Practical application of Western medical acupuncture in neurological conditions

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5 Practical application of Western medical acupuncture in neurological conditions

CHAPTER CONTENTS

Introduction 84
Clinical reasoning framework 84
Part 1: Sensory function 84
Case study 5.1: level 1: Nociceptive pain in multiple sclerosis 84

Treatment 85
Points 85
Outcome 85
Comment 85
Case study 5.2: level 1: Pain from active trigger point in Brown-Séquard syndrome 86

Treatment 86
Points 86
Outcome 86
Comment 86
Case study 5.3: level 1: Paraesthesia and dysaesthesia in transverse myelitis 86

Functional ability 86
Treatment 86
Points 87
Outcome 87
Comment 87
Case study 5.4: level 2: Back and hip pain in choreoathetoid cerebral palsy 87

Functional ability 87
Treatment 87
Points 87
Outcome 88
Comment 88
Case study 5.5: level 1: Impaired sensation affecting dexterity in stroke 88

Treatment 88
Points 88
Outcome 88
Comment 88
Part 2: Motor function 88
Case study 5.6: level 1: Inability to move fingers following spinal stroke 88

Functional ability 89
Treatment 89
Points 89
Outcome 89
Comment 89
Case study 5.7: level 2: Inability to move arm or leg poststroke 89

Functional ability 89
Treatment 89
Points 89
Outcome 89
Comment 90
Case study 5.8: level 1: Spasticity in legs affecting walking in multiple sclerosis 90

Treatment 90
Points 90
Outcome 90
Comment 90
Case study 5.9: level 1: Dyskinesia and ‘off’ symptoms in Parkinson’s disease 91

Treatment 91
Points 91
Outcome 91
Comment 91
Part 3: Visceral dysfunction 91
Case study 5.10: level 1: Overactive bladder in multiple sclerosis 91

Functional ability 91
Treatment 91
Points 92
Outcome 92
Comment 92
Case study 5.11: level 2: Constipation in multiple sclerosis 92

Treatment 92
Points 92
Outcome 92
Comment 92
Part 4: Generalized symptoms 92
Case study 5.12: level 1: Insomnia in cervical myelopathy 92

Treatment 93
Points 93
Outcome 93
Comment 93
Case study 5.13: level 1: Fatigue affecting daily activities in multiple sclerosis 93

Treatment 93
Points 93
Outcome 93
Comment 93
Case study 5.14: level 2: Depression in multiple sclerosis 93

Treatment 93
Points 93
Outcome 94
Comment 94
Case study 5.15: level 2: Acute anxiety following traumatic brain injury 94

Treatment 94
Points 94
Outcome 94
Comment 94
Case study 5.16: level 2: Agitation secondary to pain in stroke 94

Functional ability 94
Treatment 95
Points 95
Outcome 95
Comment 95
Summary of clinical reasoning in neurological conditions 95

Selection of points 95
Depth of needling 95
Stimulation 95
Course of treatment 95

KEY POINTS

• Acupuncture can be very valuable for a wide range of symptoms in neurological conditions.
• Dividing symptoms into broad categories of sensory, motor, visceral and generalized dysfunction simplifies the clinical reasoning process.
• The lack of large randomized controlled trials does not mean that acupuncture may not be beneficial.
• Acupuncture clinical reasoning is a logical process and requires consideration of aspects such as level of stimulation and duration of treatment.

Introduction

Research has indicated possible applications for acupuncture in neurological conditions. However there are many cases when the evidence base is inadequate to guide practice. Clinicians regularly meet patients who might benefit from acupuncture. The development of a coherent clinical reasoning framework allows practitioners to devise treatment schedules for any patient who may present to the clinic, drawing insights from Western scientific literature.

Clinical reasoning framework

A clinical reasoning framework can be based around the major problems that people with neurological conditions may complain of, namely sensory, motor, visceral and generalized disorders (Table 5.1). The literature regarding these presentations has been explored in Chapter 4.

Table 5.1 Clinical reasoning framework in neurological conditions

Key issue Examples Acupuncture options
Sensory problems
Impaired sensation
Pain
Hypersensitivity
Unpleasant provoked or spontaneous sensations such as tingling or burning

Needle locally in area of sensory loss or pain
Needle extrasegmentally for generalized pain-relieving effects
Consider use of EA for strong stimulation, e.g. to influence impaired sensation or chronic pain presentations
Consider scalp acupuncture over sensory line
Motor problems
Weakness or inactivity
Spasticity or rigidity
Needle into muscle of interest
Consider trigger point acupuncture to gain muscle relaxation and reduction in pain
Consider EA to gain contraction of muscle and to encourage increased activity
Consider EA to gain muscle contraction as a prelude to muscle relaxation where excess muscle activity is present
Consider scalp acupuncture over motor line
Visceral problems Bladder or bowel dysfunction
Consider the autonomic supply to the organ and needle segmentally
Also needle extrasegmentally for generalized effects on the organ
Generalized problems
Insomnia
Fatigue and reduced energy levels
Depression
Anxiety or agitation
Use important points, particularly those on the front of the body or those in the back over the sympathetic outflow between T1 and L2
Consider points on the head to influence the trigeminal system
Consider ear acupuncture to gain general calming effects, e.g. via vagus nerve

EA, electroacupuncture.

There follows a series of practical cases which aim to illustrate a range of possible approaches to treatment. Each case provides information regarding the ‘dose’ of treatment such as choice of points, level of stimulation, duration of treatment and course of treatment.

Part 1 Sensory function

Case study 5.1: level 1: Nociceptive pain in multiple sclerosis

A 53-year-old woman with multiple sclerosis fell and fractured her right calcaneum. She was unable to put any weight through her heel due to pain. Consequently, she walked with a marked limp and had to lean on her husband for support. Pain on weight-bearing was 6–7/10. She was only able to walk 100 metres with difficulty and with assistance and was at risk of falling again. Her timed 10-metre walk took 31 seconds and she scored 42/56 on a Berg Balance Scale.

Treatment

She received a course of six acupuncture treatments over 3 weeks, each treatment lasting 25 minutes. The needles were stimulated initially for Deqi and then again at 5-minute intervals.

Points

Right ST 36, SP 5; bilateral LI 4, LR 3.

Outcome

Pain reduced to 0–1/10. This allowed her to put weight through her heel, and to participate actively in rehabilitation to improve balance, strength and mobility. After treatment she was able to walk up to 200 metres independently with elbow crutches. Her balance and safety were improved. Timed 10-metre walk took 12 seconds and Berg Balance Score was 47/56.

Comment

Local points combined with generalized points resulted in an excellent result for this patient. The calcaneus is innervated by the medial calcaneal nerve and the first branch of the lateral plantar nerve. Both nerves arise from the tibial nerve (L4–S3). Selection of local points in the muscles sharing a common innervation with the calcaneus allowed modulation of pain on a segmental basis. This case illustrates how useful acupuncture can be within a physiotherapist’s range of skills.

Case study 5.2: level 1: Pain from active trigger point in Brown-Séquard syndrome

A 34-year-old man presented with a 1-month history of right shoulder pain. He had developed right-sided C5 Brown-Séquard syndrome 7 months previously. This had affected the right side of his spinal cord, leaving him with impaired movement below C7 on the right and impaired sensation below T10 on the left. The patient was able to walk independently indoors but needed to use one crutch outdoors. The patient’s social worker had contacted the patient’s physiotherapist to enquire whether an increase in funding for additional carers was required due to the patient’s increasing difficulty in managing daily activities.

On assessment the patient reported constant pain in the right shoulder, rating this as 8/10. He had poor dexterity in his hands and the addition of shoulder pain made it difficult for him to dress independently. There was no history of recent shoulder injury. Examination indicated weakness throughout the upper limb, including the shoulder region, and a local increase in muscle tone in right upper trapezius. This region was locally tender and palpation reproduced the patient’s pain.

Treatment

The patient received one acupuncture treatment to deactivate trigger points in upper fibres of trapezius. LI 4 was added bilaterally for 15 minutes for generalized pain relief. In addition he was provided with activities to improve stability and strength of the right shoulder. He received one follow-up session 6 months later, providing advice on sleeping position.

Points

Trigger points in upper fibres of trapezius, LI 4 bilaterally.

Outcome

Pain reduced immediately to 3/10 and in the next few days reduced further to 0/10. There was no recurrence until 6 months later. At this time advice on supported sleeping position was provided. There were no further reports of pain. No increase in funding for carers was required.

Comment

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