with the Department of Medicine, Doctor Abuaisha and his colleagues performed a long-term study to investigate the effectiveness of traditional Chinese acupuncture and its impact on neuropathic pain (Abuaisha et al, 1998). The study titled “Acupuncture for the Treatment of Chronic Painful Peripheral Diabetic Neuropathy: A Long-term Study”, took an experimental and quantitative approach. Forty-six patients with chronic peripheral neuropathy were treated with acupuncture to determine its efficacy and long-term effectiveness (Abuaisha et al, 1998). The criteria for selecting the participants included those who were fifty years or older, presented with at least two symptoms of diabetic neuropathy, and had been diagnosed with diabetes for at least ten years (Abuaisha et al, 1998). There were two people that did not remain in the study for the entire length of time, one of which could not complete the acupuncture treatments because of a pregnancy, and the other whose whereabouts remain unknown (Abuaisha et al, 1998). Both of these participants were excluded from the statistical analysis and results of the data. Twenty-nine of the forty-six patients were on standard medical treatment previous to receiving acupuncture. Each person received six treatments: one to two treatments per week depending on patient preference. These patients were closely followed for eighteen to fifty weeks and the results showed that forty-four of these patients showed significant improvement in primary and/or secondary symptoms (Abuaisha et al, 1998). There was no difference in the findings between participants who received one treatment a week and the participants who received two. This was one of the very first studies that explored a new approach to pain management of this disorder and ended up showing extremely promising results (Abuaisha et al, 1998). Although this study showed very promising results, the sample size was small, and further research needs to be done to prove the efficacy of this subject. A lack of a placebo group for comparison results limited the reliability of this study. Throughout this research, “acupuncture was proven to be a safe and effective therapy for the long-term management of painful diabetic neuropathy, although it’s mechanism of action remains under speculation” (Abuaisha et al, 1998, p117).
Japanese acupuncture and traditional Chinese medicine acupuncture are the two forms available to people wanting treatment. Brisbane Natural Health published an article titled “Japanese Acupuncture vs Traditional Chinese Medicine Acupuncture”, comparing and contrasting these two types of needling approaches. Japanese acupuncture uses smaller and sharper needles, remains very gentle and superficial skin contact, does not involve the use of herbs or lotions, places emphasis on the use of palpation (touch) before needle treatment, and creates a more relaxed environment for the patient (Japanese Acupuncture vs Tradition Chinese, 2018). Chinese acupuncture uses thicker and longer needles, goes deeper into the skin, uses herbs and lotions as means of relaxation to the patient, and creates more skin bruising and irritation because of the needle manipulation and depth (Japanese Acupuncture vs Tradition Chinese, 2018). A general overview of information was given throughout this article; however, it was not peer-reviewed but instead gave factual information regarding these different needling styles.
“Two Styles of Acupuncture for Treating Painful Diabetic Neuropathy” was a quantitative pilot study with randomized control trials performed by a group of doctors and researchers out of Harvard and Boston Medical Center, the “clinical and mechanistic effects of two styles of acupuncture, Traditional Chinese Medicine (TCM) and Japanese acupuncture, were compared for the treatment of painful diabetic neuropathy” (Ahn et al, 2018, p.12). There were seven patients enrolled in this experiment, and three received TCM and four received Japanese acupuncture. These patients were selected from primary care at Beth Israel Deaconess Medical Center in Boston Massachusetts (Ahn et al, 2018). The patient was eligible if he/she was eighteen years of age or older, had Type I or Type II diabetes, had experienced pain or tingling in both extremities for more than six months, scored more than a 40/100 on the McGill Pain Questionnaire, and were acupuncture naïve (Ahn et al, 2018). These patients received 10 treatments: one treatment each week. This study was based off of other studies that have suggested that acupuncture provides the assistance for pain reduction. However, this study was taken a step farther in trying to adopt acupuncture as the therapy for diabetic neuropathy. The 11-point Likert Scale severity of daily pain scale was used to evaluate the pain attributed to their diabetic neuropathy at week 0, 5, and 10 throughout the treatments (Ahn et al, 2018). The results of this experiment led to valid conclusions. Japanese acupuncture was more tolerable and created better pain management for the patient in the face of the disorder. All patients reported lower pain scores throughout the course of the treatments (Ahn et al, 2018). This study suggests that acupuncture may truly be effectual for particular individuals with diabetic neuropathy (Ahn et al, 2018). Given the small sample size, it is difficult to draw a strong conclusion from this research as stated by the authors. Also, a larger study with a placebo control group would be more effective.
Synthesis and Answer to Clinical Question
Diabetic neuropathy needs to be managed in order to allow the individual to gain back independence, functional status, and control. If this approach is taken either pharmacologically or with traditional medicine using acupuncture, patients deserve to have a control on their symptoms. When comparing the two interventions, prescribed drugs and acupuncture, there has been more cases of positive control and management using acupuncture rather than medicine. Decreased symptoms and improved independence have been reported in all cases of acupuncture approaches. First-line medicines used to treat diabetic neuropathy are designed to treat other disorders such as depression and epilepsy and have been shown to manage only certain symptoms of the disorder and bring on other unintended adverse effects to the patient. Some people only have access to the pharmacologic approach in treating their symptoms, and the medical team has to be willing to work with these individuals to find the most effective and least adverse treatment option to manage their pain. Advocating for patients and providing people impacted by this disorder with the tools and resources regarding the newly found research towards acupuncture could start an entirely new movement towards positively impacting day to day lives. In conclusion, patients effected by diabetic neuropathy should be educated on acupuncture and how this natural needling has changed the lives of other people because ultimately, it could change their life as well.