Ayurvedic Management of Diabetic Complications - A Case Report

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© 2023 P. Suparya Subash and P. V. Giri. This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY NC ND) ( https://creativecommons.org/licenses/by/4.0/ ) CASE REPORT Ayurvedic Management of Diabetic Complications - A Case Report P. Suparya Subash 1 * , P. V. Giri 2 1 Senior Research Fellow, Vaidyaratnam Ayurveda College, Thrissur, Kerala, India 2 Professor, Department of Kayachikitsa, Vaidyaratnam Ayurveda College, Thrissur, Kerala, India ABSTRACT Diabetes mellitus can fall under Prameha in Ayurveda . Long-standing Prameha leads to several complications. Some of the subsequent complications of diabetes mellitus are diabetic osteomyelitis, charcot foot, peripheral neuropathy, diabetic ulcer, periarticular arthritis, etc. This case will be discussing a patient who had some of the above complications. Diabetic complications were badly affecting his day-to-day activities. Hence, the treatment was mainly focused on reducing his symptoms. 73-year-old upper-middle-class man resided at Vijayawada for the past 70 years and worked as a businessman (egg cellar) for 50 years there, admitted to Vaidyaratnam Ayurveda College hospital on 2020 January 21 st , presented with numbness of both upper limbs and lower limbs and difficulty in walking for the past 2 years and difficulty to raise left upper limb for the past 1 year. The case was diagnosed as Prameha Upadrava . Accordingly, the basic Ayurvedic principles were used for the treatment. Along with internal medicines, Rookshana, Snehana, Swedana, Sodhana, Rasayana, and Samana therapies were also administered. After 47 days of treatment, he was able to walk without moving to one side like he used to. He was also relieved of tremors and the numbness had begun subsiding. His left shoulder joint flexion and abduction were possible up to 120*. This case categorically emphasizes the need for positively constructive and effective results if two systems of medicine go hand in hand at different stages of treatment to achieve optimum healing of the patient. This case also tells us the importance and effectiveness of Rasayana therapy in Prameha . 1. INTRODUCTION Type 2 diabetes mellitus is a chronic metabolic disorder in which prevalence has been increasing steadily all over the world [1] It is assessed that in 2011, 366 million people had diabetes mellitus; by 2030, this would have risen to 552 million [2] In every country, the number of people with type 2 diabetes mellitus is increasing with 80% of people living in lowand middle-income countries [1] As a result of lifestyle and environmental risk factors, the incidence of type 2 diabetes mellitus fluctuates substantially from one geographical region to the other [3] Type 2 diabetes mellitus is due primarily to genetics and lifestyle factors [4] In the development of type 2 diabetes mellitus, several lifestyle factors are known to be important; these are physical inactivity, sedentary lifestyle, cigarette smoking, and generous consumption of alcohol [5] Obesity has also been found to contribute to approximately 55% of cases of type 2 diabetes mellitus [6] Some of the subsequent complications of diabetes mellitus are diabetic osteomyelitis, charcot foot, diabetic peripheral neuropathy, diabetic ulcer, Corresponding Author: Dr. Suparya Subash P, Sreeprasadam, 4 th Street, Ragamalikapuram, PO Poothole, Thrissur - 680 004, Kerala, India. Email: suparya@gmail.com periarticular arthritis, etc. Diabetic neuropathy is a common disease and is defined as signs and symptoms of peripheral nerve dysfunction are associated with diabetes mellitus in patients and in whom other causes of peripheral nerve dysfunction have been excluded [7] Diabetes neuropathy is a relatively early and common complication affecting approximately 30% of diabetes patients [8] There is a higher prevalence of diabetes mellitus in India (4.3%) [9] Probably Asian Indians are more prone to insulin resistance and cardiovascular mortality [10] The incidence of diabetic neuropathy in India is not well known, but in a study from South India, 19.1% of type II diabetic patients had peripheral neuropathy [11] The invention of insulin and hypoglycemic medicines have done a great service in the management of diabetes mellitus, but these patients are not getting a proper solution for their neuropathic complications [12] Diabetes mellitus can fall under Prameha in Ayurveda . Longstanding Prameha leads to several complications. This case will be discussing a patient who had some of these complications. Diabetic complications were badly affecting his day-to-day activities. Hence, the treatment was mainly focused on reducing his symptoms. Internally, Kaphamedhokara, Agni Deepana, and Bala Vardhaka medicines were administered. Kriyakramas such as Dhanyamla Dhara, Rasayana therapy, and Thakradhara were also administered International Research Journal of Ayurveda & Yoga Vol. 6(9), pp. 15-20, September, 2023 Available online at http://irjay.com ISSN: 2581-785 X DOI: 10.47223/IRJAY.2023.6903 ARTICLE INFO Article history : Received on: 02-08-2023 Accepted on: 17-09-2023 Available online: 30-09-2023 Key words : Diabetic peripheral neuropathy, Periarticular arthritis, Prameha upadrava , Rasayana therapy, Thakradhara

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Subash and Giri: Diabetic Complications Managment in Ayurveda 2023; 6(9):15-20 16 2. CASE HISTORY This is a known case of type 2 diabetes mellitus patient for the past 10 years, hypertension and dyslipidemia for the past 2 years, amputation was done on his right 2 nd toe 2 years back, and was left with a painful ulcer on the dorsal aspect of the foot. After that, he felt gait imbalance and tremors. Gradually, he noticed a decreased sensation in both lower limbs, numbness of both upper limbs and lower limbs, especially on the sole of foot and fingers of both hands, difficulty in buttoning shirts, and difficulty in flexion of fingers. The symptoms were persistent and had no effect on diurnal variation or temperature variations. 1 year back, he also noticed a restricted and painful movement of his left shoulder. He was under allopathic medication for the past 2 years and his diabetes mellitus is under control. However, he did not get any symptomatic relief 2.1. Personal History Everyday, he used to consume cooked fish (live in stagnant water), curd and sweets, and mutton every Sunday (for the past 2 years, he is a vegetarian), his appetite was altered, bowel movements were not satisfactory, and only had a frequency of 3 times a week along with hard consistency, micturition 4–5/day, 2–3/night, sleep was disturbed due to numbness. He had a habit of alcohol (2 peg) intake and puff a cigar occasionally. Systemic hypertension was present. There is no known history of diabetic mellitus in the family. However, his father and brother passed away due to myocardial infarction 2.2. Treatment History At the time of admission, he was taking Esogress D tab, Nebivolol 5 mg., Teneligliptin 20 mg & metformin hydrochloride 1000 mg tab, Progynova - NT, Cilostazone 50 mg, Ecospirin 75 mg, Atoder. 20 mg, Telmisartan 40 mg, Alprazolam, Inj. humstard 30/70 32-unit 30 unit. Ayurvedic treatment is given along with these medications 2.3. General Examination His vitals were within normal limits. Antalgic gait with moderate built. pallor, icterus, cyanosis, and lymphadenopathy were absent. Height was 164 cm, weight was 77 Kg, and BMI was 28.62 kg/m 2 . Dorsalis pedis pulse and posterior tibial pulse were elicited, and right dorsalis pedis pulse was prominent 2.4. Systemic Examination 2.4.1. Nervous system examination Appearance and behavior were neat, well dressed, and cooperative; the emotional state was pleasant, oriented to time, date, person; and general intelligence was intact. There was no wasting of muscles. Softtouch sensation, pain sensation, cold touch sensation, and vibration perception were intact in both upper limbs. A hot touch sensation was absent in the right palm of dermatomes C 6, C 7, and C 8. The soft-touch sensation was absent in L 4, S 2 of the left foot, and L 5 of the right foot. Cold and hot touch sensations and pain sensations were absent up to the middle of both forelegs. The hot perception was absent in L 5 of the right lower limb. Vibration perception was absent in both lower limbs. Proprioception was impaired and graphesthesia was partially impaired. NORFOLK QOL DN [13] was calculated as 107 2.4.2. Locomotory system examination Periarticular arthritis on the left shoulder joint (flexion and abduction possible up to 90* - measured using a goniometer, Apley Scratch test was positive with negative drop arm test and negative pain arch syndrome) 2.4.3. Integumentary system examination Diabetic dermopathy and absence of hairs in both lower limbs were noticed. Diabetic foot (painful ulcer with 1.45*2.15 cm on the dorsal aspect of the right foot beneath to 3 rd toe) and onychomycosis were present 2.5. Diagnostic Assessment Investigations include blood routine, FBS, PPBS, Hb 1 AC, and urine routine were seen within normal limits. He is Kapha Pitha in Prakriti. Vyana Vayu, Samana Vayu, Apana Vayu, Pachaka Pitha, Brachaka Pitha, Ranjaka Pitha, Kledaka Kapha, Sleshma Kapha, Rakta, Mamsa, Meda, and Asthi Dhatu Snayu and Nakha Upadhatus, Medho Vaha, Asthi Vaha, and Mamsa Vaha Srotas were vitiated. Udakavaha and Mutravaha Srotas are involved from the initial stage of Prameha itself. Rogamarga is Madhyama and the prognosis is Yapya. Nidanas are detailed in the discussion. The case was diagnosed as Prameha Upadrava (complications mainly including peripheral neuropathy, periarticular arthritis, and diabetes ulcer) 2.6. Thérapeutique Intervention Treatment was planned mainly focusing on reducing his clinical features (prime importance given to the Upadrava Vyadhi ). It is after assessing the Bala and Agni of this person, the treatment was started Internal medicines [Table 1] were stopped during rest (13 February 2020 and 25/26 February 2020), Snehapana, Sodhana, and Rasayana therapy. Externally [Table 2], Dhanyamla Dhara planned for Samyak rookshana and it was attained in 14 days. Snehapana was administered with Dhanwantharam Ghritam , and the dosage was increased in succeeding days [Table 3] and stopped when Samyak Snigdha was reached. Followed by Snehana, Abhyanga steam and after proper Sodhana, Rasayana [Table 4] was given. Finally, Thakradhara was administered (Abhyangam was done with Prabhanjana Vimardana Thailam and Siroabhyangam with Nisosiradi Thailam ) 3. RESULTS After the treatment, NORFOLK QOL DN was calculated as 70. His tremors subsided completely. He was able to walk without moving to one side. Even though the difficulty in flexion of fingers of both upper limbs persists, there is also improvement in left shoulder joint movements (flexion and abduction before treatment 90*, after treatment 120*). His symptoms such as numbness get reduced and his sleep becomes normal. A comparison between before and after treatment is given in Tables 5 and 6 4. DISCUSSION For the past 70 years, he had the habit of Sthira Thoya Matsya (cooked), curd, and sweet intake on almost all days. Sthira Thoya Matsya is Guru in nature, the curd is Guru and Kaphamedokara, [14] and Madhura is Kapha Vardhaka [15] This particular Nidana Seva can aggravate Kapha Dosha . As the Kapha has Mandha property, [16] it will take a relatively long time for the pathogenesis process. Maybe due to the seasonal changes or something that impart Vidhaha to the body, Pitha Dosha may also get vitiated, and thus, Poorvarupas of Prameha could have been produced. If Jatharagni in the Koshta gets aggravated, it will lead to the elevation of Vata and as a result, Prameha Lakshanas were also seen in the body. As Kapha is Medoasryam and since it is also situated between Mamsa and Medas , the Kapha vitiation may lead to the diminution of Dhatwagni. Even after the manifestation of the diseases, if Nidanas

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Subash and Giri: Diabetic Complications Managment in Ayurveda 2023; 6(9):15-20 17 effective results if two systems of medicine go hand at different stages of treatment to achieve optimum healing of the patient 6. ACKNOWLEDGMENTS Nil 7. AUTHORS’ CONTRIBUTIONS All the authors contributed equally in design and execution of the article 8. FUNDING Nil 9. ETHICAL APPROVALS This study not required ethical clearance as it is case study 10. CONFLICTS OF INTEREST Nil 11. DATA AVAIBALITY This is an original manuscript and all data are available for only review purposes from principal investigators 12. PUBLISHERS NOTE This journal remains neutral with regard to jurisdictional claims in published institutional affiliation REFERENCES 1. Olokoba AB, Obateru OA, Olokoba LB. Type 2 diabetes mellitus: A review of current trends. Oman Med J 2012;27:269-73 2. IDF Diabetes Atlas. 9 th ed; 2019. Available from: https://diabetesatlas org/en [Last accessed on 2020 Sep 30] 3. Zimmet P, Alberti KG, Shaw J. Global and societal implications of the diabetes epidemic. Nature 2001;414:782-7 4. Ripsin CM, Kang H, Urban RJ. Management of blood glucose in Type 2 diabetes mellitus. Am Fam Physician 2009;79:29-36 5. Hu FB, Manson JE, Stampfer MJ, Colditz G, Liu S, Solomon CG, et al . Diet, lifestyle, and the risk of Type 2 diabetes mellitus in women. N Engl J Med 2001;345:790-7 6. Centers for Disease Control and Prevention (CDC). Prevalence of overweight and obesity among adults with diagnosed diabetes- -United States, 1988–1994 and 1999–2002. MMWR Morb Mortal Wkly Rep 2004;53:1066-8 7. Bansal V, Kalita J, Misra UK. Diabetic neuropathy. Postgrad Med J 2006;82:95-100 8. Davidson S. Davidson’s Principles and Practice of Medicine. 20 th ed. Amsterdam: Elsevier Publication; 2006. p. 843 9. Sadikot SM, Nigam A, Das S, Bajaj S, Zargar AH, Prasannakumar KM, et al . The burden of diabetes and impaired glucose tolerance in India using the WHO 1999 criteria: Prevalence of diabetes in India study (PODIS). Diabetes Res Clin Pract 2004;66:301-7 10. Bajaj M, Banerji MA. Type 2 diabetes in South Asians: A pathophysiologic focus on the Asian-Indian epidemic. Curr Diab Rep 2004;4:213-8 11. Ashok S, Ramu M, Deepa R, Mohan V. Prevalence of neuropathy in Type 2 diabetic patients attending a diabetes centre in South India. J Assoc Physicians India 2002;50:546-50 are continued, there is a chance for Vatha to get Avarana by Kapha and Pitha. This long-standing pathogenesis weakens the Jatharagni and ama is produced as a result. At the same time, it may severely affect the functioning of the Medhodhatwagni. Snayu (Upadhathu of Medas , [17] produced by Khara Paka of Sneha portion of Medhas [18] ) also gets vitiated and thus produces Upadhathu Pradhoshaka Vikaras such as Supthi, Sthamba, and Sankocha . Depending on disease progression, succeeding Dhatus may get vitiated Basic Ayurvedic principles were applied in the treatment. That is Rookshana, Snehana, Swedana, Sodhana, Rasayana, and Samana therapies were administered, respectively. Initially, Dhanyamla Dhara was used. Dhanyamla is Seetha in Sparsa [19] It helps to establish the normalcy of digestive fire and corrects metabolism, destroys Ama and hence removes the block from the body tissues, promotes nourishment, helps in cleansing channels of the body, removes excess fat from the body, improves blood circulation, and helps in the Significant reduction of subcutaneous fat. The therapy is very effective in Kapha-Vata’s predominant conditions. It helps in compacting obesity, reducing inflammation, and activates nerves [20] Dhanyamla can help provide nutrients to nerve fibers and can help treat signs and symptoms of diabetic neuropathy [21] Dhanwantharam Ghritam was used for Snehapana , [22] then Swedana (for Abhyanga Vatahara Taila ), and Sodhana were done, respectively. Rasayana therapy administered to those whose body has not been purified becomes useless, just like coloring a dirty cloth [23] Hence, Shilajatu Rasayana was given after the Sodhana. Shilajatu Bhavana (7 times) was done with a decoction of the proper drug suitable for the disease [24] Nisakathakadi Kashayam was used as Bhavana Dravya as it is indicated in Prameha . Next, he was made to consume ghee prepared with drugs of a bitter taste, for 3 days; then he should consume Silajathu with the decoction of Triphala, Patola , and Madhuka , for 3 days (each one separately and one succeeding day) [25] It has Kashaya Tikta rasas, Sheeta virya, TridoshAhara, Vrishya, Balya, Mutrala, Lekhana, Yogavahi, and Rasayana properties [26] Thakradhara produces a coolant effect on the brain and the whole nervous system and hence releases the stress and anxiety of our mind; when all these are relaxed, the body functions including the heart functions take place in a relaxed manner, the circulation of blood, and nutrients correctly take place, the peripheral resistance is reduced, the channels of the body open up and the cells start flushing the toxins and overall metabolism gets improved [12] Internally, Varanadi Kashayam was used due to its Kapha Medhohara and Agni Deepthi properties [27] For Vyadhikshamatham, Indukantham Kashaya was given. Vyoshadi Guggulu also has Kaphamedhohara as well as Vatahara properties [28] Kapikachu has antioxidant activity and is used in the management of nervous disorders [29] After 47 days of treatment, he was able to walk without moving to one side like he used to. He was also relieved of tremors and the numbness had begun subsiding. His left shoulder joint flexion and abduction were possible up to 120*. Difficulty in flexion of fingers of both upper limbs persists 4.1. Limitation Multiple therapeutic interventions contributed to the patient’s outcome 5. CONCLUSION Shilajatu Rasayana is highly effective in diabetic complications. This case categorically emphasizes the need for positively constructive and

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Subash and Giri: Diabetic Complications Managment in Ayurveda 2023; 6(9):15-20 18 12. Chaurasia SV, Bhat PK, Ramachandra KR. Effect of ayurvedic therapy in the management of lower limb complications related to diabetes mellitus - a case study. J Ayurveda Integr Med Sci 2016;1:102-7 13. Vinik EJ, Hayes RP, Oglesby A, Bastyr E, Barlow P, Ford-Molvik SL, et al. The Development and validation of the Norfolk QOL-DN, a new measure of patients’ perception of the effects of diabetes and diabetic neuropathy. Diabetes Technol Ther 2005;7:497-508 14. Tripathi B. Ashtanga Hridayam Vagbhata. 3 rd ed., Vol. Suthrasthanam. Ch. 5/34. Mannuthypo, Thrissur: Publication Department Harisree Hospital; 2011. p. 122 15. Tripathi B. Ashtanga Hridayam Vagbhata. 3 rd ed. Vol. Suthrasthanam. Ch. 10/9. Mannuthypo, Thrissur: Publication Department Harisree Hospital; 2011. p. 251 16. Tripathi B. Ashtanga Hridayam Vagbhata. 3 rd ed. Vol. Suthrasthanam. Ch.1/12. Mannuthypo, Thrissur: Publication Department Harisree Hospital; 2011. p. 37 17. Acharya YT. Charaka Samhita. Vol. 4. Chikitsastanam 15/17. Varanasi: Chowkhamba Sanskrit Series Office; 2015. p. 14 18. Murthy KR. Illustrated Suhsruta Samhita. Vol. 1 Sutra Sthanam. Ch. 45/215. Varanasi: Chaukhambha Orientalia; 2016. p. 60 19. Shastri AD. Suhsruta Samhita. Vol. 1 Sutra Sthanam. Ch. 45/215. Varanasi: Chaukhambha Sanskrit Sansthan; 2016 20. Vandana C, Srivastava AK, Gusain M, Priyanka. Efficacy of dhanyamla sarvanga dhara in the management of obesity: An analytical review. Int J Ayurveda Pharma Res 2008;6:82 21. Mishra A, Sanakal AI, Prashanth AS. A comparative clinical study to assess the effect of dhanyamla dhara and dashmoola kashaya dhara in signs and symptoms of diabetic sensory neuropathy. Int Ayurvedic Med J 2020;8:6 22. Tripathi B. Vagbhata’s Ashtanga Hridayam. Reprinted, 2012. Vol. 2. Chikitsa Sthanam. Ch. 7/19-24. Varanasi, Mannuthypo, Thrissur: Choukhamba Press; 2012. p. 386 23. Tripathi B. Vagbhata’s Ashtanga Hridayam. 6 th ed., Vol. 3. Uthara Sthanam. Ch. 39/4. Varanasi; Mannuthypo, Thrissur: Choukhamba Press; 2012. p. 381 24. Tripathi B. Vagbhata’s Ashtanga Hridayam. 6 th ed., Vol. 3. Uthara Sthanam. Ch. 39/133. Varanasi, Mannuthypo, Thrissur: Choukhamba Press; 2012. p. 403 25. Tripathi B. Vagbhata’s Ashtanga Hridayam. 6 th ed., Vol. 3. Uthara Sthanam. Ch. 39/136-138. Varanasi: Mannuthypo, Thrissur: Choukhamba Press; 2012. p. 404 26. Shastri K, Upadhyay Y, et al. Charaka Samhita. Sutra Sthana 17/117- 118. Varanasi: Chowkhamba Sanskrit Series; 1998. p. 366 27. Tripathi B. Ashtanga Hridayam Vagbhata. 3 rd ed., Suthra Sthanam. Ch. 15/22. Mannuthypo, Thrissur: Publication Department Harisree Hospital; 2011. p. 356 28. Tripathi B. Vagbhata’s Ashtanga Hridayam. 6 th ed., Vol. 2. Chikitsa Sthanam. Ch. 21/50. Varanasi, Mannuthypo, Thrissur: Choukhamba Press; 2012. p. 506 29. Phytochemistry and Pharmacological Activity of Mucuna pruriens: A Review. ResearchGate. Available from: https://www.researchgate net/publication/317304163_phytochemistry_and_pharmacological_ activity_of_mucuna_pru [Last accessed on 2020 Sep 25] How to cite this article : Subash PS, Giri PV. Ayurvedic Management of Diabetic Complications - A Case Report. IRJAY. [online] 2023; 2023;6(9);15-20 Available from : https://irjay.com DOI link- https://doi.org/10.47223/IRJAY.2023.6903

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Subash and Giri: Diabetic Complications Managment in Ayurveda 2023; 6(9):15-20 19 Table 1: Internal medicines Medicines Dosage Time Varanadi Kashayam and Indukantham Kashayam 15 ml+45 ml hot water 6 am, 6 pm Vyoshadi Guggulu 1-0-1 With Kashayam Gandharvahastadi Kashayam 15 ml+45 ml hot water as Pathi kashayam Kapikachu Choornam 15 g with milk After food, 2 times a day Brihat Triphala Choornam 15 g with hot water At night, If constipation Table 2: Kriyakrama Date Procedure Medicines 22 January 2020– 4 February 2020 Dhanyamla Dhara Dhanyamla 5 February 2020– 9 February 2020 Snehapanam Dhanwantharam Ghritam and (10 drops) Dhanwantharam Thailam 101(A) 10 February 2020 and 11 February 2020 Abhyanga steam Prabhanjana Vimardanam Thailam 11 February 2020 and 12 February 2020 Virechanam Gandharvahastadi Thailam 14 February 2020– 25 February 2020 Rasayana Seva Shilajatu 27 February 2020– 04 February 2020 Thakradhara Along with Panchagandha Choornam Abhyangam Prabhanjana Vimardanam Thailam Shiro Abhyangam Nisosiradi Thailam Table 3: Day-wise Dhanwantharam Ghritam dosage Date Dosage 05 February 2020 25 ml 06 February 2020 50 ml 07 February 2020 100 ml 08 February 2020 150 ml 09 February 2020 200 ml Table 4: Rasayana therapy Date Medicine 14 February 2020–16 February 2020 Gulguluthikthaka Ghrita 25 ml at 6 am 17 February 2020–19 February 2020 12 g Shilajatu * with 60 ml Triphala Kwatha at 6 am 20 February 2020–22 February 2020 12 g Shilajatu * with 60 ml Padola Kwatha at 6 am 23 February 2020–25 February 2020 12 g Shilajatu * with 60 ml Madhuka Kwatha at 6 am * Shilajatu triturated 7 times in Nisakathakadi Kashayam

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Subash and Giri: Diabetic Complications Managment in Ayurveda 2023; 6(9):15-20 20 Table 5: Diabetic neuropathy symptom score Symptoms Before treatment After treatment Scoring Unsteadiness on walking 1 0 1=Present 0=Absent Numbness 1 1 1=Present 0=Absent Burning, aching pain, tenderness in legs or feet 1 0 1=Present 0=Absent Pricking sensation 1 0 1=Present 0=Absent Total 4 2 Table 6: Toronto clinical scoring system Symptom score Before treatment After treatment Scoring Pain 1 0 0=Absent, 1=Present Numbness 1 1 0=Absent, 1=Present Tingling 1 0 0=Absent, 1=Present Weakness 0 0 0=Absent, 1=Present Ataxia 1 0 0=Absent, 1=Present Reflex score 0=Normal, 1=Reduced, 2=Absent Knee reflex right 0 0 Knee reflex left 0 0 Ankle reflex right 0 0 Ankle reflex left 0 0 Sensory test score 0=Normal, 1=Abnormal Pinprick 1 0 Temperature 1 1 Light touch 1 1 Vibration sense 1 1 Position sense 1 1 Total score 9 (moderate DPN) 5 (mild DPN) DPN: Diabetic peripheral neuropathy

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