Does acupuncture help neuropathy? Good question. But before trying to answer that question, why does a rheumatologist care about neuropathy anyways? Isn’t neuropathy more of a neurology thing? The answer to that question is yes and no. If you’ve read a few RheumDoctor articles, you’ve probably realized that rheumatology is not just about joints. It’s about the immune system, and the immune system affects ALL organs including the nervous system. That being said, innumerable autoimmune diseases affect nerves including: lupus, rheumatoid arthritis, Sjogren’s syndrome, vasculitis, ankylosing spondylitis/axial spondylitis, scleroderma, myositis, sarcoidosis, etc. I could go on, but I think you get the point?
So what is neuropathy anyway?
In medical terms, neuropathy, more specifically peripheral neuropathy, occurs when peripheral nerves are malfunctioning for any number of reasons. Peripheral nerves are those that DO NOT involve the brain or spinal cord. When it involves multiple nerves, we call it polyneuropathy. When it involves one nerve, we call it mononeuropathy.
Symptoms that are suggestive of neuropathy include:
- Numbness
- Tingling
- Burning
- Pain out of proportion to stimulation (e.g., touching intact skin should not cause pain)
- Weakness
- Cramping
- Itching
- Temperature dysregulation
Some people describe neuropathy as invisible pain. Someone can be in terrible agonizing pain, but physically they look perfectly normal.
How do you diagnosis neuropathy?
Peripheral neuropathy can be diagnosed clinically, with nerve conduction tests, and with a special type of skin biopsy called an epidermal nerve fiber density test. Don’t get me wrong, I’m all about history and physical exam, but when it comes to diagnostics, I like to have some hard data supporting my clinical diagnosis. This is why a suspicion of peripheral neuropathy typically should be supported by either a nerve conduction test and/or a skin biopsy.
Nerve conduction tests are pretty much the go to test when it comes to neuropathy. The doctor measures the conduction of electrical impulses that go down the nerves. This type of test is good to diagnose problems with large myelinated nerves. Not so much for small, unmyelinated nerve fibers like the ones found on the skin. When the doctor suspects the problem is coming from small fibers, a skin biopsy is the way to go. In very special and unique cases, an actual biopsy of a large nerve may be required. In the world of rheumatology, this can happen if there is a suspicion for systemic vasculitis. This includes really rare diseases like Wegener’s (although we don’t it that anymore)¹, Churg-Strauss (we don’t call it that anymore either)², and microscopic polyangiitis.
What causes neuropathy?
The most common diseases in general include diabetes, chemotherapy, carpal tunnel syndrome, Lyme disease, alcohol abuse, vitamin deficiencies, low thyroid, HIV, and hepatitis C infection. At that point, you start getting into the weird and rare diseases. This is where rheumatic autoimmune diseases feature. Unfortunately, despite exhaustive workups, in about one-third of cases, a specific cause is never found. This is called idiopathic neuropathy.
Treatment of neuropathy
First, treat the underlying disease. Unfortunately, in most situations this is not enough. Medications that are often used include: gabapentin, pregabalin, duloxetine, amitriptyline, topiramate, and carbamazepine. In extreme situations, infusions with immunoglobulin are used particularly with demyelinating autoimmune conditions. When all else has failed, and I mean, ALL else has failed narcotic medications for breakthrough pain be necessary. Every person and situation is unique, so it’s important to work closely with your physician to figure out the best plan of action.
It’s important to note that all these medications have potentially serious or undesirable side effects. Increasingly, people are searching for alternatives treatments. Long a staple of Chinese traditional medicine, there’s recently been an increased interest in using acupuncture to treat neuropathy.
But is there any evidence and is it safe?
Acupuncture for the treatment of peripheral neuropathy: a systematic review and meta-analysis
Researchers recently sought to determine whether acupuncture was safe and efficacious for the treatment of peripheral neuropathy. They searched multiple medical databases including Medline, AMED, Cochrane, Scopus, CINAHL, and clinitrials.gov looking for studies that matched stringent entry criteria. About one thousand studies were identified, but only 13 made the cut.
They selected randomized controlled trials studied acupuncture for neuropathy caused by diabetes, Bell’s palsy, carpal tunnel syndrome, HIV, and idiopathic conditions. What they found was that acupuncture generally was effective for diabetic neuropathy, Bell’s palsy, and carpal tunnel syndrome. In these cases, they even found improvement in nerve conduction study parameters in both sensory and motor nerves. More data was necessary to determine whether acupuncture was effective in cases of HIV-associated neuropathy but there was a positive trend. With regards to idiopathic neuropathy, there was insufficient evidence. Then again, there were hardly any trials that looked into this type of neuropathy.
Does this mean that everyone with diabetic neuropathy should start acupuncture ASAP? Hold your horses. The researchers also noted that there was A LOT of variability between studies and A LOT of bias. Evidence-based medicine is all about comparing oranges with oranges and apples with apples in an unbiased way. If these conditions are not met, then it really becomes difficult to determine what caused what.
The following are some of the problems that the researchers identified.
Methodological problems with standardization
- Point selection
- Number of needles used
- Needle retention time
- Needling depth
- Needle manipulation
- Use of moxibustion
- Use of electroacupuncture vs. manual acupuncture
Methodological problems with sample size
- Only two of the studies stated sample size
- Many trials were likely underpowered (You cannot make generalizations from a small group of people)
Methodological problems with improper control and blinding
- In many cases researchers were not blinded
- In many cases participants were not blinded
Methodological problems with outcome measures
- Most trials assessed improvement with subjective measures of improvement instead of hard evidence.
- Only 4 out of 13 trials actually did nerve conduction tests before and after, to see whether anything changed.
On the up side, acupuncture was found to be safe. Serious side effects only occurred in people suffering from HIV-associated neuropathy. Otherwise, acupuncture seems pretty safe.
Conclusion
Basically, the meta-analysis demonstrated that acupuncture is generally safe and that it may help in people suffering from diabetic neuropathy, Bell’s palsy, and carpal tunnel syndrome. Autoimmune disease-associated neuropathy is a big unknown. However, these results should be taken with a grain of salt. Although the meta-analysis in itself used good methodology, the researchers were not working with the studies with the best methodological practices in the world.
This brings me back to my first question. Does acupuncture help neuropathy? My answer to that questions is as follows.
As always, think for yourself! You now have the tools to make an educated, unbiased, objective, informed decision regarding health.
References
UpToDate
Dimitrova A, Murchison C, Oken B. Acupuncture for the treatment of peripheral neuropathy: a systematic review and meta-analysis. J Altern Complement Med. 2017 Jan 23. doi: 10.1089/acm.2016.0155.
Notes
Wegener’s = granulomatosis with polyangiitis. And they wonder why people still call it Wegener’s?
Churg-Strauss = eosinophilic granulomatosis with polyangiitis