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| REVIEW ARTICLE |
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| Year : 2019 | Volume
: 6
| Issue : 2 | Page : 53-59 |
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An ayurvedic approach to the diagnosis and management of diabetic neuropathy
Rehana Parveen1, Himangshu Baruah2
1 Department of Kaya Chikitsa, North Eastern Institute of Ayurveda and Homoeopathy, Shillong, Meghalaya, India
2 Department of Rasa Shastra and Bheshaja Kalpana, North Eastern Institute of Ayurveda and Homoeopathy, Shillong, Meghalaya, India
| Date of Submission | 15-Jan-2021 |
| Date of Acceptance | 17-Jan-2021 |
| Date of Web Publication | 05-Mar-2021 |
Correspondence Address:
Dr. Rehana Parveen
Department of Kaya Chikitsa, North Eastern Institute of Ayurveda and Homoeopathy, Shillong - 793 018, Meghalaya
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/AYUHOM.AYUHOM_3_21
Diabetic neuropathy is the most common complication of diabetes but is still underdiagnosed and undertreated. Approximately 50% of patients with diabetes eventually develop neuropathy. The primary aim of the current diabetes management strategies is to achieve tight blood glucose level control. However, intensive blood glucose control alone does not necessarily reduce the risk of developing diabetic vascular complications. The scholars of Ayurveda have studied Prameha in detail. The features such as karapadadaha (burning sensation), cumcumayana (tingling sensation), suptata (numbness) are symptoms seen in prameha either in the prodromal stage, in the actual exhibition stage or in the complication stage, can be identified as Diabetic peripheral neuropathy. The growing side-effects of modern pharmacological agents do not provide an everlasting solution thus being a persuasion to search an amicable solution in Ayurveda for which understanding the disease, its pathogenesis in Ayurvedic perspective will aid in deciding the line of treatment which can replace or complement the conventional therapy.
Keywords: Ayurveda, diabetic neuropathy, prameha, upadrava, vibration test
How to cite this article:
Parveen R, Baruah H. An ayurvedic approach to the diagnosis and management of diabetic neuropathy. AYUHOM 2019;6:53-9 |
| Introduction | |  |
Diabetes mellitus is a disease with detrimental health complications and premature mortality. Globally and across all ages, it is estimated that at least 1 in 20 deaths are attributable to diabetes and its complications.[1] The prevalence of diabetes among all age-groups worldwide is presently estimated to be 8.3%.[1] As the incidence of diabetes is escalating globally so is the case with its complications. Diabetic neuropathy (DN) is the most common complication of diabetes reaching 45%–50% prevalence compared to 25%–30% of retinopathy and 20% of nephropathy.[2],[3] Functional and structural impairments of the peripheral nervous system due to hyperglycemia are generally defined as DN[4] and its diagnosis is based on the exclusion of other diseases.[5] Most common among the neuropathies are chronic sensorimotor distal symmetric polyneuropathy (DPN).[6]
Intensive blood-glucose control alone does not necessarily reduce the risk of developing diabetic vascular complications. The early recognition and appropriate management of neuropathy in the patient with diabetes are important as up to 50% of DN may be asymptomatic,[7],[8] and patients are at risk of insensate injury to their feet.[9]
The disease DN is not directly mentioned in Ayurvedic texts. It can be considered a sequel to Madhumeha which occurs due to further vitiation of the doshas or due to Vyadhikarshana. The features such as karapadadaha (burning sensation), cumcumayana (tingling sensation), suptata (numbness) are symptoms seen in prameha either in the prodromal stage, in the actual exhibition stage or in the complication stage, can be identified as diabetic peripheral neuropathy.[10]
In spite of many advances, the conventional management of DN is not up to the mark and associated with lots of sides. Diabetic vascular complications are postulated to be initiated and exacerbated by multiple signaling pathways which are obviously linked to each other in a synergistic order. Herbal medicines possessing a mixture of phytochemicals are capable of targeting multiple pathways in a synergistic manner, which could mean that these may be an effective solution to the prevention and management of diabetic vascular complications. Hence understanding the disease in terms of Ayurveda is of prime importance.
| Materials and Methods | | |
General and specific review of published articles on PubMed, Google Scholar, Medline, and Ovid search engines using keywords: diabetic polyneuropathy and neuropathy in Ayurveda: alongside preexisting Ayurvedic classical texts have been used for the present work.
| Diabetic Neuropathy | | |
DN is defined as the presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after the exclusion of other causes.[4] A careful clinical examination is needed for the diagnosis since asymptomatic neuropathy is common. A minimum of two abnormalities (symptoms, signs, nerve conduction abnormalities, quantitative sensory tests, or quantitative autonomic tests) is required for diagnosis and, for clinical studies; one of these two abnormalities should include quantitative tests or electrophysiology.[11] Standardized testing using nerve symptom scores and nerve impairment scores to quantify weakness, loss of reflexes, and sensory deficits have proved invaluable in diagnosis and monitoring of progress. It is frequently under diagnosed the cause of which is that the prevalence rate of DPN is quite variable depending on patient population, the definition of neuropathy, and diagnostic methods.[12] Using 128 Hz tuning fork, reflex hammer, and monofilament, half of the patients can be detected.[9]
Classification
[Table 1] describes the classification originally proposed by Thomas and later modified over years. It is important to note that different forms of DN often coexist in the same patient.
| Diabetic Neuropathy in Ayurveda | | |
In Ayurvedic text, a very scientific description is available about diabetes mellitus in the name of madhumeha but we do not find any direct description of DN but as per Charak, it is not always essential to name a disease rather one should consider the nature of the disease (prakriti), the organ involved (adhistana) and the etiological factors (samuthana) and do the treatment accordingly.[13]
In the light of the above statement if we try to understand DN in Ayurveda we find scattered mentions of the condition under the purvarupa, rupa and upadrava of Madhumeha. In fact, all the upadravas mentioned by Charak[15] do point towards some or the other form of neuropathy as mentioned below.
Upadravas of prameha in relation to diabetic neuropathy
Acharya Charaka has mentioned eight upadravas,[15] all of which can be related to neuropathy in modern terms [Table 2].
From the foregoing, it is evident that Ayurvedic acharyas were well versed with the complications of Madhumeha from the very beginning. Description of pramehapidika is similar to furunculosis and carbuncles and putimamsa may be inferred as gangrene or foot ulcers which are a common sequel of DN leading to the reduced sensation of lower extremities.
| Pathophysiology of Diabetic Neuropathy | | |
Diabetic peripheral neuropathy (DPN) is a multifactorial disorder resulting from complex interrelated metabolic and vascular defects. Although hyperglycemia has a definite role in its pathogenesis and progression, the resulting defects in glucose metabolism underlying DN still remain uncertain. Glucose-related or “gluco-toxic” metabolic pathogenic mechanisms include the activation of the aldose reductase (AR) pathway, which alters cellular redox potential, promotes intercellular sorbitol and fructose accumulation, and exacerbates oxidative stress. In turn, increased oxidative stress may have unanticipated effects on nerve osmolyte levels and nerve growth factor metabolism. Alternatively, a reduction in nerve blood flow has been invoked to be of primary etiological importance and has been attributed to alterations in certain vasoactive agents. Therefore, the following can be listed as the key factors in the pathogenesis of DN:[16],[17],[18]
- AR and oxidative stress
- Sorbitol redox hypothesis
- Protein kinase C activity
- Microvascular factors
- Altered nitric oxide metabolism in DN
Assessment and staging of diabetic neuropathy
The ability to assess treatment regimens for DN necessitates the establishment of reliable criteria for its evaluation and staging. Assessment both clinically by a Neuropathy Symptom Scale or Neurologic Disability Score and electrophysiologically through nerve conduction studies gives valid discrimination between neuropathy and absence of neuropathy.[14]
Dyek's staging of diabetic neuropathy
- Grade 0 = no abnormality of NC, no neuropathy
- Grade 1a = abnormality of NC, without symptoms or signs
- Grade 1b = NC abnormality of stage 1a plus neurologic signs typical of DPN but without neuropathy symptoms
- Grade 2a = NC abnormality of stage 1a with or without signs (but if present, <2b) and with typical neuropathic symptoms
- Grade 2b = NC abnormality of stage 1a, a moderate degree of weakness (i.e., 50%) of ankle dorsiflexion with or without neuropathy symptoms.[14]
| Samprapti as Per Ayurveda | | |
In madhumeha which is a type of vatajaprameha, there is Dhatuksaya, Ojaksaya and Vataprakopa. If madhumeha is not properly controlled then this vitiated vayu starts spreading throughout the body and produce the features of DN via the following mechanisms [Figure 1].
In addition, the vitiated kapha, pitta, meda, rakta, mamsa etc cause avarana to vata. The chalatva of vata is decreased due to obstruction. This causes chestahani and vimargagamana of vata. It can eventually lead to disruption of motor or sensory function of vata and lead to the manifestation of symptoms such as paraesthesia and numbness according to anubandha (association) of various doshas and dushyas.[21] E.g, in kapahanubandhu-supti, gaurava, shaityaetc and in pittanubandha – daha, toda, etc.
Samprapti ghatak
Dosa – Vata (predominantly Vyanavayu)
Pitta (predominantly Pachak pitta)
Kapha (predominantly Tarpakkapha)
Dushya – Rasa, rakta, mamsa, meda, majja, sukra, ojas, ambu, lasika, vasa.
Agni-Jatharagni, bhutagni, dhatvagni
Ama – At dhatu level.
Adhistana – Mastishkapradhanavatanadi.
Srotas-Majjavaha, medavaha, mutravaha, udakavaha.
Srotodushti – Sanga
Rogamarga– Abhyantaramarmaasthisanthigata
Sadhya-asadhyata – Krichasadhyavyadh
| Clinical Presentation of Diabetic Neuropathy | | |
The spectrum of clinical neuropathic syndromes described in patients with diabetes mellitus includes dysfunction of almost every segment of the somatic peripheral and autonomic nervous system [Table 3].[14] | Table 3: Clinical presentation in different forms of diabetic neuropathy
Click here to view |
| Symptomology of Diabetic Neuropathy in Ayurveda | | |
The different references of neuropathic symptoms of diabetes featured as purvarupa, rupa, upadrava of prameha and also those mentioned in other contexts have been enlisted in [Table 4] and [Table 5]. It is evident that certain purvarupas of prameha are considered as symptoms of neuropathic complications of diabetes by modern science. This observation of acharyas has been validated by several studies which suggested that IGT may lead to polyneuropathy, reporting rates of IGT in patients with chronic idiopathic polyneuropathies between 30% and 50%.[22]
Autonomic dysfunctions
Many features mentioned in relation to upadravas of prameha can be traced to the symptoms of diabetic autonomic neuropathy, as already presented above.
| Diagnosis | | |
Symptoms of neuropathy are personal experiences and vary markedly from one patient to another. A detailed clinical examination along with the following tests is the key to the diagnosis of DPN.[23]
- Light touch perception
- Pin prick test
- Reflex testing
- Vibration testing
- Quantitative sensory testing
- Nerve conduction studies
- Morphologic testing-muscle biopsy, nerve biopsy.
| Treatment | | |
Despite advances in the understanding of the metabolic causes of neuropathy, treatments aimed at interrupting these pathological processes include tight glucose control; treatments are for reducing pain and other symptoms.
Nonpharmacological treatment comprises of regular exercise, quitting of smoking, limiting the amount of alcohol intake, maintaining a healthy weight, proper foot care, and use of orthotic footwear if necessary and gait training, etc. Pharmacological treatment involves the use of drugs like SSRI, SNRI, anti-convulsants, tricyclic anti-depressants, opioids for neuropathic pain and topical agents like capsaicin, lidocaine, etc. Other agents like α-lipoic acid, methylecobalamine, AR inhibitors, benfotiamine, etc., are also being used.[8]
Treatment of DPN in Ayurveda
As per Ayurveda, DN is multifactorial (bahudoshaavastha), hence a multi-directional approach is required. In DM, when symptoms such as burning sensation are present, treatment for pittavrita vata[24] should be given and when symptoms such as numbness is present, kaphavrita vata[25] treatment should be given [Table 6]. To summarize the following points should be taken care of during the treatment:
- Dhatu vardhana and Rasayana chikitsa
- Tridoshasamak and chiefly vatasamak chikitsa
- Sothahara chikitsa
- To check bahudravata and ruksa guna
- To provide strength to the sthana i.e., majja dhatu
- Promotion of agni and oja
- Use of drugs having rasayana, balya, jivaniya as well pramehangna properties
- Use of yapanabasti and dhara.
Drug research
A study has shown that ethanolic extracts of tinospora cordifolia (TC) demonstrated a significant increase in the tail-flick reaction time in Wistar albino rats at doses of 100 and 200 mg/kg b.w. (P < 0.05) as compared to the control group.[26] In-vitro AR inhibition was observed with TC with an IC50 of 103 mcg/ml[26] and also showed effective and high levels of evidence for its action against DN, gastropathy and Diabetic foot ulcer.[27] Guduchi also has been extrapolated to have strong neuroprotective activity against oxygen and glucose deprivation.[28]
Oral treatment of diabetic rats with Azadirachta indica, Allium sativum, Momordica charantia, and Ocimum sanctum extracts (500 mg/kg of b.w) have been showed to lower the blood glucose level and also inhibited the formation of lipid peroxides and reactivated the antioxidant enzymes.[29] It is well known that oxidative damage is one of the most important factors in the genesis of DPN.
In another study, experimental evidence of the preventive effect of Enicostemma littorale Blume (2.5 g/kg) on nerve function and oxidative stress in animal model of DN was seen, hence evaluating its anti nocireceptor activity.[30]
A study carried out on the efficacy of Bhumyamalaki powder 3 g and Atibala root decoction of 10 g twice a day for 30 days on 33 patients of DN, assessing on the basis of Neuropathy analyzer machine recording of sensory perception of vibration, cold and hot sensations showed that both the drugs can revert the diminished sensory perception and can reduce the symptoms significantly.[31]
| Discussion | | |
Development of DN from madhumeha should be understood under a triangular approach of Prakriti – Adhishtana – Samutthana[13] with samprapti as a denominator. Symptoms of DN has been represented under three stages, i.e., stage before madhumeha, during madhumeha and madhumeha with upadrava, taking dosha, dushya, ama, agni and srotas into consideration. The pathogenic factors involved in the genesis of DPN are-Tridoshaprakopa (chiefly vataprakopa with pitta and kaphaanubandha), Dhatukhsaya and Snayusotha.
If we compare the literature counter part of modern medicine and Ayurveda in relation to DN, a grossly similar picture of the condition is evident. It is supposed that small nutrient vessels (vasa nervosum) which provide nutrition to nerves become occluded (i.e. srotorodha occurs-which is one of the chief causes of vata-prakopa). This leads to deficiency in nutrition to nerves (i.e. deficiency in tarpana of snayu-snayugata tarpakakapha ksaya). Ultimately deficient nutrition of nerves leads to axon degeneration and demyelination of nerve sheaths and thus DN is produced. Here, axon degeneration and demyelination of nerve sheath may be attributed to vataprakopa and kaphakshaya.
In a diabetic patient, the usual pathway of glucose metabolism (i.e. via Glucose-6-PO4) becomes depressed and sorbitol pathway becomes predominant. This rapid rate of activity of enzyme sorbitol dehydrogenase may be attributed to pitta vriddhi. Thus, the involvement of tridosha is apparent in DN.
It is evident that certain features of purvarupa of prameha point towards signs and symptoms of neuropathy. Though modern science considers neuropathy as complication of diabetes recent studies suggest that 10%–18% of patients have evidence of nerve damage at the time their diabetes is diagnosed, suggesting that even early impairment of glucose handling, classified as prediabetes, is associated with neuropathy.[6] Several studies have also suggested that IGT may lead to polyneuropathy, reporting rates of IGT in patients with chronic idiopathic polyneuropathies between 30% and 50%.[22]
Hence, it is evident that the scattered reference of DN available in Ayurveda is still relevant and logical in the current day scenario.
| Conclusion | | |
Although a common and important complication of diabetes, neuropathy has not been studied as often or as extensively as other microvascular complications like retinopathy and nephropathy. In addition, the reported prevalence estimates vary widely between countries, in part due to the difference in sampling methods and lack of consensus on diagnostic criteria. Further studies are required to generate a matrix of scientific evidence at the clinical and pre-clinical levels, including chemical, cellular, and animal studies, to develop effective medicines in Ayurveda for the prevention and treatment of diabetic complications.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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