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

This is a good example of one treatment having a major impact. Impaired upper-limb function following the development of Brown-Séquard syndrome meant that this patient’s ability to function independently was more vulnerable to minor change. The presence of shoulder pain raised the possibility of an increase in care package to support him. The application of acupuncture avoided this necessity and represents an invaluable treatment option.

Case study 5.3: level 1: Paraesthesia and dysaesthesia in transverse myelitis

A 32-year-old woman presented with unpleasant sensations in her legs since the onset 6 weeks previously of transverse myelitis at T12/L1. She reported problematic pins and needles and feelings of ‘tightness’ in her legs, particularly in the thighs. Assessment revealed low tone, weakness and quadriceps spasticity as well as sensory and proprioceptive impairment in the lower limbs. In addition she was incontinent of urine.

Functional ability

She was unable to stand unassisted and used a sliding board for moving from bed to wheelchair. She was independently mobile in a wheelchair. She needed the assistance of one person for activities of daily living.

Treatment

The patient received 12 acupuncture treatments lasting 30–40 minutes over 3 weeks. The needles were not stimulated at any point. She also received ongoing physiotherapy to improve her ability to stand and walk.

Points

Local needling was carried out into the area of unpleasant sensations using bilateral ST 31, ST 34, GB 31 and GB 34.

Outcome

This patient reported significant improvement as a result of the acupuncture treatment and stated that it had ‘kickstarted everything else’. During the treatments the patient reported a pleasant tingling sensation in both legs and a feeling of deep relaxation. Following treatments she noticed a reduction in unpleasant sensations, improved sensation in the soles of the feet and a ‘better sense of her legs being there’. In addition she noted increased muscle activity in her left foot and improved right quadriceps control in gait directly after treatment.

Comment

Needling into the area of discomfort with long treatment times and no stimulation reduced dysaesthesia. The treatments were provided intensively in an attempt to make a sustained difference and to allow the patient to progress. This amount of treatment time looks substantial. However these treatments may easily be provided within the context of a busy neurorehabilitation gym. Needle insertion takes just a few minutes. The patient can then be distantly monitored whilst other patients are being treated. In fact this can be a very efficient treatment option.

Case study 5.4: level 2: Back and hip pain in choreoathetoid cerebral palsy

A 42-year-old woman presented with a 2-year history of low-back and left hip pain. Pain had recently become more severe and she rated both pains as 8/10. The pain affected her ability to concentrate at university and she was becoming low in mood. She reported that the back pain was worse when standing or transferring into her wheelchair. These were positions which caused lumbar extensor spasm. Hip pain was worse when standing or lying on the left side at night.

Examination indicated severe choreoathetoid movements affecting all four limbs and trunk. Hyperextension of lumbar spine was evident on standing with bilateral spasm of paraspinals. In addition malalignment was evident in her legs with severe hyperextension of the knees and dystonic foot posture. Palpation revealed local tenderness over both L5/S1 facet joints, acute tenderness over the left greater trochanter and active trigger points in right and left gluteus medius and minimus. Assessment suggested facet joint problem at LS/S1 due to severe and repeated hyperextension of the lumbar spine, combined with gluteal enthesopathy.

Functional ability

The patient was able to transfer in and out of her wheelchair independently. She used an electric wheelchair for mobility. She received daily assistance with washing and dressing from carers.

Treatment

A range of different options were trialled, including acupuncture and transcutaneous electrical nerve stimulation (TENS). She received a course of eight acupuncture treatments over 5 weeks. Early treatments involved the deactivation of trigger points in gluteus medius and gluteus minimus at the beginning of the session. This was often followed by the insertion of 5–6 needles around and over the left greater trochanter combined with bilateral ST 36. Needles were gently stimulated initially for Deqi and then left in situ for 20–25 minutes. Acupuncture was trialled for treatment of the back pain but was difficult, carried safety risks due to the patient’s involuntary movements and was of limited benefit. TENS at 110 Hz over the lumbar spine was therefore trialled with greater success. In addition she received physiotherapy to try and improve selective control at the trunk as well as providing stretches into flexion for lumbar spine.

Points

Gluteus medium and minimus trigger points; Huatojiaji points bilaterally at L4 and L5 (trialled twice). Six points immediately around and over greater trochanter; ST 36 bilaterally.

Outcome

The patient experienced good short-term relief of hip and buttock pain with pain reducing to 2/10. There was no sustained change in back pain secondary to needling but good pain relief was obtained by using TENS on the lumbar spine overnight. This patient required ongoing monitoring and was later referred on for review by the pain team.

Comment

Acupuncture provided substantial relief of hip pain for 3 months. However it was difficult to sustain pain relief due to the extreme stresses placed upon the patient’s joints due to the choreoathetoid movements. Treatment of back pain in the presence of involuntary paraspinal spasms was very difficult and issues of safety raised by Watson [1] are relevant in this situation. Trial of TENS was more successful and provided a simple option that she could use whenever the back pain was problematic. In complex presentations it is important to remember the limitations of any one technique and involve other professionals as necessary.

Case study 5.5: level 1: Impaired sensation affecting dexterity in stroke

A 61-year-old man presented with marked sensory impairment in his right upper limb, 2 months after a stroke. He had impaired awareness of light touch, deep touch, thermal sensation and proprioception. Assessment indicated good motor ability. However, his sensory impairment hampered his ability to complete functional activities requiring fine dexterity; for example, he was unable to do up buttons. He was able to walk independently and was independent in daily activities but slow due to poor manual dexterity. He had been unable to work since his stroke.

Treatment

The patient received eight acupuncture treatments over 8 weeks. Each treatment lasted for 30 minutes. Needles were stimulated initially for Deqi and then restimulated at 5-minute intervals. No other interventions were provided during this time.

Points

Right LI 4, L1 5, LI 10, LI 11 and SI 3.

Outcome

The patient experienced substantial improvement in sensation and proprioception which resulted in improved manual dexterity and improved function; for example he was able to do up buttons. This improved dexterity allowed him to return to his job working in a bar.

Comment

Studies have demonstrated improved motor dexterity following somatosensory stimulation in stroke [2]. These studies usually provide stimulation over a peripheral nerve such as the median nerve and aim for the patient to feel strong paraesthesia. This physiotherapist used points throughout the upper limb local to the area of sensory deficit, provided strong stimulation and gained improvements in sensation and motor function. In planning such treatments it would be useful to consider the peripheral nerves supplying the target areas and select points to stimulate these nerves.

Part 2 Motor function

Case study 5.6: level 1: Inability to move fingers following spinal stroke

A 54-year-old woman presented with difficulty with finger movement following a spinal stroke 6 months previously. The stroke had affected the anterior portion of the spinal cord extending from C5 to T1. On assessment she had severe limitation of movement in both hands. On the left she had no finger flexor activity and this could not be stimulated by the use of electrical nerve stimulation.

Functional ability

The patient had lived with her daughter since the stroke. She was able to walk independently. She was able to wash independently but needed help with fine finger tasks such as tying her shoe laces.

Treatment

She received five electroacupuncture treatments over 2 weeks. Needles were inserted into the target muscle and stimulated at 2 Hz for 25 minutes. Visible finger flexion was obtained on each occasion during treatment. In addition she completed upper-limb active exercise, stretches and functional tasks for hand muscles.

Points

Needles were inserted into either flexor digitorum superficialis or flexor digitorum profoundus. Usually only two needles were inserted, with one at either end of the muscle belly.

Outcome

After two treatments this patient was able actively to flex her fingers through a few degrees. After four treatments she began using her finger flexors as part of basic functional tasks such as picking up a plastic beaker. In addition attempts to stimulate the muscles using electrical stimulation transcutaneously were now successful in obtaining finger flexion.

Comment

This case highlights the possibility of stimulating muscle activity more easily and more specifically when needles are inserted directly into the muscle. This may be of benefit to some individuals at early stages of their rehabilitation and for muscles which are located more deeply. In addition, the intensity required for electroacupuncture is much lower than that required for transcutaneous stimulation since the high electrical impedance of the skin has been overcome. Electroacupuncture is therefore more comfortable for many patients and provides a therapeutic option for those who are unable to tolerate transcutaneous electrical stimulation.

Case study 5.7: level 2: Inability to move arm or leg poststroke

A 57-year-old man presented with dense right hemiplegia and sensory impairment 6 weeks after a middle cerebral artery infarction. On assessment he had severe low tone throughout the right side except for clonus in right plantarflexors. He had no active movement in his arm or leg, grade 0/5, after 6 weeks of intensive inpatient rehabilitation on a specialist stroke unit using a wide range of modalities. Motor Assessment Scale score was 9/48.

Functional ability

He was able to stand but his right leg was inactive. He was unable to walk and was dependent on a wheelchair for mobility. He needed help with daily activities.

Treatment

The patient received eight scalp electroacupuncture treatments at 100 Hz for 25 minutes over 4 weeks. First treatment was given to the motor line over the lesioned (left) hemisphere. All subsequent treatments needled the motor line over intact hemisphere. Intensity was turned up until the patient could feel a gentle buzzing sensation of the scalp. Active assisted movement of right arm and leg was carried out during acupuncture treatment. His inpatient rehabilitation programme continued.

Points

Four needles were inserted along the length of the motor line. Electroacupuncture was attached to needles at either end of this line of needles.

Outcome

There was no change after treatment 1. During treatment 2 there was the sudden development of active movement in the right arm and leg after 10 minutes of stimulation as follows: grade 1+ in finger flexors, shoulder flexors and abductors; grade 2– in elbow flexors (through 45°), and knee extensors (60°); grade 3– in hip flexors (30°). By the end of eight treatments there had been continued improvement in movement as follows: grade 2– in finger flexors (20°), hip extensors (20°), knee flexors (30°); grade 3– in elbow flexors (60°), shoulder flexion (40°), shoulder extension (30°), hip flexion (70°); grade 4– at knee extension. The patient had developed basic arm movement but was unable to use this functionally. He was able to stand with more activity in his right leg and was able to walk 10–15 metres with the assistance of one person. Motor Assessment Scale score was 17/48.

Comment

The physiotherapist was trying to understand how scalp acupuncture might influence motor ability. Papers reporting inhibition of lesioned hemisphere by the intact hemisphere seemed relevant, as well as those reporting the application of transcranial magnetic stimulation over the intact hemisphere to reduce this transcallosal inhibition and improve motor ability in stroke [3, 4]. Therefore during treatment 2 she provided electroacupuncture stimulation over the intact hemisphere. During this treatment she elicited the first active movement in 6 weeks. This sudden development of movement resembles improvements reported in Chinese texts on scalp acupuncture. We cannot be sure what mechanisms are at work in this case. However the outcome was improved motor ability so that the patient could use his right leg and begin to walk. Scalp acupuncture has received very little attention in the scientific literature despite repeated reports of benefit for cerebral conditions from China. Research seems long overdue.

Case study 5.8: level 1: Spasticity in legs affecting walking in multiple sclerosis

A 48-year-old woman developed increased spasticity in her left hamstrings. She had been diagnosed with multiple sclerosis 12 years previously. She had been able to walk short distances with a frame until she was recently admitted to hospital with pneumonia. Assessment revealed bilateral spasticity, particularly of the hamstrings, with flexor spasms affecting the left leg more than the right. She had substantial muscle weakness of legs and trunk. She was unable to put weight through her left leg and was unable to walk. Physiotherapy over the previous 4 weeks had tried a wide range of treatments to improve her mobility. The physiotherapist had therefore discussed with the patient and her family the real possibility that she might not regain the ability to walk.

Treatment

The patient received four acupuncture treatments over 3 days in prone lying. Trigger points in up to seven different areas in the left hamstrings were located and deactivated using fanning technique. High-intensity, low-frequency electroacupuncture at 2 Hz eliciting strong muscle twitches of the left hamstrings was then applied for 10 minutes. Physiotherapy to assist her to stand followed immediately after acupuncture.

Points

Trigger points in hamstrings. Electroacupuncture points were selected at either end of the medial and lateral hamstrings within the muscle belly and connected up along the length of the muscle.

Outcome

Immediately after the first treatment she was able to stand and take weight through her left leg for the first time since her recent illness. Further acupuncture treatments before physiotherapy gained a similar outcome. She regained the ability to walk independently with a frame 8 weeks later. At this point her timed 10-metre walk took 56 seconds. She has continued to maintain this level of independent walking ability over subsequent years.

Comment

In this case the physiotherapist had tried every option to help the patient to walk. Focal weakening of the hamstrings with botulinum toxin was considered. This option may have reduced the flexor spasm but was unlikely to have helped her regain the ability to stand. Acupuncture was very much the last attempt to help this patient. The immediate improvement after the first treatment was unexpected but allowed physiotherapy to build on this ability and eventually help the patient to regain independent mobility. This treatment would not work for all patients. Indeed in some patients electroacupuncture applied to the leg muscles might exacerbate the flexor spasms. However it is an option worth trying.

Case study 5.9: level 1: Dyskinesia and ‘off’ symptoms in Parkinson’s disease

A 64-year-old man presented with increasing motor symptoms of dyskinesia, ‘off’ periods and freezing. He also reported neck pain of 8/10. The patient had been diagnosed with Parkinson’s disease 7 years previously and attended a specialist Parkinson’s clinic for regular monitoring. He was able to walk independently with one stick but reported frequent falls.

Treatment

This man received eight acupuncture treatments over 4 weeks. Each treatment lasted 25 minutes. Needles were initially stimulated for Deqi. No further stimulation was provided. The presence of involuntary dyskinesia during treatment required the use of a substantial number of pillows to ensure he was well supported and comfortable. He was monitored closely throughout treatment.

Points

Left GB 21, LI 14, bilateral LI 4, SI 3. During later treatments GV 20, bilateral GB 20 and LR 3 were added.

Outcome

The patient experienced a rapid reduction of neck pain to 0/10. Dyskinesias were reduced with fewer ‘off’ periods and fewer falls. He was also able to reduce his parkinsonian medications.

Comment

The physiotherapist treating this patient had hoped to gain a reduction in the patient’s neck pain. However after a number of treatments it was obvious that his motor symptoms were also improving. This is an intriguing finding in view of the possibility that pain and dyskinesia share some common pathophysiological mechanisms [5].

Part 3 Visceral dysfunction

Case study 5.10: level 1: Overactive bladder in multiple sclerosis

A 23-year-old woman with multiple sclerosis presented with frequency, urgency, urge incontinence and nocturia. This had become worse over the last few months since a recent relapse of multiple sclerosis. Physiotherapy treatment sessions of 45 minutes were regularly interrupted 2–3 times every day due to frequency, i.e. approximately 10–15 times per week. Incontinence Impact Questionnaire (IIQ-7) score was 19/21. Bladder scan following micturition indicated effective bladder emptying. Urinalysis was normal. This patient’s symptoms suggested overactive bladder syndrome with detrusor hyperreflexia.

Functional ability

The patient was able to walk up to 5 metres with a frame but was very unsteady due to trunk and lower-limb ataxia and weakness as well as mild plantarflexor spasticity. She needed help from one person for activities of daily living.

Treatment

She received eight acupuncture treatments over 4 weeks, each treatment lasting 25 minutes. Electroacupuncture at 20 Hz [6] was trialled on the first treatment but this caused flexor spasms. Therefore all treatments involved manual acupuncture with no stimulation.

Points

SP 6, SP 4 bilaterally for first treatment. SP 6, LR 3 bilaterally for all subsequent treatments.

Outcome

Frequency, urgency and nocturia were reduced. The patient also reported improved sleep and improved daytime energy levels. Her physiotherapy sessions were less disrupted. On average she needed to go to the toilet only once or twice during physiotherapy sessions over the entire week. This allowed her to concentrate on work to improve balance and mobility. Her IIQ-7 score was 14/21.

Comment

Parasympathetic outflow to the detrusor emerges at spinal levels S2–4 (see Chapter 4). SP 6 in flexor digitorum longus (S1–2) and LR 3 in the first dorsal interosseous muscle (S2–3) ensured that afferent information would arrive at relevant levels of the sacral spinal cord, with the aim that this would modulate bladder function.

Case study 5.11: level 2: Constipation in multiple sclerosis

A 52-year-old woman with multiple sclerosis presented with a range of symptoms including low mood, irritability, anger and tearfulness, headaches most days, infrequent bowel activity, opening bowels once each week with difficulty, poor sleep, waking frequently, daytime fatigue and numb left arm. In addition she had poor condition of skin below her knees which was dry, red and in places cracked. She could transfer with help from one person but was unable to walk.

Treatment

She received 10 treatments over 5 weeks. Each treatment lasted 25 minutes. Needles were stimulated initially for Deqi. No further stimulation was given. During the early treatments the condition of the skin on her legs prevented the use of any points below the knee. However by treatment 6 the skin condition had improved so much that ST 36 could be needled.

Points

Bilateral LI 11, LI 4 and Yintang in treatments 1–5. Bilateral ST 36 added in subsequent treatments.

Outcome

Early treatments resulted in decreased irritability, reduction in headaches, increased energy levels, increased sensation in left arm and improved skin condition of legs from broken skin to healed skin. The improved skin condition permitted the safe addition of ST 36 bilaterally. Needling this point resulted in an immediate impact on bowel function with sensations in the abdomen after treatment and bowels opened later that day. Following subsequent treatments bowel activity increased to bowels open on alternate days. She reported feeling better for having more regular bowel activity.

Comment

ST 36 is highlighted as an important point to influence bowel activity and this was relevant in her case. The needle at this point is inserted into tibialis anterior, which is innervated by the deep peroneal nerve (L4–5). Skin overlying this point is supplied by the lateral cutaneous nerve of calf (L4–5, S1). Innervation of the bowel emerges from L1–2 and S2–4. Needling of ST 36 therefore does not enter the same spinal segments as those controlling bowel activity, although there will be links between adjacent segments via interneurones. Part of acupuncture’s influence on the bowel is through generalized effects of stimulating the limb rather than purely segmental mechanisms.

Part 4 Generalized symptoms

Case study 5.12: level 1: Insomnia in cervical myelopathy

A 61-year-old woman presented with insomnia. She had recently had cervical spine decompression for cervical myelopathy and exhibited mild bilateral lower-limb spasticity and generalized weakness. She was able to stand but was unable to walk. She was dependent on a wheelchair for mobility and on carers for assistance to wash and dress. A persistent lack of sleep was interfering with her ability to participate actively in rehabilitation.

Treatment

The patient received four acupuncture treatments of 25 minutes over 2 weeks. Needles were stimulated for Deqi initially but no further stimulation was given.

Points

Yintang, bilateral HT 7, ST 36, SP6.

Outcome

There was marked improvement in sleep allowing her to participate more effectively in rehabilitation, with a reduction in daytime sleepiness. After the second treatment the patient reported: ‘I cannot remember the last time I slept that well’.

Comment

Improvement of sleep is one of the commonest reports following acupuncture for any reason in patients with neurological conditions.

Case study 5.13: level 1: Fatigue affecting daily activities in multiple sclerosis

A 38-year-old woman presented with fatigue limiting her ability to carry out daily activities, including looking after her children, particularly later in the day when her fatigue was more pronounced. She had been diagnosed with multiple sclerosis 5 years previously. She was able to walk with one stick. The fatigue had become worse recently since she had started Tysabri. Modified Fatigue Impact Scale (MFIS) was 54/84.

Treatment

The patient received eight acupuncture treatments, of 25 minutes over 6 weeks. Needles were stimulated for Deqi at the beginning of the treatment and once more halfway through treatment.

Points

CV 6, bilateral LI 4, LR 3, SP 6, ST 36.

Outcome

The patient experienced reduced fatigue, improved sleep pattern and increased energy levels. She reported that she was able to look her after children more easily. She also reported fewer side-effects from Tysabri. MFIS reduced to 33/84.

Comment

Fatigue is common and problematic in neurological conditions. A relatively short course of acupuncture resulted in substantial benefits for this patient as well as for her family. It also helped to reduce medication side-effects.

Case study 5.14: level 2: Depression in multiple sclerosis

A 42-year-old woman presented with depression, uncertainty about the future, muzzy head and generalized fatigue. She was on antidepressant medications. She was able to walk unsteadily with elbow crutches. On assessment truncal ataxia and mild lower-limb spasticity were evident. She had recently retired from work due to ill health.

Treatment

The patient received eight treatments of 25 minutes over 4 weeks. Needles were stimulated initially for Deqi. There was no further stimulation.

Points

Points included a selection from bilateral ST 36, SP 10, SP 6, SP 3, LR 3, KI 3 as well as right LI 11, left HT 7, GV 20, Yintang, bilateral Huatojiaji at T 3, 4, 7, BL 20, ST 44 and ST 40. On average eight needles were used for each treatment.

Outcome

The patient was calm and relaxed during and after treatment. She reported that her head felt clearer, her mood was lighter and she felt more optimistic and more self-confident. She also said that she felt less stressed and ‘more like her old self back again’. She felt she could tackle things more easily. She also noted an improvement of circulation in her hands and feet.

Comment

Key features of depression include feelings of low self-confidence and little optimism about the future. This patient’s impairments and functional ability changed very little but the provision of acupuncture provided a substantial effect on her outlook. She felt she was in a position to look to the future and move forward with her life. In turn this allowed her to make best use of the rehabilitation services that she was accessing at that time.

Case study 5.15: level 2: Acute anxiety following traumatic brain injury

A 48-year-old man presented with acute anxiety. He had sustained a traumatic brain injury 2 months previously. He was functionally very able but presented with cognitive impairment and acute anxiety. He was withdrawn and finding it difficult to participate in cognitive-behavioural therapy sessions which he was receiving to help manage his anxiety. General Health Questionnaire-12 (GHQ-12) score was 27/36. He was previously fit and active, worked fulltime and enjoyed a healthy social life.

Treatment

The patient received 14 treatments over 6 weeks with initial treatments provided on alternate days. There was no stimulation of needles on the first two treatments. In subsequent treatments the needles were stimulated at 10-minute intervals. Early sessions lasted 25 minutes. Sessions gradually increased to 35–40 minutes.

Points

Yintang, bilateral LI 4, ST 36, KI 6. In later treatments some points were substituted with HT 7, LR 3, GB 34 and back Shu points.

Outcome

The patient experienced a reduction in anxiety, was able to participate effectively in cognitive-behavioural therapy sessions and spontaneously began socializing with other patients on the unit after the second treatment. GHQ-12 score was 9/36.

Comment

Acupuncture resulted in a general calming of this man who had recently undergone a very stressful traumatic accident. This allowed him to engage more effectively in therapies to assist him to move forwards in his life. After the first couple of treatments he started becoming more sociable on the unit, coming out of his room and talking with other patients. The physiotherapist had noticed this effect with other patients she had treated with acupuncture after traumatic brain injury.

Case study 5.16: level 2: Agitation secondary to pain in stroke

A 59-year-old man presented with agitation due to severe central neuropathic pain throughout the left side of his body. He had sustained a stroke 5 weeks previously causing dense left hemiplegia, moderate spasticity in upper and lower limb, left hemisensory impairment and inattention to left side of space. He exhibited severe agitation and called out on any attempts to move his left side. Medications had limited effect. He was completely unable to participate in rehabilitation due to pain.

Functional ability

He was unable to use his left arm, stand or walk. He was dependent on a hoist and on two people to move him from bed to wheelchair. He required the assistance of one to two people to assist him with all daily activities.

Treatment

The patient received 16 acupuncture treatments over 5 weeks with initial treatments closer together. Each treatment lasted 20–25 minutes according to how long the patient was able to lie still. There was no stimulation of needles. The physiotherapist sat immediately by the patient’s right side throughout treatment and limited movement of his right arm on the occasions when he attempted to move it.

Points

Bilateral LI 4, LR 3.

Outcome

The patient experienced a substantial reduction in agitation. He became very relaxed by the end of each treatment, allowing effective therapy immediately after acupuncture. Pain gradually reduced over the course of treatment and he was therefore able to participate in rehabilitation. He eventually developed the ability to stand and take a few steps.

Comment

This may not be the case to attempt when you are fresh from your first acupuncture course. However with close and careful monitoring such patients may gain substantially from treatment. Body acupuncture was selected in this case. Ear acupuncture might have been another good option to consider, perhaps in combination with body needling on the left side, which he was unable to move. This would have eliminated the risk posed by the man moving his right arm restlessly.

Summary of clinical reasoning in neurological conditions

Selection of points

To gain specific effect in local tissues, select points in those tissues; to gain a generalized effect, needle ‘big’ points on arms and legs, e.g. LI 4, LR 3, ST 36.

Depth of needling

To gain a specific segmental effect consider whether the needle needs to be in the dermatome, myotome or sclerotome. Trigger point acupuncture or electrical stimulation of muscles will require needles to be in the muscles. Otherwise needle to the usual recommended depth.

Stimulation

This will depend on both the state of the patient and the desired outcome. If the patient is agitated, anxious or in substantial pain minimal or no stimulation would generally be more helpful. In situations which are chronic, difficult to change or where you are aiming to influence sensory or motor inactivity, select stronger stimulation which might include electroacupuncture. In spasticity you may select minimal or no stimulation or you may select strong electroacupuncture stimulation according to the effects you are aiming for and the response of the individual patient.

Course of treatment

This will depend on the response of the patient. Some patients may need just a few treatments, often backed up by other options such as physiotherapy. Some may need a longer course of treatment. The possibility of follow-up would be useful for some patients.

References

[1] Watson P. Modulation of involuntary movements in cerebral palsy with acupuncture. Acupunct Med. 2009;27(2):76-78.

[2] Conforto A.B., Cohen L.G., dos Santos R.L., et al. Effects of somatosensory stimulation on motor function in chronic cortico-subcortical strokes. J Neurol. 2007;254(3):333-339.

[3] Boggio P.S., Alonso-Alonso M., Mansur C.G., et al. Hand function improvement with low-frequency repetitive transcranial magnetic stimulation of the unaffected hemisphere in a severe case of stroke. Am J Phys Med Rehabil. 2006;85(11):927-930.

[4] Murase N., Duque J., Mazzocchio R., et al. Influence of interhemispheric interactions on motor function in chronic stroke. Ann Neurol. 2004;55(3):400-409.

[5] Lim S.Y., Farrell M.J., Gibson S.J., et al. Do dyskinesia and pain share common pathophysiological mechanisms in Parkinson’s disease? Mov Disord. 2008;23(12):1689-1695.

[6] Kabay S.C., Yucel M., Kabay S. Acute effect of posterior tibial nerve stimulation on neurogenic detrusor overactivity in patients with multiple sclerosis: urodynamic study. Urology. 2008;71(4):641-645.

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