There have been two systematic reviews of acupuncture in general neurology [10, 11]; both reports have concluded that the studies included showed no definitive data on the use of acupuncture for MS, although there might be a positive influence on the secondary symptoms. However, Hopwood & White [12] advise caution in reading systematic reviews, stating the review quality and conclusions depend on the research work included, mentioning in particular the difficulties facing researchers in adequately controlling acupuncture trials. Some qualitative work, including that by Pucci et al. [13], indicates that the use of acupuncture by MS patients is quite high and 61.5% of the patients interviewed in the Pucci study claimed that acupuncture was beneficial.

Acupuncture has been found to have a consistently beneficial effect on insomnia, although the quality of studies has been variable [14]. Auricular acupuncture for insomnia has also been investigated [15], offering moderately positive evidence for acupuncture. The auricular points used were mainly in the helix so could indeed have affected the parasympathetic nervous system and thus provided a calming effect. These were not investigations specific to MS but they are relevant.

A recent review of the use of complementary therapies in MS included acupuncture [16] and patients described it as generally relaxing but also a treatment which increased their energy and feelings of well-being. More specifically they said it reduced pain, increased flexibility, improved balance and reduced recovery time from relapses. The text does not offer information on the type of acupuncture given but it is likely to be of the traditional type as Western health professionals do not generally include acupuncture in the ‘black box’ of therapies for MS yet.

Acupuncture treatment for MS

Considering the symptoms in Table 8.1, it is clear that acupuncture may be able to affect most of them.

Table 8.1 Symptom picture for multiple sclerosis

Symptom	Characteristic presentation	Multiple sclerosis
Decreased mobility	Rigidity
Fatigue	Lack of energy
Pain		X
Muscle spasm	Tremor
Contractures	Stiffness and rigidity
Autonomic changes	Slowing circulation
Cognition/mood	Apathy Depression

Communication Bladder problems Constipation

X, usually absent; , common; , very frequent.

Body acupuncture

Body points can be selected according to local symptoms or according to the organ system that seems to be affected at the time. MS patients are subject to a considerable variation in severity of symptoms, and remissions and exacerbations are characteristic of the disease. A minimal selection of the appropriate points is necessary as overtreatment is very easy and patients can often be quite exhausted by their acupuncture treatment (Table 8.2). Needling is generally applied to the affected limbs.

Table 8.2 Multiple sclerosis – useful points

Scalp acupuncture

This is occasionally used in MS but has no research evidence to support it. Logically, work on the motor or sensory cortical lines could be helpful when treating changes in limb function. Jiao Shunfa has made anecdotal claims that scalp acupuncture can help with pain, paralysis and vertigo in MS [17].

TCM approach

Traditional Chinese medicine (TCM) offers an apparently complex approach to what is a complex disease process but when considered as separate and distinct stages the syndrome theories can be easily applied. The most commonly adopted TCM staging for MS was originated by British acupuncturists Blackwell and MacPherson [18] and offers a logical framework for treatment.

MS can be considered as four stages (Table 8.3): the first stage is remission, either before the disease process has really started or, far more likely, as an interval where symptoms recede and a near-normal state is regained.

Table 8.3 Staging of multiple sclerosis

Stage 1	Stage 2
Remission	Meridian problem Support Spleen and Stomach

Stage 3	Stage 4
Spleen Qi Xu Liver Blood Xu	Kidney Xu

The second stage is where the meridian symptoms predominate and the patient is aware of sensory or minor motor changes.

As the disease progresses, evidence of Zang Fu organ failure becomes apparent, with the patient now feeling fatigued and often ill. Chinese theory holds that MS is fundamentally an invasion of Damp Heat and this will begin to affect the Stomach, Spleen and Liver, leading to a mixed picture of symptoms. Ultimately this internal state will affect Kidney energy and the final picture in the fourth stage is that of a serious Kidney energy deficit.

This is an infinitely variable process and, fortunately, many patients do not reach stage 4, perhaps not even stage 3. However the aim of acupuncture is to treat and support the evident problems in the current stage and return the patient to the stage preceding.

Stage 1: remission

For the sake of clarity, it is assumed that in a remission stage there are no active symptoms so the only therapy required will be preventive. Since the patient is undergoing a major disease process, support for the Stomach and Spleen will be useful, allowing the regenerative processes of the body full support from nutrition and digestion. Also in this stage it is useful to emphasize lifestyle advice, attention to diet generally, relaxation and rest when appropriate, and some form of recreational exercise.

Stage 2: external channel problem

Often there is a sudden onset, sometimes preceded by an emotional trauma. The symptoms are acute in nature and appear to be caused by Damp Phlegm or Damp Heat in the meridians, possibly originally caused by an invasion of Cold Damp.

The symptoms include weakness, heaviness, tingling and numbness in the extremities, cold limbs, and aching in the back or shoulders. Quite often patients complain of vertigo, blurred or double vision. The tongue has a greasy white coating, indicating Damp, and the pulse is slippery or empty.

Points to be used include: Zhongwan CV 12, Fenglong ST 40, Sanyinjiao SP 6, Yinlingquan SP 9, Pishu BL 20 and Zusanli ST 36. Blockages in the meridians causing local problems such as numbness in the feet should be dealt with by inclusion of local points such as Bafeng.

Stage 2: moving inwards (Damp Heat invades and obstructs channels)

This indicates a progression of the disease and the symptoms may now include numbness in the lower limbs with accompanying weakness, slackness of joints and gravitational oedema. The whole body feels heavy and the legs may feel cold, although the feet may feel hot. The joints are often painful. The patient does not react well to heat and may complain of tightness of the chest. Occasionally there is fever with frequent, urgent, dark yellow urine. The tongue is greasy with a yellow coat and the pulse is rapid and slippery.

Points to be used include Dazhui GV 4, Hegu LI 4, Yinlingquan SP 9 and Taibai SP 3. Plum blossom needling can be used to influence stagnation over the Huatuojiaji points, and other points for local, superficial symptoms should still be included.

(Plum blossom or seven star needling uses a flexible 6-inch (15-cm) hammer with a group of short needles on the head. The skin is lightly tapped in order to produce an erythema over the area.)

Blackwell and MacPherson [18] offer a helpful differentiation between stages 2 and 3 (Table 8.4).

Table 8.4 Damp in the channels changing to Liver Blood Xu

Damp affecting the channels	Liver blood deficiency
Widespread numbness	Extremities numb and tingling
Heavy, aching limbs	Stiff limbs, increased muscle tone
Variable onset and progression	Slow gradual onset
Continuous symptoms	Symptoms much worse when the patient is tired
Emotions mostly unchanged, possible depression with generally low motivation	Either apathetic or anxious with tight, brittle emotions
Pulse full or normal	Pulse choppy or thready

Stage 3: Middle Jiao involvement

This tends to be the stage that is most often seen by physiotherapy services. All the preceding symptoms may be present, the resulting disability cannot be ignored and the patient seeks help. In TCM terms the production of Qi and Blood by the Spleen is now diminishing, resulting in deficiency. The retention of Damp in the system weakens the Spleen further, initiating a vicious circle.

The Zang Fu organs of the Middle Jiao will need support, starting with the Spleen but progressing to the Liver.

Stage 3.1: Spleen Qi Xu

The symptoms include tiredness, listlessness, flaccidity of muscles and a tendency to fatigue. The patient may have a poor appetite and a pale sallow complexion and suffer from bowel problems, in particular loose stools. The tongue will be swollen and tooth-marked and the pulse empty, thin and weak.

Points to be used include Zusanli ST 36, Taibai SP 3, Zhangmen LR 3, Weishu BL 21, Sanyinjiao SP 6, Zhongwan CV 12 and Pishu BL 20. As usual, add points to deal with superficial or channel problems as necessary. Figure 8.1 shows how the different syndromes which may be present are interlinked and interdependent.

Figure 8.1 Moving through the stages of multiple sclerosis in traditional Chinese medicine terms.

After Blackwell and MacPherson [18].

Stage 3: Liver Blood Xu

The symptoms include blurred vision, always worse when tired, and a pale dull face. There may be muscle stiffness with cramps, spasticity and mild tremor.

The tongue will tend to be pale and dry and the pulse thin and choppy.

Points that can be used include Zusanli ST 36, Ququan LR 8, Geshu BL 17, Pishu BL 20, Sanyinjiao SP 6, Guanyuan CV 4 and Ganshu BL 18. As before, use local points for superficial symptoms.

Stage 4: Kidney Xu

In this stage the problem is predominantly one of Kidney deficiency and is characterized by weakness, fatigue and emaciation. Both Yin and Yang Kidney need tonification. The chronic Spleen Qi Xu depletes the Kidney Yang and the chronic Liver Blood Xu depletes both Kidney Jing and Kidney Yin.

Symptoms include severe weakness and fatigue. The patient often appears spiritless and there may be a pale complexion and premature ageing. Muscle weakness and atrophy are likely to be marked. Stiffness and muscle spasm are also common with severe tremor and ataxia. Low-back pain is often very distressing but it will be useful to check the wheelchair provision as well as using acupuncture. When a patient spends long periods of time in a chair it is essential to make sure the chair fits correctly. Other symptoms are urinary urgency, incontinence or retention. The tongue will be pale and wet and the pulse weak.

Points to use include Taixi KI 3, Shenshu BL 23, Xuanzhong GB 39, Guanyuan CV 4, Ciliao BL 32. Mingmen GV 4 is added for Kidney Yang Xu and Zhaohai KI 6 for Kidney Yin Xu (Figure 8.2).

Figure 8.2 Differentiation of kidney syndromes.

Summary

The use of acupuncture points in stages 1 and 2 will be indicated by the local symptoms but will tend to be distal. In stage 3, support is needed for the organs: ST36, SP 6, LR 3 plus back Shu points. In stage 4 use back Shu points and Kidney points, particularly KI 3.

Other syndromes which may occur in MS

Qi and blood deficiency

Poor or absent circulation of Qi and Blood is seen in TCM as the cause of both pain and also poor movement ability. The blockage may in fact be caused by early manifestations of Phlegm Heat (see below). Local points on the most affected limbs will also be useful.

Common symptoms are: chronic tremor of a limb or limbs, sallow complexion reluctant speech and lack of facial expression. Also found are stiff neck, cold painful limbs, general poverty of movement, unsteady gait with difficulty in taking the first step, dizziness and blurred vision.

Treatment

Tonify Qi, nourish Blood, energize the meridians and dispel Wind.

• ST 36 Zusanli tonifies Qi and Blood.

• SP 6 Sanyinjiao tonifies Qi and Blood.

• LR 8 Ququan nourishes Liver Blood.

• CV 4 Guanyuan nourishes Blood generally.

• SP 10 Xuehai improves Blood circulation in the lower limb.

Phlegm Heat agitating Wind (affecting Liver)

There are three different syndromes associated with the stirring of Liver Wind. They can be caused by:

1. internal heat, caused by penetration of an exogenous pathogen to the interior. This is characterized by serious febrile diseases in children, e.g. measles or meningitis.

2. inability of the deficient liver Yin to control the liver Yang with subsequent internal Wind symptoms (more associated with Parkinson’s disease)

3. deficiency of Liver Blood [19].

Treatment for all three will aim to subdue the Liver Wind, which can be very dangerous, frequently leading to Wind Stroke or cerebrovascular accident. Otherwise the Liver energies need controlling or tonifying according to whether the underlying symptoms exhibit excess or deficiency. The prevention of stroke depends on getting this balance correct but it will not really affect or prevent the onset of Parkinson’s disease or MS.

Liver Wind is often associated with hypertension, stroke, epilepsy and trigeminal neuralgia (often found in the later stages of MS). It may be exacerbated by prolonged frustration or anger, both of which are said to damage the Liver. It is also linked to obesity and a lack of physical exercise.

The symptoms include vertigo, tremor, convulsions, muscle spasms and stiff neck. Facial paralysis, tinnitus and hemiplegia may also be present.

Liver and Kidney Yin deficiency

This situation is often the precursor to Liver Yang rising. If the cooling Yin of the Liver is depleted the Yang becomes hyperactive and rises upwards, producing the symptoms of headache, dry eyes and tinnitus. The Heat also causes irritability and anger, emotions damaging to the Liver. This syndrome is a combination of both excess and deficiency, although the excess symptoms seem more obvious.

Liver Yang rising is a fairly common pattern and will be mentioned again in this book as it is closely associated with neurological damage. Stress, frustration, anger and resentment build up over a long period of time, obstructing the free flow of liver Qi. This produces heat, which dries up Yin. Yin thus cannot control Yang, which rises to the head. In contrast, the person could be relatively cool in the lower part of the body.

Symptoms will include: general frailty, dizziness, tinnitus, insomnia, headache, night sweats, low-back pain, stiff neck, back and knees and mental restlessness. Often also present will be lack of facial expression, poor memory and general physical clumsiness.

Treatment

Nourish Yin, dispel Wind, energize the meridians.

• CV 4 Guanyuan supports Kidney Yin

• BL 23 Shenshu Back Shu point for the Kidneys

• KI 3 Taixi nourishes Kidney Yin

• SP 6 Sanyinjiao nourishes Kidney Yin

• BL 18 Ganshu Back Shu point for the Liver

• LR 8 Ququan nourishes Liver Yin

• LR 3 Taichong Liver source point. Balances Liver, moves Qi.

Summary

Acupuncture treatment for MS seems to be endlessly complex but in reality follows the pattern of symptoms very closely, with Western medical acupuncture probably being most appropriate for the motor and sensory problems involving the limbs and the TCM theories more apposite when tackling the underlying disease process. It characterizes the best way of tackling most neurological conditions with acupuncture.

When deciding how best to organize treatment sessions, it must be borne in mind that MS patients can easily be overtreated and will become very fatigued after just a few points. Do not leave the needles in too long and limit the points used. Also remember the relapse/remission character of the disease and try to arrange for your patients to be able to refer themselves for more treatment immediately, if a relapse occurs.

Case study 8.1: level 1 case study

The patient was a 47-year-old woman, diagnosed with MS 4 years previously. She was still active and in part-time employment. She had a weak leg and forearm on the left side but she was generally mobile, normally using only a stick to help with her walking. She had a wheelchair to help when she was ill or particularly fatigued.

She presented for treatment in the wheelchair saying both her feet felt ‘funny’ and that she was afraid to walk as she felt as though she was ‘walking in soft sand’. She had previously had successful acupuncture for a painful shoulder.

Impression

She had a local exacerbation of MS symptoms: Damp Heat in the meridians affecting the lower limbs. Apart from the changed sensation her legs were stiff and cold.

Treatment

Points used: Bilateral Bafeng and GB 34. This was kept simple in order to minimize fatigue. The needles were only left in for 10 minutes the first time.

She returned in 2 days and the treatment was repeated for 20 minutes as she had had no ill effects the first time. After the second treatment she said the strange sensation was going, the ground no longer felt soft but she was hesitant to leave the wheelchair.

Results

After three more treatments she attended for treatment using only the stick again and said her feet felt quite normal now. The range of knee and ankle movement and the skin temperature had returned to normal.

This woman returned for treatment about 6 months later with the same problem. It had come back after a holiday abroad where the weather had been particularly hot. It was resolved again after four treatments.

This was clearly not a cure, but the strong sensory stimulation provided by the Bafeng combination of points seemed to produce temporary relief of her symptoms.

Case study 8.2: level 3 case study

The patient

A 50-year-old female was referred to the community neurorehab team following a 6-month history of declining mobility, increase in muscle spasms and right leg pain causing falls at home. She had been diagnosed with relapsing-remitting MS several years previously, and stopped work 4 years after diagnosis. Prior to this deterioration, she lived alone and was independently self-caring. She took her dog for at least one walk daily, and was dependent on a friend only for shopping. She used an electric wheelchair and an adapted car and could walk up to 50 metres with two crutches.

Medications included baclofen 15 mg four times a day and tramadol as needed.

Assessment

Her main problems, due to the right leg pain and increase in right leg muscle spasms, were reported as:

• disturbed sleep

• daily falls

• unable to drive

• increased difficulty standing from armchair

• increased difficulty standing to cook meals.

Objective assessment revealed the following:

• right hip: 40° extension from neutral, severe pain at end of range active or passive movement

• tender on palpation all quadriceps muscles, with palpable taut bands of trigger points (TPs) in muscle bellies

• unable to lie prone due to pain

• right knee 20° extension, pain at end of range passive stretch

• right ankle: 15° dorsiflexion from plantigrade

• standing hips and knees flexed

• hips adducted

• right heel off ground

• mobility: only able to manage up to 5 metres due to pain; used upper limbs and elbow crutches to propel flexed legs forward

• function: slow, but independent with all transfers in the home.

Pain was made worse by standing for more than 5 minutes, or standing after sitting. Yoga helps; pain is worst in the evening, the patient has difficulty sleeping. Referrals were made to social services for meals on wheels, morning care, shopping and cleaning and to wheelchair services to review for an indoor wheelchair.

Impression

The patient’s function was limited by pain caused by active TPs in the right quadriceps muscles due to underlying increase in lower-limb flexor muscle tone as the patient’s MS progressed.

Treatment

Pain relief was the primary aim of treatment, with a view to review mobility indoors with crutches if pain and muscle spasms decreased.

Initially, treatment focused on deactivating the TP in the quadriceps muscles to provide pain relief for the right hip. Manual palpation of the TP caused severe pain so acupuncture was chosen as the treatment of choice for TP release, as manual release techniques would have been too painful.

See below for details of the first two treatments, focusing on local hip points for pain relief and deactivating quadriceps muscle TPs.

Treatment 1

5 minutes in left side lying.

Points: GB 30 Rt, GB 34 Rt, GB 39 bilateral + 4 TPs in quadriceps muscles.

Treatment 2

2 days later, 10 minutes in supine.

Points: GB 34 Rt, +7 TPs in quadriceps muscles.

Research has reported that treating patients with MS with acupuncture provoked spasms, clonus and even tonic-clonic muscle contractions of the extremity muscles [20]. Similarly, this patient experienced an increase in right leg flexor spasms during acupuncture, perhaps because a deep insertion was used, making the treatment very uncomfortable. This made it too difficult to insert needles on the anterior of the hip (such as at ST 31), and the needles were removed after 5 minutes of the first treatment.

There was some limited response but it was decided that a TCM approach utilizing the extra meridians might be more successful. The Conception Vessel meridian was used for pain on the anterior surface of the body, the Governor Vessel meridian to help the back and central nervous system, the Dai Mai to treat pain in the lower half of the body and the Chong Mai to help general circulation.

Treatment 3

3 days later; 15 minutes treatment in supine. LU 7 and KI 6 bilateral

Treatment 4

4 days later; repeated treatment +BL 62 (opening point for GV meridian)

The patient continued with treatment twice a week and eventually had eight treatments, during which the opening points for the extra meridians, GV, CV, Dai Mai and Chong Mai were slowly added. Thus by the last treatment the eight points used in diagonal were:

• LU 7 / KI 6

• BL 62 / SI 3

• GB 41 / TE 5

• SP 4 / PE 6, never left for longer than 20 minutes.

Deqi was achieved at all points and manual stimulation of the needles approximately every 5 minutes during treatment helped to maintain this.

Only a minimal increase in right leg flexor spasms was noted during acupuncture using distal points only.

Table 8.5 gives details of pre- and posttreatment measures for right hip pain. As can be seen from Table 8.1, acupuncture provided good temporary pain relief, lasting between 1 and 3 days. Some of the acupuncture-induced analgesia was maintained over the course of treatment. The client reported the worst pain was 40/100 on completion of the course of acupuncture, a 50% reduction from the worst pain experienced before acupuncture treatment commenced.

Table 8.5 Outcomes for each acupuncture treatment in case study 8.2