Abstract
Background:
Painful peripheral neuropathy is a condition that may be associated with diabetes as well as other causes of neuropathy. Common treatments for the pain include topical application of capsaicin as well as using oral medications, typically gabapentin. The results are variable and rarely provide substantial lasting relief.
Cases:
This report describes how a simple and easy to perform acupuncture technique—interosseous membrane stimulation—was used to treat painful neuropathy in 3 patients: 1 with painful diabetic neuropathy; 1 with idiopathic painful neuropathy; and 1 with painful neuropathy caused by exposure to Agent Orange while serving in Vietnam.
Results:
The 3 patients had much relief from the pain associated with their neuropathy for several weeks at a time. With regular treatments, sustained relief was obtained any without the addition of new medication.
Conclusions:
Interosseous membrane stimulation is safe, simple, and effective for treatment of painful neuropathy. This treatment should be considered for patients who are suffering with painful neuropathy.
INTRODUCTION
Peripheral Neuropathy occurs in ∼ 50% of patients suffering from diabetes. 1 Pain from neuropathy can be debilitating. There is no reliably effective treatment that is specific for relieving the discomfort. Multiple other potential etiologies of painful neuropathy include alcohol use; nutritional factors; exposure to chemotherapy; and inflammatory, hereditary, metabolic, and autoimmune diseases. In the Veterans Administration (VA) population, patients who were exposed to Agent Orange in Vietnam may suffer with painful neuropathy that develops later in life. 2 Most medications that are used to treat painful neuropathy symptoms take weeks to adjust and may have side-effects, including sedation and weight gain. This article describes the authors' experience in treating painful neuropathy with interosseous membrane stimulation resulting in prompt relief with benefits that typically last for weeks.
METHODOLOGY
Stimulation of the interosseous membrane between the long bones in the forearm or leg can produce relief of neuropathic pain in the distal extremities. In the following 3 cases dealing with painful feet, 0.3 × 75-mm Hwato needles were placed bilaterally between the lateral border of the anterior tibialis muscle and the medial border of the extensor digitorum longus muscle approximately at the level of ST-37. Needles were advanced to a depth of ∼25–35 mm until the tip was felt to pierce the interosseous membrane. The exposed length of the needles were manually activated by repeated flicking or strumming with the intent of creating a response in the interosseous membrane. Shallow needle placement was not felt sufficient to stimulate the autonomic nerve endings supplying the interosseous membrane. In addition, needles at a shallow depth would not have remained in place during the vigorous stimulation. Electroacupuncture and laser acupuncture were not used as parts of the treatments.
Following a few minutes of stimulation, the patient typically experienced a warmth around the tip of the needle or a pleasant or “floating “sensation associated with a resolution of the discomfort. During another few minutes, this sensation migrated distally over the extremity, eventually encompassing the digits. The treatment time was usually 10 minutes or less. Patients did not experience an aching or tingling De Qi sensation. Propagation of the response involved all of the extremities distal to the site of stimulation and was not limited to nearby meridians.
THREE CASES: TREATMENTS AND RESULTS
Case 1
A 73-year-old man with a diagnosis of painful diabetic neuropathy presented to the clinic in 2021. He had been diagnosed in 2006 with prediabetes when he presented with tingling in the distal extremities. No other causes of peripheral neuropathy were found. He described the dysesthesias as a burning sensation that was worse in his feet than in his hands and being most painful at night. Gabapentin was started in 2008 and, after several years, switched to pregabalin in an attempt to control his discomfort. Battlefield Acupuncture in 2021 reduced his pain for ∼3 days. In September of 2021 he was treated with interosseous membrane stimulation for the first time. He had complete relief from his burning dysesthesias for ∼4 weeks.
Since then, he had 6 more treatments at ∼8-week intervals with the most dramatic pain relief lasting 4–6 weeks, and, overall, a general reduction of his level of pain over time from 6/10 to 2/10. He consistently reported a warm feeling spreading over his feet during the treatment Although after 2 treatments he did not notice much change in his pain level at the time of treatment, his wife reported that he always slept more peacefully at night for 4 weeks or more after a treatment, and that, to her, he appeared to be in less pain. The patient has confirmed repeatedly that he feels so much better after treatments that he does not want to stop his every 6–8-week visits.
Case 2
A 73-year-old man presented in 2016 after attending another facility for several years with a diagnosis of idiopathic painful neuropathy. He described having relentless numbness, tingling feet with repeated electric shock–like sensations throughout the day that were worse at night. Although he was a Vietnam veteran, he had no history of Agent Orange exposure. He did, however, relate sustaining a nonfreezing cold injury, Trench Foot,3,4 relating that the numbness in his feet began during his service with a “bad case of foot rot. … they were infected, and [caregivers] told me to soak my feet in Clorox.” He was treated with multiple drug regimens for pain relief, including 150 mg t.i.d. of pregabalin and 50 mg b.i.d. of tramadol.
In 2018, this patient was referred from another neurology provider in the clinic to try acupuncture for pain control. Interosseous membrane stimulation was performed in 2018, and the patient reported that, by the end of the first treatment, his feet felt “like they were in heaven.” He had no pain or a tolerable amount of pain for several weeks after each treatment session. Over the last 4 years, he has returned an average every 4–6 weeks for more than 40 treatments.
Case 3
A 75-year-old man, with a documented history of Agent Orange exposure in 1967 while he was serving in Vietnam, developed burning paresthesia in both feet in 2011. Electromyography/nerve conduction velocity testing in 2012 revealed evidence of moderate sensory polyneuropathy. Work-up for treatable causes of neuropathy included laboratory studies for vitamins B6 and B12; thyroid, serum protein electrophoresis, and antinuclear antibody panels; and a sensory–motor neuropathy panel. The findings were all were normal. Medications used to treat him included 600 mg t.i.d. of gabapentin, which gave him some relief, as did 60 mg/day of duloxetine. However, 150 mg b.i.d. of pregabalin was not effective.
Prior to acupuncture treatment, he experienced constant pain at a level 5/10 and intermittently had bouts of “screaming pain.” Treatment with interosseous membrane stimulation consistently reduced his pain from 5/10 to 0/10 the day of treatment and provided sustained relief of ≤2/10 for up to 2 months. By the end of 2021, he had been treated 12 times and his painful peripheral neuropathy seemed to be in remission. In February of 2022, the patient's discomfort recurred, but now he is comfortable with a treatment every 3 months.
DISCUSSION
During interosseous membrane stimulation treatment, patients describe some variation of a wave of spreading “warmth,” associated with a “pleasant feeling,” or a “floating feeling” that replaces their discomfort. The sensation of warmth suggests an increase of blood flow in the affected limb. Autonomic innervation of tendons, ligaments, and joint capsules was described in 2001 by Ackermann et al. 5 Sensory nerve endings have been found throughout the interosseous membrane of the forearm, a structure like the interosseous membrane of the leg. The interosseous membrane has large sensory fibers with encapsulated endings specialized for detecting vibration and pressure. 6 The control of blood flow to the extremities is a complex process. Spinal and supraspinal control have been identified as well as the presence of a local sympathetic veno–arteriolar axon reflex. 7
The authors postulate that stimulation of the interosseous membrane during the described treatment results in a discharge from autonomic fibers embedded in the interosseous membrane fibers resulting in a local increase of blood flow. This might be studied further by use of infrared skin-temperature measurements or thermographic imaging of the distal extremity before and after treatment. Regarding the long-lasting response to interosseous membrane stimulation, the authors conjecture that this effect may be the result of a decrease in inflammatory factors mediated by a cholinergic anti-inflammatory response.8–12 The actual role of the interosseous membrane could be investigated further by doing a control study using shallower needle placement or laser acupuncture stimulation. The time interval between treatments of the 3 cases reported was determined by each patient's individual need. The authors plan a larger study involving more patients during which the optimum time interval between treatments may also be evaluated.
CONCLUSIONS
Interosseous membrane stimulation is an acupuncture treatment that is easy to perform in just a few minutes. With further rigorous study, the authors hope that the treatment described herein will prove to be an effective and inexpensive acupuncture technique that can provide pain relief for patients with painful peripheral neuropathy from a variety of causes.
Footnotes
AUTHOR DISCLOSURE STATEMENT
No financial conflicts of interest exist.
FUNDING INFORMATION
No funding was received for this article.