This case study highlights the effectiveness of acupuncture in reducing the progression of neuropathy in one patient with type I diabetes and illustrates the importance of a thorough medication analysis when multiple pharmaceuticals are prescribed by allopathic practitioners.
64 Year-Old Treated for Diabetic Neuropathy
Abstract:
A 64 year-old male patient diagnosed with Type I Diabetes in 2012 sought care at the ACTCM Clinic beginning October 2020. I began treating him in January 2021 for peripheral neuropathy in the lower extremities, as well as occasional upper back tension and stress. The Traditional Chinese Medicine diagnosis for this patient was Spleen Qi Deficiency, Liver Qi Stagnation, and Qi and Blood Stasis in the Lower Extremities. This patient consistently received one acupuncture treatment per week. Due to the chronic nature of his Western diagnosis, our treatments focused on the successful interruption of the progression of neuropathy in the feet and legs. His prognosis is positive and we expect that loss of sensation will not progress further with continued weekly acupuncture treatment.
Chief Complaint:
Peripheral Neuropathy of the Lower Extremities
Patient History:
A 64 year-old male patient received a diagnosis of type I diabetes mellitus in 2012 after a viral infection in the salivary glands. He began losing weight and experiencing increased thirst and peripheral somatic neuropathy. His blood glucose is currently well managed with an implanted continuous glucose monitor and Humelog kwik-pen and Lantus SoloStar subcutaneous insulin injections, as well as management of diet.
This patient began getting acupuncture treatments at Kaiser previous to seeking treatment at ACTCM. Treatments at Kaiser were very successful in returning sensation to his feet and lower legs. He experienced increased temperature sensation, balance, and overall feeling in his feet and legs. The neuropathy persisted around his knees feeling like an Ace bandage was wrapped around them. The other area where the neuropathy persisted was on the lateral lower legs following the course of the peroneal nerve. The patient reported that anytime there was a lapse in weekly acupuncture treatments, the neuropathy would return and increase.
The patient reported asthma diagnosed in childhood and is currently managed with 200 mg Montelukast q.d. and an Advair inhaler used prn. He also takes a 200 mg statin q.d. to manage cholesterol levels.
The patient experiences stress from owning his own business. He currently works full time and has recently felt increased stress from an uncertain relationship with his business partner. He reports that he is the type of person who does not express his emotions until it builds to an intolerable level at which point, he explodes, although he reports that this has become much milder as he has aged.
Vitals:
heart rate: 70 BPM
blood pressure: 120-138 systolic and 68-86 diastolic
O2 saturation: 96-100%
temperature: 97.3-98.9 degrees F
weight: 171 pounds
height: 69 inches
Medication Analysis:
Montelukast (Singulair)
10 mg tablet PO q.PM
Anti-inflammatory, bronchospasm prevention, anti-allergic, leukotriene blocker
Mood/mental changes, numbness/tingling/pain in arms/legs, muscle weakness, uncontrolled muscle movements
Advair inhaler (Fluticasone + Salmeterol)
2 oral inhalations BID 12 hours apart
Anti-inflammatory steroid, bronchodilator
Upper respiratory tract fungal infection, throat irritation, voice changes, HAs, nausea, muscle/bone pain, weakened immune system, blurred vision
Atorvastatin (Lipitor)
10-80 mg PO qd
HMG-CoA reductase inhibitor, inhibits cholesterol biosynthesis
HAs, difficulty sleeping, myalgia, dizziness, N/V, GI d/o, low levels of platelets, memory loss, neuropathy, hyperglycemia, myositis, elevated CPK.
Grapefruit juice – liver enzyme inhibitor increases plasma levels of statins
Humalog kwik-pen insulin lispro injection
Dosage is dependent on current metabolic needs of patient, dose increments of 1 unit.
Lowers blood glucose in patients with diabetes mellitus
Hypoglycemia, allergic reaction, hypokalemia, lipodystrophy, interaction with Thiazolidinedione drugs
Lantus Solostar insulin glargine
Dosage individualized - 1/3 total daily insulin requirement
Lowers blood glucose in patients with diabetes mellitus
Interaction with Pioglitazone or Rosiglitazone may lead to hypoglycemia, edema, or heart failure
Western Medicine Review:
Type I diabetes mellitus (DM) is associated with the autoimmune or infectious destruction of the insulin producing ß-cells of the pancreas, typically in children, adolescents, and young adults (Maclean, 2018). Destruction continues without symptoms until too few ß-cells remain to produce enough insulin and blood glucose levels increase beyond the body’s ability to control it. At this point insulin must be administered through injections.
The sequelae of type I DM include cardiovascular disease, stroke, and kidney failure. Other morbidities associated with DM include blindness, gangrene, chronic skin infections, sensory deficit, and peripheral neuropathy.
The pathophysiology of peripheral somatic neuropathy is based on the hyperglycemic state of DM and its effect on capillary and nerve tissues (Dejgaard, A., 1998). Uncontrolled glucose levels in the blood lead to biochemical abnormalities resulting in functional loss in nerve tissue and neuronal lesions. Chronic hyperglycemia also results in changes to the microvascular system inhibiting blood flow to the neurons and resulting in ischemia and oxidative stress. This leads to further loss of function in the neurons.
Signs and symptoms of diabetic neuropathy vary widely depending on the specific nerves affected. Dys-, para-, hypo-, or hyperaesthesia, allodynia, burning, tingling, ‘pins and needles,’ electric sensations, deep or superficial pain, muscle weakness, or cramps are the most commonly reported symptoms. Often, symptoms are worse at night.
Treatment strategies focus on aldose reductase inhibition and improving strict metabolic control. Both strategies attempt to interrupt the damage done to nerve fibers. Since peripheral nerves are able to regenerate, unlike those of the central nervous system, symptoms of peripheral neuropathy may be alleviated when damage to those nerves cease.
Clinically it is important to catch any co-morbidities associated with loss of sensation in the peripheral nerves. These may present as non-healing wounds, loss of balance or coordination, and restricted circulation to the extremities.
Chinese Medicine Review:
Diabetes mellitus (DM) is known as tang niao bing, ‘sweet urine disease,’ in Traditional Chinese Medicine and the first mention of this disease appears in Simple Questions (HuangDiNeiJingSuWen) in the 1st century BCE (Maclean, 2018). Xiao Ke is the resulting disease state characterized by persistent thirst, hunger, copious urination, and weight loss.
The pathology of DM can be seen through the six levels, primarily the tai yin (Spleen and Lungs) and shao yin (Heart and Kidney) levels. Because the Kidneys are the ultimate support for all other organs, a preexisting or acquired weakness in the Kidneys leaves the Spleen vulnerable to failure when stressed by prolonged Liver Qi stagnation, poor diet, or invasion by an external pathogenic factor.
In type I DM, the Spleen’s transformative function is not supported by the Kidney, therefore the Spleen cannot perform its function of transforming and transporting food into Qi. This results in the buildup of the sweet precursor to Qi in the blood. This excess ‘sweetness’ in the blood generates dampness which can condense into phlegm (blocking Qi and Blood flow), create heat (further condensing dampness), and damage Yin (thickening the blood.) All patterns then lead to obstruction in the vessels, channels, and collaterals resulting in loss of sensation or dysfunction of the nerve tissue.
The inability of the Spleen to transform food into Qi results in further Qi deficiency as well as Yin Deficiency as Yin can only be built through the intake and transformation of Yin-nourishing foods. As this pattern progresses, the Kidneys are increasingly called on to bolster the Spleen which further depletes the Kidneys. One can see the positive feedback loop that, if uninterrupted, will ultimately lead to a jue yin level disorder and death.
The etiology of type I DM stems from the trigger of an external pathogenic factor invading the body of a patient with a deficiency in the shao yin. In this case, the pathogen bypasses the tai yang and directly invades the shao yin via the Urinary Bladder-Kidney channel connection.
Emotional factors such as shock or trauma can disrupt the Heart-Kidney harmony resulting in a weakness that would allow a pathogen to enter the shao yin level. Liver Qi constraint or overwork can weaken the Spleen initiating the cycle mentioned earlier.
Treatment from a Traditional Chinese Medicine perspective is focused on Tonifying Spleen Qi, Moving Qi and Blood, Activating the Channels and Collaterals, and Nourishing the Kidneys. Dietary recommendations center around strictly limiting sugar and simple carbohydrates as well as high fat foods.
Observation and Examination:
Tongue: pink to red and dusky, occasionally scalloped, thin white fur
Pulse: well rooted, slippery cun, wiry guan, thready chi
Physical Assessment: dry and scaly skin of the lower extremities, cold skin temperature around knees and feet. Muscle tension in the SanJiao and Small Intestine channels of the upper back/trapezius. Numerous moles and scars from excised melanomas on the back and shoulders.
Assessment:
Western Diagnosis: Type I Diabetes mellitus with peripheral somatic neuropathy
TCM Diagnosis: Spleen Qi Deficiency, Liver Qi Stagnation, Qi and Blood Stasis in the Channels and Collaterals of the Lower Extremities
TCM Treatment Principle:
Tonify Spleen Qi, Smooth Liver Qi, Move Qi and Blood in the Lower Extremities, Calm Shen
Treatment Strategy:
Weekly acupuncture treatments utilizing points on the yang ming channels, the Shu Stream point on the Liver channel, and the meeting point of Sinews on the Gall Bladder Channel to restore movement of Qi and Blood and activate the channels. Tonify and strengthen the transforming and transporting function of the Spleen, harmonize the Liver and nourish the Kidneys, and invigorate the Blood using SP6 and SP9. Nourish the Kidneys using the Yuan Source point on the Kidney channel. Invigorate Blood using moxa on the channels of the lower extremities.
Course of Treatment:
Acupuncture:
Du24 Shenting – to calm the Shen
LI-4 Hegu + LV3 Taichong – to vigorously activate the Qi and Blood to free flow throughout the whole body
PC6 Neiguan – assists in smoothing Liver Qi, regulates and calms the Shen
SJ5 Waiguan – confluent point of the Yang Wei, linking all yang channels and treating the yang aspects of the body.
ST31 Biguan + ST34 Liangqiu + GB34 Yanglingquan – treats numbness of the knee
ST36 Zusanli – He-sea and earth point of the Stomach channel, fortifies the Spleen’s function of transforming and transporting, tonifies Qi and nourishes Yin, activates the channel
SP9 Yinlingquan – the He-sea and water point of the Spleen channel, harmonizes the Spleen and resolves dampness
SP6 Sanyinjiao – meeting point of the Spleen, Liver, and Kidney channels, harmonizes the Liver, tonifies the Kidneys, invigorates Blood, calms the Shen, activates the channel, resolves dampness, tonifies Spleen and Stomach, treats counterflow cold of the foot
KD3 Taixi – Yuan-source and earth point of the Kidney channel, nourishes Kidney deficiency, anchors the Qi
KD1 Yongquan – treats cold sensation of the feet and shins and chronic numbness of the feet, calms the Shen
Moxa:
Rice grain moxa applied to visible areas of stagnation on the lower legs, tiger moxa applied to points around the knee (ST36, GB34, ST34, SP9).
GuaSha:
GuaSha performed on the SanJiao and Small Intestine channels of the upper back to break up stagnation in the trapezius muscles.
Herbal Prescription:
Although the patient was not interested in taking an herbal formula, the prescription most appropriate for his pattern would be BuYangHuanWuTang with added NiuXi and DuZhong. This formula specifically addresses deficiency of normal and Yang Qi with Blood stasis obstructing the channels. Specifically, conditions in which Blood stasis is caused by the deficiency of Qi. This formula acts to tonify the Qi, invigorate the Blood, and unblock the channels. The added NiuXi and DuZhong act to guide the formula to the lower extremities.
Recommendations:
Daily self-massage of the legs with the liniment PoSumOn and sesame oil was recommended to the patient as a way to invigorate Blood and unblock the channels between acupuncture appointments.
Analysis and Conclusion:
This patient case clearly illustrates the etiology of disease from both a Western and TCM perspective. He experienced a viral infection/external pathogenic factor which triggered an autoimmune response attacking an already weakened pancreas/Spleen due to overwork and stress/Liver Qi stagnation. Type I DM was the result.
His asthma diagnosis indicates a weakened Kidney function from childhood which contributed to the progression of diabetes and peripheral neuropathy as the Kidneys were unable to prop up his deficient Spleen.
Although his blood glucose levels are well managed, the damage done to his peripheral capillaries and nerves which have resulted in blood stasis and superficial loss of sensation need consistent treatment to allow the nerves to heal and sensation to return. In addition, the unresolved Liver Qi stagnation resulting from the patient’s continued stress and overwork further debilitates his compromised Spleen weakening his prognosis.
The medications this patient is currently taking have a few additive interactions with some of the herbs in BuYangHuanWuTang, which could be a positive change for the patient if he was interested in eventually lowering the dosage of insuli or discontinuing the use of the statin. This would need to be monitored in cooperation with his PCP to appropriately adjust medications as the herbal formula may gradually reduce the need for them. Fortunately, the patient has a continuous glucose monitor that allows adjustment of insulin dosage as a matter of course, so attention would only need to be placed on the gradual introduction of the herbs so that a sudden hypoglycemic state could be avoided.
The patient would need to be educated about the other potential interactions with the herbs in BuYangHuanWuTang and blood thinning or antiplatelet medications so that the patient could avoid these while taking the formula.
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