Rédacteurs : Claude Pernice, Johan Nguyen, Henri Truong

Diabetic Peripheral Neuropathy

Neuropathie diabétique

Articles connexes : - neuropathies périphériques - diabète -

1. Systematic Reviews and Meta-Analysis

1.1. Generic Acupuncture

1.1.1. Yu 2021 ☆

Yu B, Li M, Huang H, Ma S, Huang K, Zhong Z, Yu S, Zhang L. Acupuncture treatment of diabetic peripheral neuropathy: An overview of systematic reviews. J Clin Pharm Ther. 2021 Jan 28. doi: 10.1111/jcpt.13351. doi

What is known and objective: To evaluate the clinical efficacy of acupuncture through a review and analysis of systematic reviews of acupuncture for the treatment of diabetic peripheral neuropathy.
Methods Systematic reviews of acupuncture treatment for diabetic peripheral neuropathy were collected by searching CNKI, VIP, Wanfang database, Chinese Biomedical Literature Database (CBM), PubMed, Web of Science and the Cochrane Library. The retrieval period was from the establishment of the database to February 14, 2020. After literature selection and extraction, included reports were evaluated in terms of the quality of the methodology and of the report using criteria from the AMSTAR2 scale and the PRISMA statement.
Results and discussion: Eighty eight reviews were retrieved. The inclusion criteria were a published systematic evaluation/meta-analysis/systematic review of acupuncture treatment for diabetic peripheral neuropathy, which included subjects meeting the diagnostic criteria for diabetic peripheral neuropathy, and which compared acupuncture treatment with non-acupuncture treatment. After the inclusion criteria had been applied, 18 reviews were finally included. According to the PRISMA statement, 3 reports were relatively complete, 12 reports had certain defects, 3 reports had considerable information missing, and 18 reports had extremely low methodological quality according to the AMSTAR2 scale. Current evidence shows that acupuncture improves diabetic peripheral neuropathy and increases nerve conduction velocity. However, the methodological quality of the reviews is generally extremely low, and most of the reviews had certain defects, showing that there is still much room for improvement in terms of the methodology and quality of the research reports.
What is new and conclusion:Acupuncture appears to have an effect on DPN, effectively improving nerve conduction and clinical symptoms. Although the methodological quality of the included studies was generally very low and defects were frequent, our study highlights areas where improvement in methodology is required. There is a need for further study of the pathogenesis of DPN, and for developing a unified standard for methods of acupuncture treatment, acupoint selection, and adverse reactions reporting. Traditional Chinese medical practices such as acupuncture should adopt an evidence-based approach to provide greater confidence in their use.

1.1.2. Jiang 2020

Jiang HL, Jia P, Fan YH, Li MD, Cao CC, Li Y, Du YZ. Manual Acupuncture or Combination with Vitamin B to Treat Diabetic Peripheral Neuropathy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Biomed Res Int. 2020. [218675]. doi

Background and ObjectiveThe efficacy of mecobalamin (vitamin B12) alone in the treatment of diabetic peripheral neuropathy (DPN) is often unsatisfactory, while acupuncture treatment is also controversial. This study compares manual acupuncture to vitamin B in DPN treatment.
Methods Randomized controlled trials on manual acupuncture treatment of DPN were retrieved from the Medline, Web of Science, PubMed, Cochrane Library, EMBASE, CNKI, WanFang, and VIP databases. Extracted research data were summarized in the tables, and methodological assessment was performed using the risk-of-bias assessment tool of Cochrane. Meta-analysis was performed by Revman 5.3, Stata 14.0, and TSA 0.9.5.10 Beta software.
Results A total of 18 randomized clinical trials (RCTs) were recruited: (1) 11 RCTs were acupuncture alone compared with vitamin B; (2) 7 RCTs were acupuncture combined with vitamin B compared with vitamin B, involving 1200 participants. Acupuncture alone improved clinical efficacy (P < 0.05) and nerve conduction velocity of the four peripheral nerves: peroneal nerve, tibial nerve, median nerve, and ulnar nerve (P < 0.05), but there was no significant difference between the group of acupuncture alone and the group of vitamin B (P = 0.36 > 0.05) in improving median nerve SCV (sensory nerve conduction velocity). Acupuncture combined with vitamin B improved clinical efficacy and nerve conduction velocity of the three peripheral nerves, peroneal nerve, tibial nerve, and median nerve (P < 0.05), and decreased the scores of the Toronto clinical scoring system (TCSS) (P < 0.05).
Conclusion Acupuncture alone and vitamin B combined with acupuncture are more effective in treating DPN compared to vitamin B. However, more high-quality RCTs on vitamin B combined with acupuncture are required to confirm our results.

1.1.3. Amato Nesbit 2019 ∅

Amato Nesbit S, Sharma R, Waldfogel JM, Zhang A, Bennett WL, Yeh HC, Chelladurai Y, Feldman D, Robinson KA, Dy SM. Non-pharmacologic treatments for symptoms of diabetic peripheral neuropathy: a systematic review. Curr Med Res Opin. 2019;35(1):15-25. [208775]. doi

ObjectiveTo systematically assess benefits and harm of non-pharmacologic interventions for diabetic peripheral neuropathy (DPN) symptoms.
MethodsMEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from 1966 to May 24, 2016 for randomized controlled trials. Two reviewers evaluated studies for eligibility, serially abstracted data, evaluated risk of bias, and graded strength of evidence (SOE) for critical outcomes (pain and quality-of-life).
Results Twenty-three trials were included. For pain, alpha-lipoic acid was more effective than placebo (moderate SOE) and frequency-modulated electromagnetic stimulation was more effective than sham (low SOE) in the short-term but not the long-term. Electrical stimulation (including transcutaneous) was not effective for pain (low SOE). Spinal cord stimulation was more effective than usual care for pain (low SOE), but had serious complications, and studies had no sham arm. Evidence for cognitive behavioral therapy and acupuncture was insufficient; no exercise or physical therapy trials met inclusion criteria. No interventions reported sufficient evidence on quality-of-life. Most studies were short-term with unclear risk of bias.
ConclusionsAlpha-lipoic acid and spinal cord stimulation were effective for pain; studies were short-term with quality deficits. Spinal cord stimulation had serious adverse events. Further research should address long-term outcomes and other non-pharmacologic treatments.

1.1.4. Nash 2019

Nash J, Armour M, Penkala S. Acupuncture for the treatment of lower limb diabetic peripheral neuropathy: a systematic review. Acupuncture in Medicine. 2019;37(1):3-15. [203215].

ObjectiveTo examine evidence for acupuncture interventions in the management of diabetes-related peripheral neuropathy (DPN) symptoms.
MethodsFive electronic databases were searched up to June 2017 for studies that included participants with symptoms of DPN, used an acupuncture intervention, and reported before-and-after DPN-related outcome measures. Two reviewers independently performed the data extraction. The level of homogeneity was assessed, and studies were appraised using the Cochrane Risk of Bias tool, the STRICTA guidelines for acupuncture reporting and the NICMAN scale for acupuncture quality.
ResultsTen studies with 432 participants were included: three randomised controlled trials (RCTs), two pilot RCTs, three uncontrolled clinical trials, one quasi-RCT and one prospective case series. Improvements in DPN pain symptoms were reported by all studies. Heterogeneity of outcome measures prevented a meta-analysis. Variations were found in needle retention time and point selection, as well as total number and frequency of treatments. Common acupuncture point selections were ST36 and SP6. Half of the studies used local point selection. Studies conducted outside China had better acupuncture reporting and quality according to the STRICTA checklist and NICMAN scales, respectively. Risk of bias was high or unclear in the majority of studies for all domains except attrition bias.
ConclusionsAcupuncture for DPN appears to improve symptoms. However, the application of acupuncture varies greatly, and the quality of included studies was generally low. Available studies have varying methodologies and different outcome measures. Further, suitably powered studies using appropriate DPN outcome measures are required.

1.1.5. Li 2015 Ø

Li Jun, Jin Yanrong, Xue Yaoming. [Influence on Acupuncture Treatment of Diabetic Peripheral Neuropathy-A Systematic Review of Randomized Controlled Trials]. World Science and Technology-Modernization of Traditional Chinese Medicine. 2015;4:819-828. [187071].

Objectives This study was aimed to evaluate the efficacy and safety of acupuncture treatment for diabetic peripheral neuropathy.
Methods MEDLINE, EMBASE, China National Knowledge Infrastructure (CNKI), and Wanfang database were searched. The study endpoints included clinical total efficacy, peripheral nerve conduction velocity and adverse reactions. The Review Manager software 5. 2 was used in the bias and risk assessment as well as efficacy. GRADE profiler software was used to evaluate quality of evidences.
Results The results showed that there were 18 randomized controlled trials (RCTs) with 1158 patients included. The clinical total efficacy rate of acupuncture treatment was obviously better than the drug control group [RR: 1. 38, 95%CI (1. 25, 1. 53), P < 0. 000 01]. The sensory nerve conduction velocity was that for nervus medianus, the acupuncture treatment group was superior to the drug control group [MD = 2. 55, 95%CI (1. 23, 3. 87), P = 0. 000 1]; for nervus peroneus communis, the acupuncture treatment group was superior to the drug control group [MD = 3. 42, 95%CI (2. 56, 4. 28), P < 0. 000 01]. The motor nerve conduction velocity was that for nervus medianus, the acupuncture treatment group was superior to the drug control group [MD = 4. 10, 95%CI (1. 01, 7. 19), P = 0. 009); for the nervus peroneus, the acupuncture treatment group was superior tothe drug control group [MD = 3. 09, 95%CI (1. 99, 4. 19), P < 0. 000 01]. The adverse reactions and safety indicators were that no adverse reaction was reported in both studies with no abnormal safety indicator. The quality of evidence showed that the sensory nerve conduction velocity for nervus peroneus communis was moderate; the motor nerve conduction velocities for nervus medianus and nervus peroneus communis were low. While, the clinical efficacy rate and the quality of evidence for sensory nerve conduction velocity of nervus medianus were relatively low.
Conclusions It was concluded that the current clinical evidences were uncertain for the efficacy and safety of acupuncture in diabetic peripheral neuropathy treatment.

1.1.6. Liu 2014 ☆

Liu Meijun, Liu Zhicheng, Xu Bin. [Systematic Review of Acupuncture Treatment on Type 2 Diabetes Peripheral Neuropathy]. Journal of Zhejiang University of Traditional Chinese Medicine. 2014;11:1326-133. [187028].

Objectives To evaluate the acupuncture treatment of type 2 diabetes peripheral neuropathy clinical curative effect and safety.
Methods Computer retrieval of the CENTRAL, Cochrane, Web Of Science, CBM, CNKI, VIP database, find al about acupuncture and moxibustion treatment of type 2 diabetic gastroparesis of randomized control ed trial (RCT), build library retrieval time until March 19, 2014. At the same time ShouJian into literature references. According to inclusion and exclusion criteria, independently by two researchers after RCT extraction and filtering, data quality evaluation, using Revman5. 2 Meta-analysis software, use the GRADE system for quality evaluation of evidence.
Results Seven studies involving 364 patients were included. Meta-analysis showed: (1) effective rate: the acupuncture compared with drugs, the results between the two groups were statistical y significant (RR=3. 35, 95% CI= (2. 05, 5. 48)], suggesting that acupuncture treatment can improve efficiency for the treatment of type 2 diabetes peripheral neuropathy. (2) MNCV: the median nerve, and results showed that the statistical significance was found between the two groups [MD=2. 29, 95%CI= (0. 61, 3. 98)]. Including philalways nervous, the result showed that between the two groups had statistical significance [MD=2. 16, 95% CI= (0. 16, 4. 16)]. (3) SNCV: includ-ing median nerve, the results showed that the statistical significance was found between the two groups [MD=1. 79, 95% CI= (0. 57, 3. 02)]. Including philalways nervous, the result showed that the two groups had statistical significance [MD=3. 59, 95%CI= (2. 28, 4. 91)]. Based on GRADE system, al the evidence was at low level and weak recommendation.
Conclusions Acupuncture-moxibustion for the type 2 diabetes peripheral neuropathy is better than the conventional medicine treatment. Limited by the quality of the inclusive literalures, it needs more high quality, large sample of RCT further argument.

1.1.7. Chen 2013 Ø

Chen W, Yang GY, Liu B, Manheimer E, Liu JP. Manual Acupuncture for Treatment of Diabetic Peripheral Neuropathy: A Systematic Review of Randomized Controlled Trials. Plos One. 2013. e73764. [160414].

Objectives Manual acupuncture has commonly been used in China, either alone or in combination with conventional medicine, to treat diabetic peripheral neuropathy (DPN). The objective of this study was to perform a systematic review to evaluate the potential benefits and harms of manual acupuncture for DPN to justify its clinical use.
Methods We searched for published and unpublished randomized controlled trials of manual acupuncture for DPN till 31 March 2013. Revman 5.2 software was used for data analysis with effect estimate presented as relative risk (RR) and mean difference (MD) with a 95% confidence interval (CI).
Results A total of 25 trials involving 1649 participants were included. The methodological quality of included trials was generally poor. Meta-analysis showed that manual acupuncture had better effect on global symptom improvement compared with mecobalamin (RR 1.31, 95%CI 1.21 to 1.42), vitamin B1 and B12 (RR 1.55, 95%CI 1.33 to 1.80), and no treatment (RR 1.56, 95%CI 1.31 to 1.85), and that the combination of manual acupuncture and mecobalamin had better effect compared with mecobalamin alone on global symptom improvement (RR 1.56, 95%CI 1.28 to 1.90). Adverse events were not reported in any trials. The asymmetric funnel plot suggested publication bias.
Conclusions Despite the number of trials of manual acupuncture for DPN and their uniformly positive results, no clinically relevant conclusions can be drawn from this review due to the trials' high risks of bias and the possibility of publication bias. Clearly defined and internationally acknowledged outcome measures are required for future study. There remains an urgent need for training Chinese researchers in conducting unbiased trials as well as prospectively registering all initiated Chinese trials to avoid publication bias.

1.1.8. Cao 2011 ☆

Cao Ping, Yang Ren-da. [Acupuncture for diabetic peripheral neuropathy: meta-analysis]. Guiding Journal of Traditional Chinese Medicine and Pharmacology. 2011;1:97-101. [186971].

Objectives To systematic reviews of acupuncture treatment of diabetic peripheral neuropathy.
Methods Acupuncture treatment in diabetic peripheral neuropathy in a systematic evaluation of randomized controlled trials, Data were analyzed using special software RevMan4.
Results Ten RCTs involving 696 patients were included, Meta-analysis showed that the efficiency of acupuncture treatment of DPN are better than the control group (P<0. 00001). Acupuncture for the improvement of nerve conduction velocity DPN is also better than the control group (motor nerve conduction velocity P<0. 00001, sensory nerve conduction velocity P=0. 0005 or P<0. 00001).
Conclusions The system evaluation results show that, compared with western medicine, acupuncture and moxibustion on diabetic peripheral neuropathy symptoms, signs and nerve conduction velocity have better effect. However, due to low methodological quality of trials, not yet fully certain that high-quality trials need to be further confirmed.

1.2. Special Acupuncture Techniques

1.2.1. Moxibustion

1.2.1.1. Tan 2020

Tan Y, Hu J, Pang B, Du L, Yang Y, Pang Q, Zhang M, Wu Q, Zhang Y, Ni Q. Moxibustion for the treatment of diabetic peripheral neuropathy: A systematic review and meta-analysis following PRISMA guidelines. Medicine (Baltimore). 2020;99(39). [212662]. doi

Background At present, the effect of western-medicine (WM) therapy to treat diabetic peripheral neuropathy (DPN) is limited. Moxibustion is a representative external treatment in traditional Chinese medicine that has been beneficial to DPN. We aim to systematically assess the efficacy and safety of moxibustion in treating DPN, following PRISMA guidelines.
MethodsEight electronic databases were searched to acquire information on eligible trials published from inception to June 1, 2019. We included randomized controlled trials (RCTs) applying moxibustion therapy with a minimum of 14-days treatment duration for DPN patients compared with placebo, no intervention, or conventional WM interventions. The primary outcomes in our study include the sensory-nerve conduction velocity (SNCV) and motor-nerve conduction velocity (MNCV). We used the Cochrane Collaboration Risk of Bias tool to assess the methodological quality of eligible RCTs. Statistical analyses were conducted using Review Manager 5.3. Risk ratios (RR) and mean differences (MD) were calculated with a 95% confidence interval (CI). The χ test was applied to assess the heterogeneity.
Results In total, 11 RCTs were included that involved 927 DPN patients. Compared with the control group, there was an increase in median MNCV (MD = 6.26, 95% CI 2.64-9.89, Z = 3.39, P = .0007) and peroneal MNCV (MD = 6.45, 95% CI 5.30-7.61, P < .00001). There was also an increase in median SNCV (MD = 6.64, 95% CI 3.25-10.03, P = .0001) and peroneal SNCV (MD = 3. 57, 95% CI 2.06-5.09, Z = 4.63, P < .00001) in the treatment groups. The treatment groups receiving moxibustion therapy indicated a more significant improvement in total effectiveness rate (RR = 0.25, 95% CI 0.18-0.37, Z = 7.16, P < .00001). Toronto Clinical Scoring System indicated a significant decrease in the treatment groups (MD = -2.12, 95% CI -2.82 to 1.43, P < .00001). Only 1 study reported that treatment groups experienced no adverse reactions. The other 10 studies did not mention adverse events.
ConclusionsMoxibustion therapy may be an effective and safe option for DPN patients but needs to be verified in further rigorous studies.

1.2.2. Electroacupuncture

1.2.2.1. Xiong 2016 Ø

Xiong WJ, Feng X, Liu JP, Chen W. Electroacupuncture for treatment of diabetic peripheral neuropathy: A systematic review of randomized controlled trials. Journal of Traditional Chinese Medical Sciences. 2016;3(1): 9-21. [162003].

Objective To assess the effectiveness and safety of electroacupuncture for the treatment of diabetic peripheral neuropathy (DPN). Clinical studies in China have shown the beneficial effect of electroacupuncture compared with conventional medicine. However, the effectiveness of electroacupuncture has not been well acknowledged internationally.
Methods We searched the following databases from their inception through February 2016: MEDLINE, the Cochrane Central Register of Controlled Trials (April, 2015), SinoMed, China National Knowledge Infrastructure, VIP, Wanfang Database, Chinese Important Conference Papers Database, and the Chinese Dissertation Database. Randomized controlled trials (RCTs) were included if they compared electroacupuncture to conventional medicine, placebo, or no treatment on DPN patients. RevMan 5.3 software was used for data analysis, with effect estimate presented as relative risk (RR) and mean difference (MD) with a 95% confidence interval (CI).
Results Eleven RCTs involving 837 participants were included. The methodological quality of included RCTs was generally poor in terms of sequence generation, allocation concealment, blinding, incomplete outcome data, and selective outcome reporting. Meta-analysis showed that electroacupuncture had a better effect on global symptom improvement than methylcobalamin (RR = 1.29; 95% CI: 1.14–1.46) and vitamin B (RR = 1.60; 95% CI: 1.33–1.94). Only two RCTs reported adverse events.
Conclusions Because of the high risk of bias of included trials, we cannot make a conclusion on the effectiveness of electroacupuncture for DPN. More rigorously designed and conducted multicenter double-blind RCTs are needed to support the use of electroacupuncture for DPN.

1.2.3. Pharmaco-acupuncture

1.2.3.1. Wang 2018 ( ST36)

Wang LQ, Chen Z, Zhang K, Liang N, Yang GY, Lai L, Liu JP. Zusanli ( ST36) Acupoint Injection for Diabetic Peripheral Neuropathy: A Systematic Review of Randomized Controlled Trials. Journal of Alternative and Complementary Medicine. 2018;24(12):1138-1149. [209326]. doi

BackgroundAcupuncture point (acupoint) injection is a common practice in China. Some trials showed that Chinese herbal extracts and/or conventional medication are injected at the Zusanli ( ST36) acupoint for the treatment of diabetic peripheral neuropathy (DPN). The study aimed to assess the effectiveness and safety of acupoint injection for DPN at the ST36 by systematically evaluating the evidence published to date.
MethodsSix databases were searched for randomized controlled trials (RCTs) of ST36 injection for DPN with primary outcome of pain, global symptom improvement, and quality of life. Methodological quality was assessed by the Cochrane risk of bias (ROB) tool. Data were analyzed using RevMan 5.3.
ResultsFourteen RCTs involving 1,071 participants with DPN were included. All RCTs were assessed as unclear or high ROB. Few RCTs adequately reported methodology-related items and needling details according to Consolidated Standards of Reporting Trials (CONSORT) and Standards for Reporting Interventions in Controlled Trials of Acupuncture (STRICTA) statement. Medications injected at ST36 included conventional medications (11 RCTs) and Chinese herbal extracts (3 RCTs). The authors of this study did not perform any meta-analysis due to the heterogeneity of medications used for injections. Two individual RCTs favored ST36 injection in relieving pain compared with intramuscular injection of the same medication. For global symptom measured by Toronto clinical scoring system, one RCT showed that ST36 injection of Fufang Danggui was more effective than intramuscular injection of vitamin B12, two RCTs demonstrated that ST36 injection of mecobalamin or Danhong with cointervention was superior, while one RCT showed no significant differences between ST36 injection and intramuscular injection of mecobalamin. For improving nerve conduction velocity (NCV), three of four individual RCTs showed that ST36 injection was better than intramuscular or intravenous injection of the same medication, two RCTs favored ST36 injection with cointervention, and one RCT favored ST36 injection without cointervention. Four RCTs reported monitoring adverse events, all of which showed no significant difference between groups.
ConclusionsLimited evidence suggests that ST36 injection appears to be safe, and potentially effective in reducing pain score and improving NCV compared with intramuscular injection of the same medication. However, poor methodological and reporting quality reduced confidence in the findings. Rigorously designed and well-reported RCTs evaluating the effectiveness of ST36 injection for DPN are warranted.

1.2.4. TCM foot bath combined with acupoint massage

1.2.4.1. Fu 2020

Fu Q, Yang H, Zhang L, Liu Y, Li X, Dai M, Yang Y, Yang S, Xie Y, Liu Y, Fu L, Liu Z, Zhang Q. Traditional Chinese medicine foot bath combined with acupoint massage for the treatment of diabetic peripheral neuropathy: A systematic review and meta-analysis of 31 RCTs. Diabetes Metab Res Rev. 2020;36(2). [215726]. doi

ObjectiveIn this study, we aim to evaluate the efficiency and safety of traditional Chinese medicine foot bath combined with acupoint massage for the treatment of diabetic peripheral neuropathy.
MethodsA total of eight online databases were searched to collect studies published up to February 2019. Study quality of each included article was evaluated by the Cochrane Collaboration risk of bias tool. Systematic reviews and meta-analyses were conducted based on the Cochrane systematic review method by using the RevMan 5.3 software. Traditional Chinese medicine foot bath combined with acupoint massage was the main therapy in experimental group. Interventions in control groups include western medicine, oral traditional Chinese medicine, other symptomatic treatment of western medicine, and blank control. Primary outcomes in this study include sensory nerve conduction velocity (SNCV), motor nerve conduction velocity (MNCV), total effective rate, and neuropathic syndrome score.
ResultsFinally, 31 trials involving 3284 participants were included. The results of systematic reviews and meta-analyses showed that traditional Chinese medicine foot bath combined with acupoint massage was significantly better compared with the control groups in terms of the total effective rate, SNCV, MNCV, and neuropathic syndrome score. No case of adverse effect was reported.
Conclusions These findings show that traditional Chinese medicine foot bath combined with acupoint massage may be safer and more effective for the treatment of DPN. However, due to the low methodological quality, further research with randomized controlled trials (RCTs) of higher quality is required to prove its efficacy and better evidence for clinical treatment.

1.3. Specific outcome

1.4. Liu 2016 (nerve conduction velocity) ☆

Liu Ji-Qin, Ke Zong-Ping, Xie Dan-Dan, Ke Xing-Mei, Li Xue-Feng. [Influence of acupuncture-moxibustion on the peroneal nerve conduction velocity in type 2 diabetic peripheral neuropathy:a meta-analysis]. Shanghai Journal of Acupuncture and Moxibustion. 2016;35(1):105-110. [187054].

Objectives To systematically evaluate the influence of acupuncture-moxibustion on the peroneal nerve conduction velocity in type 2 diabetic peripheral neuropathy (DPN), and to provide clinical references for acupuncture-moxibustion treatment for DPN.
Methods By searching the CBM, CNKI, VIP, Wanfang, Pubmed, Springer and Medline databases, randomized controlled trials (RCT) of acupuncture-moxibustion for the type 2 DPN published from January 2000 to January 2014 were retrieved and the relevant data of the peroneal nerve conduction velocity were collected for methodological evaluation. RevMan 5. 1 software was adopted to conduct the meta-analysis.
Results Totally 10 RCTs were recruited with 685 cases involved, including 355 cases in the treatment group and 330 cases in the control group. The meta-analysis results indicated that acupuncture-moxibustion can produce a better effect in improving the motor nerve conduction velocity (MNCV) and sensory nerve conduction velocity (SNCV) of peroneal nerve in type 2 DPN than the treatments used in the control group, and the differences were statistically significant between the two groups [MD=3. 55, 95%CI (0. 79, 6. 31); MD=4. 10, 95%CI (0. 22, 7. 99)].
Conclusions Acupuncture-moxibustion can improve the peroneal nerve conduction velocity in type 2 DPN, and thus is worth application in clinic. Due to the limitation of the included studies, such as small sample size and low quality of the articles and high probability of bias, RCTs of large sample size and high quality are required to confirm the above conclusions.

2. Overviews of of systematic reviews

2.1. Fan 2021

Fan Wei-jingLiang Shi-bing Liu Guo-bin. Review of systematic reviews of acupuncture for diabetic peripheral neuropathy. Journal of Acupuncture and Tuina Science. 2021;19(2):95 - 103. [218462]. doi

Objective To review the systematic reviews of acupuncture for diabetic peripheral neuropathy (DPN) and to provide evidence for clinical decisions.
Methods Published systematic reviews targeting acupuncture treatment of DPN were searched using computer through both Chinese and English databases till July 1, 2019. Two researchers screened the papers based on inclusion and exclusion criteria and conducted report quality evaluation, methodological quality assessment and evidence quality grading using the preferred reporting items for systematic reviews and meta-analyses (PRISMA), assessment of multiple systematic review 2 (AMSTAR 2) and grading of recommendations assessment, development and evaluation (GRADE).
Results Ten systematic reviews were included, involving 11 outcome measures. According to PRISMA, 6 items were sufficiently reported while 1 item was not; AMSTAR 2 appraised that all the included systematic reviews were of low quality in the methodological evaluation; according to GRADE, of the 30 clinical evidences, only 5 were graded moderate while the remained were graded low or extremely low. Descriptive analysis showed that acupuncture can significantly improve DPN symptoms, accelerate the conduction velocities of sensory and motor nerves, and up-regulate the content of plasma nitric oxide (NO), while the adverse reaction rate was low.
Conclusion Acupuncture can produce satisfactory clinical efficacy in treating DPN, but the existing problems, such as low-quality evidence, unitary outcome measures, poor methodological quality of systematic reviews and nonstandard reporting, need to be treated cautiously; meanwhile, more high-quality clinical trials are required to elevate the level of evidence.

2.2. Lin 2021

Lin T, Huang F, Zhao S, Qiu M, Wen J, Liu M. Acupuncture for diabetic peripheral neuropathy: An overview of systematic reviews. Complement Ther Clin Pract. 2021. [218678]. doi

Background Acupuncture has been widely used to treat diabetic peripheral neuropathy (DPN) in China as a complementary and alternative therapy. This study aims to summarize the characteristics and evaluate the methodology quality of the systematic reviews (SRs) regarding acupuncture for DPN.
Methods A comprehensive literature search was performed from inception to February 2020. We assessed the methodological quality of the included SRs with the Assessment of Multiple Systematic Reviews 2 (AMSTAR 2) tool, adopted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist to evaluate the reporting characteristics of included SRs, and utilized the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to evaluate the quality of evidence for outcomes including total effective rate, sensory nerve conduction velocity, motor nerve conduction velocity and adverse events. One-way analysis of variance and multiple linear regression were conducted to evaluate the associations between characteristics and two index scores (PRISMA and AMSTAR 2).
Results Eighteen SRs were included in this overview. The methodology quality of the included SRs ranged from very low to high. Only protocol registration and funding source reported were associated with the AMSTAR 2 index scores, while no variable showed significant difference in the PRISMA scores. The overall quality of evidence in included SRs ranged from “very low” to “moderate”.
Conclusion This overview suggested beneficial effects of acupuncture on DPN, whereas the results should be interpreted with cautious owing to methodology flaws, providing reference for further improvement of the study design.

3. Clinical Practice Guidelines

⊕ positive recommendation (regardless of the level of evidence reported)
Ø negative recommendation (or lack of evidence)

3.1. Michigan medicine. University of Michigan 2017 ⊕

Management of Type 2 Diabetes Mellitus. Guidelines for Clinical Care Ambulatory. Michigan medicine. University of Michigan. 2017:33P. [197536].

Acupuncture and TENS. Several studies have shown the efficacy of using traditional acupuncture for the treatment of painful diabetic neuropathy. Transcutaneous Electrical Nerve Stimulation (TENS) has also been evaluated and has been shown to reduce lower extremity pain associated with PDN.

3.2. American Academy of Neurology et al (AAN, USA) 2011 Ø

Bril V , England J, Franklin GM, Backonja M, Cohen J, Del Toro D, Feldman E, Iverson DJ, Perkins B, Russell JW, Zochodne D; American Academy of Neurology et al. Evidence-based guideline: Treatment of painful diabetic neuropathy: report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology. 2011;76(20):1758-65. [192689]. .

Other interventions such as exercise and acupuncture do not have any evidence for efficacy in treating PDN.