Inspired by Hoerder et al 2023.[1]
DPN – diabetic peripheral neuropathy
key to acronyms
ACUCIN – acupuncture for chemotherapy-induced neuropathy
ACUDIN – acupuncture for diabetic induced neuropathy
ACUDPN – acupuncture in diabetic peripheral neuropathy
NCS – nerve conduction studies
ARC – acupuncture in routine care (a set of trials from Germany in the 00’s)
MA – manual acupuncture
VAS – visual analogue score
SR – systematic review
EA – electroacupuncture
RCT – randomised controlled trial
This paper was published in mid-December 2023 in the World Journal of Diabetes. It is a relatively small pragmatic trial from a well-known group based at the Charité Universitätsmedizin, Berlin. It is also an excuse for me to start a new category on the blog for DPN – probably the most common cause of peripheral neuropathy.
German colleagues have been coining a number of acronyms for acupuncture trials in peripheral neuropathy over recent years. I have highlighted ACUCIN on this blog already,[2] and that led me to ACUDIN,[3] which I had overlooked previously. This paper is the second publication of results from the ACUDPN trial.[4] The first publication reported the results of overall subjective complaints (the primary outcome of the trial),[5] and this one focusses on neurological scores and NCS.[1]
The ACUDPN trial was a bit like the ARC trials that were part of the Modellvorhaben Akupunktur,[6] in that a course of acupuncture was added to routine care and compared with routine care alone in a parallel arm RCT. After the initial phase of treatment (12 sessions of MA over 8 weeks) and follow-up (8 further weeks), the control group then received acupuncture and the original acupuncture group were simply followed up to the 24-week point – the end of the trial.
The MA protocol involved a set of mandatory bilateral points plus additional optional points based on a Chinese medicine diagnosis. The mandatory points were all in the lower limb: ST34, ST40, SP6, KI3, LR3, Bafeng. In total the patients would have had between 18 and 24 needles per session.
Unsurprisingly, the results demonstrated a significant improvement in VAS subjective complaints related to DPN over the course of the initial treatment phase. This improvement was maintained at the 16-week point. The control group then caught up but did not seem to do quite as well as the group who were randomised to get the acupuncture first.
All of the neurological scores demonstrated significant improvements at week 8 and most of these benefits persisted to week 16; however, no significant differences could be measured in NCS. Unlike the trials mentioned above (ACUCIN and ACUDIN), which did measure changes, NCS was not measured by needle neurography, but using a handheld point of care device (POCD).
An SR of acupuncture for painful DPN published in November 2023 included 25 trials and 1561 patients.[7] 24 trials were from China and one from the UK, the results of which were published in Acupuncture in Medicine in 2014.[8] The pooled results of the meta-analyses within this review were based on subjective outcomes and were in favour of acupuncture treatment over control, where the control was usually some form of conventional treatment that was often used in both groups, ie A+B vs B design. Only 2 of the 25 trials employed a sham technique.
I had a memory of EA being used successfully in DPN from the 90’s… back in the days when papers were read as photocopies of journal articles obtained from libraries. The paper was not listed in the SR, so I searched back in my records to find it. I recalled that the first author’s name started with an A. It was a good paper, and the research was from Manchester, but it did not mention EA and it was not an RCT.[9] It was a well conducted cohort trial of acupuncture in patients (n=46) with chronic painful DPN. 44 patients completed the treatment (6 courses over 10 weeks) and 34 patients (77%) showed significant improvement.
References
1 Hoerder S, Habermann IV, Hahn K, et al. Acupuncture in diabetic peripheral neuropathy-neurological outcomes of the randomized acupuncture in diabetic peripheral neuropathy trial. World J Diabetes. 2023;14:1813–23.
2 Friedemann T, Kark E, Cao N, et al. Acupuncture improves chemotherapy-induced neuropathy explored by neurophysiological and clinical outcomes – The randomized, controlled, cross-over ACUCIN trial. Phytomedicine. 2022;104:154294.
3 Meyer-Hamme G, Friedemann T, Greten J, et al. Electrophysiologically verified effects of acupuncture on diabetic peripheral neuropathy in type 2 diabetes: The randomized, partially double-blinded, controlled ACUDIN trial. J Diabetes. 2021;13:469–81.
4 Dietzel J, Hörder S, Habermann IV, et al. Acupuncture in diabetic peripheral neuropathy-protocol for the randomized, multicenter ACUDPN trial. Trials. 2021;22:164.
5 Dietzel J, Habermann IV, Hörder S, et al. Acupuncture in Patients with Diabetic Peripheral Neuropathy-Related Complaints: A Randomized Controlled Clinical Trial. J Clin Med. 2023;12:2103.
6 Cummings M. Modellvorhaben Akupunktur–a summary of the ART, ARC and GERAC trials. Acupunct Med. 2009;27:26–30.
7 Zhou L, Wu T, Zhong Z, et al. Acupuncture for painful diabetic peripheral neuropathy: a systematic review and meta-analysis. Front Neurol. 2023;14:1281485.
8 Garrow AP, Xing M, Vere J, et al. Role of acupuncture in the management of diabetic painful neuropathy (DPN): a pilot RCT. Acupunct Med. 2014;32:242–9.
9 Abuaisha BB, Costanzi JB, Boulton AJ. Acupuncture for the treatment of chronic painful peripheral diabetic neuropathy: a long-term study. Diabetes Res Clin Pract. 1998;39:115–21.
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