E-ISSN:2456-3110

Review Article

Diabetic neuropathy

Journal of Ayurveda and Integrated Medical Sciences

2022 Volume 7 Number 1 Jan-Feb
Publisherwww.maharshicharaka.in

Ayurvedic and modern approach to Diabetic Neuropathy: A Review

Prafulla Mohite P.1*, Deshmukhe P.2, Vitthal Lokhande S.3
DOI:

1* Pratima Prafulla Mohite, Post Graduate Scholar, Dept. of Kayachikitsa, Hon. Shri. Annasaheb Dange Ayurved Medical College, Ashta, Sangli, Maharashtra, India.

2 PN Deshmukhe, HOD & Professor, Dept. of Kayachikitsa, Hon. Shri. Annasaheb Dange Ayurved Medical College, Ashta, Sangli, Maharashtra, India.

3 Smita Vitthal Lokhande, Associate Professor, Dept. of Kayachikitsa, Hon. Shri. Annasaheb Dange Ayurved Medical College, Ashta, Sangli, Maharashtra, India.

In Ayurveda, Diabetes mellitus closely resembles a disorder called Madhumeha, which is a subtype of Vataja Prameha. In Avarnjanya Madhumeha vitiated Kapha, Pitta and Meda causes Avarana to Vata that leads its aggravation causing diminution of vital Dhatus. This may lead to the complication of Madhumeha such as Diabetic Neuropathy. Neuropathy is a common complication of diabetes affecting approximately 30% of diabetic patients. Diabetic neuropathies are thought to result from diabetic micro vascular injury involving small blood vessels that supply nerves in addition to macro vascular conditions that can culminate in diabetic neuropathy. Although the invention of insulin and hypoglycemics have done a great service for diabetics, yet these patients do not get a proper solution for their neuropathic complications. The most common signs found in diabetic sensory polyneuropathy are diminished perception of vibration sensation and impairment of all other modalities of sensations. As per Ayurvedic principles there is involvement of Vata and Pitta Dosa in diabetic neuropathy. In Ayurvedic classics symptoms like Suptata (numbness) and Daha (burning sensation) in body parts especially in hands and feet are described as Purvarupa of Prameha. Daha is also described among the Upadravas (complications) of Prameha. These are very common features of diabetic neuropathy. As we know that diabetic neuropathy is common complication amongst diabetics. In conventional medicine tricyclic antidepressants, anticonvulsants, opiates, membrane stabilizers and antioxidants are used in diabetic peripheral polyneuropathy for symptomatic relief. All these drugs have their side effects. Hence there is need to find out safer and effective treatment from the sources other than conventional medicine.

Keywords: Diabetic neuropathy, Diabetes Mellitus, Prameha Upadrava, Madhumeha

Corresponding Author How to Cite this Article To Browse
Pratima Prafulla Mohite, Post Graduate Scholar, Dept. of Kayachikitsa, Hon. Shri. Annasaheb Dange Ayurved Medical College, Ashta, Sangli, Maharashtra, India.
Email: 		Pratima Prafulla Mohite, PN Deshmukhe, Smita Vitthal Lokhande, Ayurvedic and modern approach to Diabetic Neuropathy: A Review. J Ayu Int Med Sci. 2022;7(1):199-204.
Available From
https://jaims.in/jaims/article/view/1638

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2022-01-15 2022-01-17 2022-01-24 2022-01-31 2022-02-07
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 16%

© 2022by Pratima Prafulla Mohite, PN Deshmukhe, Smita Vitthal Lokhandeand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

Journal of Ayurveda and Integrated Medical Sciences 2022;7(1)199
Mohite P. et al: Ayurvedic and modern approach to Diabetic Neuropathy: A Review

Introduction

Uncontrolled chronic hyperglycemic condition can cause damaging effects on organs such as heart, kidney, eye, and nerve leading to vascular complications.  Diabetic neuropathy (DN) is one of the common microvascular complications affecting the majority diabetic population worldwide. DN is characterized by degenerative neuronal loss due to alterations in nerve damage and repair process which result in progressive loss of sensation. The prevalence of diabetic peripheral neuropathy (DPN) ranges from 16 to 87% with painful diabetes-related neuropathy about 26%. The lower limb amputation is 10–20-fold more common in diabetic patients as compared to non-diabetic patients. Significant neuropathic pain occurs in 7.5% to 24% of all patients with diabetes.[1]Chronic hyperglycaemia contributes to pathological changes like demyelination of nerves, narrowing of neuronal capillary, axonal thickening, neuronal damage, and loss of nerve fibers). The neuronal damage can be attributed to elevated levels of oxidative stress and advanced glycation end products (AGEs) in nerves. Depending on the affected nerves, symptoms of diabetic neuropathy can range from pain and numbness in your legs and feet to problems with your digestive system, urinary tract, blood vessels and heart. Some people have mild symptoms. But for others, diabetic neuropathy can be quite painful and disabling.[2]

The disease Prameha can be understood as having three stages based on the severity of Dhatudusti and Kaphaja, Pittaja and Vataja Lakshanas are manifested in the I, II and III stages respectively. Prameha Upadravas are manifested only in the terminal stage i.e., with the Dusti of all Dhatus. Neuropathy analyser machine has been used for exact recording of sensory perception of vibration, cold and hot sensations which costs around several thousands. Many single drugs and Ayurvedic formulations are used in practice have significant effect on the symptoms of numbness, tingling, burning sensation and pain in the patients of diabetic neuropathy.

Aims and Objectives

  1. To study the literature regarding the diabetic neuropathy through Modern & Ayurveda
  2. To study the treatment modalities in diabetic neuropathy as per Ayurvedic view.

Modern View[3]

Symptoms[4]

There are four main types of diabetic neuropathy. Symptoms will depend on the type & which nerves are affected. Usually,symptoms develop gradually.

Peripheral Neuropathy

This is distal symmetric peripheral neuropathy. It's the most common type. It affects the feet and legs first, followed by the hands and arms. Signs and symptoms of peripheral neuropathy are often worse at night, and may include:

  • Numbness or reduced ability to feel pain or temperature changes
  • Tingling or burning sensation
  • Sharp pains or cramps
  • Increased sensitivity to touch
  • Serious foot problems, such as ulcers, infections, and bone and joint pain

Autonomic Neuropathy

The autonomic nervous system controls your heart, bladder, stomach, intestines, sex organs and eyes. Diabetes can affect nerves in any of these areas, possibly causing:

  • A lack of awareness that blood sugar levels are low (hypoglycemia unawareness)
  • Bladder or bowel problems

Journal of Ayurveda and Integrated Medical Sciences 2022;7(1)200
Mohite P. et al: Ayurvedic and modern approach to Diabetic Neuropathy: A Review
  • Slow stomach emptying (gastroparesis), causing nausea, vomiting and loss of appetite
  • Changes in the way your eyes adjust from light to dark
  • Decreased sexual response

Proximal Neuropathy (Diabetic Radiculopathy)

This is diabetic amyotrophy - often affects nerves in the thighs, hips, buttocks or legs. It can also affect the abdominal and chest area. Symptoms are usually on one side of the body, but may spread to the other side. You may have

  • Severe pain in a hip and thigh or buttock
  • Eventual weak and shrinking thigh muscles
  • Difficulty rising from a sitting position
  • Severe stomach pain

Mononeuropathy (Focal Neuropathy)

There are two types of mononeuropathy - cranial and peripheral. Mononeuropathy damage to a specific nerve. May also lead to:

  • Difficulty focusing or double vision
  • Aching behind one eye
  • Bell's palsy
  • Numbness or tingling in your hand or fingers, except your pinkie (little finger)
  • Weakness in your hand that may cause you to drop things.

Investigation of Diabetic Neuropathy[5]

Neuropathy is diagnosed on the basis of symptoms and a physical examination. During the examination, blood pressure and heart rate, muscle strength, reflexes and sensitivity to position, vibration, temperature or a light touch is checked. The doctor also does other tests to determine the type & extent of nerve damage.

  1. Comprehensive Foot Exam
  2. Electromyography (EMG)
  3. Quantitative Sensory Testing (QST)
  4. A check of Heart Rate Variability
  5. Ultrasound
  6. Nerve Conduction Study

Samprapti Ghatak of Diabetes Neuropathy

  • Doshas - Vata (mainly), Kapha Pitta.
  • Dooshyas - Rakta, Twak, Mamsa (main), Meda, Vasa, Rasa, Ambu Lasika, Majja, Shukra, Ojas
  • Agni - Dhatvagni Mandhyata
  • Srotas - Raktavaha (mainly) Medavaha Mamsavaha, Rasavaha Majjavaha, Shukravaha
  • Srotodusti - Sanga and Vimarga Gamana
  • Udbhava Sthana - Hasta, Pada
  • Sanchara Sthana - Sira, Dhamani
  • Adhistana – Raktavaha (mainly), Medovaha Srotas including Vapavahana
  • Vyakta Sthana - Hasta-Pada Daha, Kriya-Alpata, Hasta-Pada Chimchimayan

Ayurvedic View

The disease diabetic neuropathy cannot be directly correlated with any Vyadhi of Ayurveda. But similar Lakshana are present in Purvaroopa and complication of Prameha. In diabetic neuropathy, mainly lancinating pain, burning sensation, tingling sensation and numbness in hands and feet are the symptoms.

Symptoms of diabetic neuropathy include;

  1. Ruja: The word pain signifies ‘Ruk’. Any kind of pain is always associated with Vayu.[7] It is included under Vataprakopaka Lakshaṇas by Astanga Hridaya, the word pain signifies ‘Ruk’. Any kind of pain is always associated with Vayu. It is included under Vataprakopaka Lakshanas by Astanga Hridaya.
  2. Daha: The word burning means Daha. Daha is felling like burn from fire. Any type of Daha always associated with Pitta, here Padadaha is due to Ashyapakarsha of Pitta by Vata.
  3. Harsha: Harsha is included in Vata Nanatmaja Roga.[8] Jhanjhanaya or Chimchimayan means tingling or clanking. Here Chala Guna of Vata is responsible for Harsha. Jhanjhanaya also described in Vatavyadhi Cikitsa in Chakardatta.
  4. Supti: Supti means numbness. Supti is a symptom of Snayu Sira Kaṇdra Dushti.[9] Supti is described in Vata Nanatmaja Roga.

In Ayurvedic classics symptoms like Suptata (numbness) and Daha (burning sensation) in body parts especially in hands and feet are described as Purvarupa of Prameha.[10] These symptoms are present in complication of Prameha.


Journal of Ayurveda and Integrated Medical Sciences 2022;7(1)201
Mohite P. et al: Ayurvedic and modern approach to Diabetic Neuropathy: A Review

Similarities of Diabetes Neuropathy and Vatarakta[6]

Symptoms and Samprapti (pathogenesis) & complications of Vatarakta has nearly resemblance with symptoms and pathogenesis of diabetic neuropathy. Etiological factors, prodromal symptoms and complications of Prameha and Vatarakta are also nearly same. Excessive use of Katu (pungent) and Tikta (bitter) Rasa, excessive walking, excessive exercises to treat Madhumeha (DM-2) [a type of Prameha] may lead to pathogenesis of Vatarakta. Micro and macro vascular changes and neuronal ischemia are the main pathology in diabetic neuropathy which are similar the Raktadusti (vitiation of blood) and Vatadusti (vitiation of  Vata) of Vatarakta.

Treatment View

Nidana Parivarjana is the main Chikitsa of every disease, Shamsodhana, Shamshamana. All Ayurvedic Acharyas explained about Nidana Parivarjana, as Kaphavardhaka Ahara Vihara should be avoided i.e., Madhura, Sheeta, Snigha, Guru Ahara etc. Activities like lack of exercise, laziness and sedentary habits must be avoided.[11] In Panchakarma purification of the body leads to maintaining their equilibrium.

Initially Mridu Snehana is done followed by the Shalishastika Pinda Swedana. Then Samshodhana is done by Vamana, Virechana.[12] Nasya, Basti, Shastika Pinda Sweda, Patrapinda Sweda is useful in treatment of diabetes neuropathy. Ayurvedic antidiabetic formulation along with Tridosha Shamaka herbs specially Vatashamaka, Shothahara property due to its diuretic nature, Nadibalya (Nervine), Vedana Sthapaka useful in the state of Diabetic Neuropathy. Bala, Atibala, Ashwagandha, Tila Taila has emollient, nourishing property and may act by its myelin sheath repair property and nourishes the Snayu and improves its actions. All these drugs have the property of Vatanashaka and may improves the myelin sheath repair property and the nerve conduction velocity which as a result in overall improvement in the total health especially Neurological health of patients of Diabetic Neuropathy.

Basti can break pathogenesis of Vata Vyadhi by removing Margavarodha by purification of channels and Dhatukshaya by its Brihmana (~nourishing) property. Basti used in the case was mainly made

of Tikta Rasa and Madhura Rasa. Mahapanchatikta Ghrita and Ashwagandha Taila (oil) were used in the formation of Basti.[13,14] Tikta Rasa is used in the treatment of Rakta Dosha and Raktavaha Srotodusti (pathogenesis in blood vessels). Tikta Rasa has Shothaghana (anti‑edematous and anti‑inflammatory) and Pittahara properties (suppression and elimination of deranged Pitta Dosha). Ghṛita and honey have Madhura Rasa (sweet taste) dominance. The combinations of these drugs may act as Vata Pittahara (suppressors and eliminators of deranged Vata and Pitta Doshas) that may reduce inflammation and treat the Diabetic neuropathy condition. Hence Basti used in the case was effective for the treatment of diabetic neuropathy. Rasayana Aswagandha has (immunomodulatory) and Balya (anabolic) properties.[15]

Udvartana

In the pathogenesis of Prameha, it is mentioned that due to the Bahu Drava Sleshma (~excess moisture content), the Sthirata (~compactness) of the muscles of the body is lost. As Udvartana is a procedure that decreases Kapha liquefaction of Medas imparts Sthirata to the body and helps in Tvak Prasadana[16] (~stimulates the skin by increasing the peripheral circulation), which was preferred. In this case, Udvartana is aimed at providing the initial Langhana and sensitization of the skin by increasing the circulation. Triphala churna,[17] Triphala + Liqorice, Kolkulathadi  Churna, Nisha Amalaki Churna can be used.

Abhyanga

After the initial Rookshana by Udvartana, Abhyanga should be done with oil which is Vatahara and also indicated in Prameha.[19] This process alleviates Vata and improves the sensory perception of the skin as Vayu dominates the tactile sensory organ located in the skin. e.g., Vatasini oil[18], Ksheerbala oil, Fish oil, Seal Oil.

Discussion

Diabetic neuropathy is damage to autonomic, motor and / or sensory nerves that results from metabolic or vascular derangements in patients with long standing diabetes mellitus. Symptoms of the disease like pain (Ruka), tingling sensation (Harsha) and numbness (Supti) are due to vitiation of Vata Dosha. Burning (Daha) sensation


Journal of Ayurveda and Integrated Medical Sciences 2022;7(1)202
Mohite P. et al: Ayurvedic and modern approach to Diabetic Neuropathy: A Review

is due to provocation of Pitta Dosha. Drugs having Rasayana, Madhumehahara property and Balya property is useful in the treatment of diabetic neuropathy. The combined Ayurvedic treatment protocol of oral drugs and external therapies were found to be effective in the management of sensory as well as motor symptoms of DPN. Concomitant use of Ayurvedic treatments and internal medications can be effective in the treatment of DPN; further use of suitable Rasayana drugs may arrest the disease progression also.

Pathya and Apathya[20]

Shyama, Kodrava, Uddalika, Godhum, Chanaka, Aadak and Kullatha which are old - are suitable to be used as foods by patients of Madhumeha (Diabetes). Vegetables of bitter taste (Tikta), meat of animals and eggs of birds of deserts like regions (Jangala mamsa), boiled Yava and its preparations, Mudag, Shali, and Shastika are all suitable as foods. Shauviraka (fermented gruel), Sura (beer), Buttermilk, oils, milk ghee, jaggery, foods processed with sours, sugarcane, juice, food prepared from flour, meat of animals of marshy regions should be avoided from use.

Reference

  1. The effects of improved glycemic control on complications in type 2 diabetes. Gaster B, Hirsch IB Arch Intern Med. 1998 Jan 26; 158(2):134-40.
  2. Diabetic neuropathy, (cited on 20 july 2019) available from https://www.mayoclinic.org/diseasesconditions/diabetic-neuropathy/symptoms-causes/syc20371580
  3. Suraj Rathod, Dr. Pratima Prabhakar Rao Surve, Dr. Vrinda P. Kadu, Dr. Ramdas B. Shinde. Concept of Diabetic Neuropathy and its management in Ayurveda. J Ayurveda Integr Med Sci 2019;4:295-299.
  4. Llewelyn, J. Gareth. "The diabetic neuropathies: types, diagnosis and management." Journal Neurology, Neurosurgery & Psychiatry 74.suppl. 2 (2003): ii15-ii19.
  5. American Diabetes Association. Diagnosis and classification of diabetes mellitus." Diabetes care 33. Supplement 1 (2010): S62-S69.
  6. Singh SK, Rajoria K, Dadhich S, An Ayurvedic
  1. approach in the management of diabetic neuropathy -a case report JOA XIII-1, 2019; 150 – 154.
  2. K.R. Srikantha Murthy editor. 1st ed, Susruta Samhita, Sutrasthan, Chapter 17, Verse 7. Vol-II.Varanasi: Chaukhamba Orientalia, 2001;pg 150.
  3. Sharma RK and Bhagwan Dash. editor, (2nd ed.). Charaka Samhita, Sutra Sthana, Chapter 20, Verse 12,English Translation, Reprint. Vol. 1. Varanasi: Chowkhamba Sanskrit Series Office; 2009. pp. 218
  4. Sharma RK and Bhagwan Dash. editor, (2nd ed.). Charaka Samhita, Sutra Sthana, Chapter 28, Verse 17,English Translation, Reprint. Vol. 1. Varanasi: Chowkhamba Sanskrit Series Office; 2009. pp. 267
  5. Aacharya Vaidya Jadavaji Trikamji., editor. Agnivesha, Charaka, Charaka samhita, Nidana Sthana, Adhyaya. Varanasi: Chaukhamba Sanskrit sansthan. 2nd ed. 47. Vol. 4. Dridhabala. Varanasi: Chaukhamba Sanskrit sansthan; 1990. 325
  6. Shukla V, editor, (2nd ed.). Charaka Samhita of charak, Chikitstasthan: Chapter 6, Verse 53. Varanasi: Chowkhambha Sanskrit Series, 2002; 261.
  7. Shukla V, editor, (2nd ed.). Charaka Samhita of charak, Chikitstasthan: Chapter 6, Verse 15-16. Varanasi: Chowkhambha Sanskrit Series, 2002; 252.
  8. Brahmasankar M. Bhavaprakasha Nighantu. Vidyotini Hindi commentary. Guḍuchyadivarga. 10th ed.,Vol. 190. Varanasi: Chaukhambha Sanskrit Sansthan; 2002. p.393.
  9. Brahmanand T. Sarangdhar Samhita; Dipika Hindi commentary. Madhyakhand 9/45‑ Varanasi: Chaukhamba Surbharati Prakashan; 2004. p. 225.
  10. Brahmasankar Misra, editor, (10th ed.), Vidhyotini Hindi commentary on Bhav Prakash nighantu, Gudichayadivarg chapter 26 verse 41. Varanasi: Chaukhambha Sanskrit Sansthan, 2002;294.
  11. Murthy SK, editor. Astagahridaya of Vagbhatta, Sutra Sthana; Dinacharya Adhyaya. Ch. 2, Ver. 15. Varanasi: Chaukhamba Surbharati Prakasan; 2004. p. 25.

Journal of Ayurveda and Integrated Medical Sciences 2022;7(1)203
Mohite P. et al: Ayurvedic and modern approach to Diabetic Neuropathy: A Review
  1. Murthy SK, editor. Astaga hridaya of Vagbhatta, Sutra Sthana. Ch. 6, Ver. 159, 5th ed. Varanasi: Chaukhamba Surbharati Prakasan; 2004.p. 105.
  2. https://www.mayoclinic.org/diseases-conditions/ diabetic-neuropathy/symptoms-causes/syc-20371580
  3. Krishnanvaidyar KV, Gopalapillai S. Sahasrayogam, Tailayoga, 26th Mullakkal: Vidyarambam publications; 2006. p. 308‑9.
  4. Bhavprakash of Bhavmishra, Prof. Murthy K.R. Shrikantha, (vol.2) Krishnadas Academy, Varanasi, First edition 2000, Page no. 489.

Journal of Ayurveda and Integrated Medical Sciences 2022;7(1)204