Review Article:
Acupuncture in nervous systemic disease
Ching-Liang Hsieh1,2 3*
1Graduate Institute of Acupuncture Science, College of Chinese Medicine, China Medical University, Taichung, 40402, Taiwan
2Acupuncture Research Center, China Medical University, Taichung, 40402, Taiwan 3Department of Chinese Medicine, China Medical University Hospital, Taichung, 40402, Taiwan
*Address correspondence to Dr Ching-Liang Hsieh, Graduate Institute of Acupuncture Science, College of Chinese Medicine, China Medical University, 91 Hsueh-Shih Road, Taichung 40402, Taiwan.
TEL: 886-4-22053366 (ext. 3600) Fax: 886-4-22035191
E-mail: [email protected]
Keywords: Acupuncture; Nervous system disease Abstract
acupuncture had been accepted widely in the Western countries. World Health Organization conducted a symposium and list 40 suitable diseases for acupuncture in 1979. The acupuncture as a tool to treat disease is very popular in the Taiwan, particularly for nervous system disease including stroke, dementia, Parkinson’s disease, headache, epilepsy, Bell’s palsy and carpal tunnel syndrome etc., but the efficacy of the acupuncture remain unclear, therefore, the aim of the present study was to review the articles whether the existing enough evidence to support beneficial effect of acupuncture. The results indicated that the acupuncture treatment is
beneficial including subacute and chronic stage of stroke for muscle spasticity, migraine prophylaxis, tension type headache, Bell’s palsy and carpal tunnel
syndrome; the efficacy of the acupuncture need more evidence including acute stage of stroke for motor function, dementia including Alzheimer’s disease, vascular dementia, Parkinson’s disease, epilepsy etc.
1. Introduction
Acupuncture and Moxibustion is used to treat disease had been many thousands years in China. Regarding to the meridian theory of acupuncture had been formation and recorded detail in “Yellow Empero’s Classic of Internal Medicine [1, 2] that is
the most ancient Traditional Chinese medicine writing. The Great Compendium of acupuncture and Moxibustion, which collect many methods and recordings of acupuncture published in the Ming Dynasty, is considered that is the basis of acupuncture theory and clinic [2]. Throughout two thousands develops, the
acupuncture had been used over the world. World Health Organization conducted a symposium and list 40 suitable diseases for the treatment of acupuncture in 1979 [3]. In fact, to our experience, the acupuncture is most common for nervous systemic disease in the department of acupuncture outpatient in Taiwan, particularly, stroke, dementia, Parkinson’s disease headache, epilepsy, Bell’s palsy and carpal tunnel syndrome etc. The therapeutic effect of the acupuncture for mention-above disease remain unclear, therefore, the aim of the present study was to investigate whether the existing enough evidence to support beneficial effect of acupuncture, review related trial articles and list in reference.
2. Acupuncture in stroke
Stroke is one of the most common diseases in Taiwan, and is third leading cause of death in Taiwan in 2011[4]. A randomized controlled study of 30 patients who stroke onset within 36 h was carried out in Taiwan, the acupuncture, three
poor baseline score than these patients without acupuncture [5]. Hsieh et al. (2007) report that EA with alternating stimulation pulses (3and 15 Hz), 8 course and over one month period, can significantly improve motor function in patients with first-ever ischemic stroke [6]. Johansson et al., (1993) in a randomized 78 stroke patients (40 patients’ control, and 38 patients acupuncture) with severe hemiplegia within 10 days after onset, the results indicated that electroacupuncture (EA) of 2 to 5 Hz, 30 min, twice a week for 10 weeks can improve balance, activities of daily living (ADL), and quality life [7]. However, Johansson et al. (2001) study 150 stroke patients from 7 medical neurological centers in Sweden; the subjects are from moderate to severe hemiparesis and between 5 and 10 days after onset. The results find that the effect of acupuncture includes 2 Hz EA, twice a week for 10 weeks, to outcome of motor function and ADL similar to transcutaneous electrical nerve stimulation (TENS) or similar to control with subliminal electro-stimulation [8], therefore, they conclude that acupuncture do not produce a beneficial effect for functional outcome in stroke patients. A 104 stroke patients study, the patients are divided into deep (2 Hz EA), superficial and no acupuncture groups, twice a week for 10 weeks. The results indicated that no significant difference in ADL and life quality between the groups, and the conclusion does not support acupuncture has a beneficial effect for patients with acute stroke [9]. Kai-Hoi Sze et al., (2002) study
106 stroke patients with moderate or severe functional impairment in Hong Kong, the acupuncture treatment start from day 3 to 15 after stroke onset and the
acupuncture apply to 10 acupoints with a over 10 weeks mean 35 session treatment. The results find that the acupuncture treatment is not significantly difference to the control with standard poststroke motor rehabilitation training; therefore, they conclude acupuncture treatment has no additional value to poststroke rehabilitation [10]. In addition, .Kai-Hoi Sze et al., (2002) carry out a meta-analysis and also obtains a similar conclusion that the acupuncture has no additional value to the poststroke rehabilitation except a small positive effect on disability [11]. Similar conclusion is reported that acupuncture is not specific efficacy for stroke patients [12].
Acupuncture treatment begins 1-3 months after stroke onset applied to sixteen patients who suffers left hemispheric ischemic infarction with right hemiplegia for twenty times with over one month period, the results find that real acupuncture is good response contrast to sham acupuncture group that no patient has good response, therefore, acupuncture is effective for the treatment of stroke [13]. Acupuncture, 30 min, three or four times/week for 6 weeks, can produce a positive long-term effect, because acupuncture group improve motor function, daily life quality and social situation is greater than non-acupuncture group in patients with
subacute stage (mean 40 days) stroke one years after discharge from hospital [14]. Recently, Liu et al. (2008) conduct a crossover randomly pilot study, the ten stroke patients who stroke was diagnosed for more than 2 years receives one of 2 Hz EA plus strength training treatment and strength training treatment only twice/week for 6 weeks and then another 6 weeks. The results indicated that the combined 2 Hz EA plus strength training treatment reduces muscle spasticity of wrist, and active wrist extension range of motion and Fugl-Meyer upper-limb scores, but no similar effect is noted in the patients with strength training treatment only, therefore, they suggest that EA reduces muscle spasticity and this effect of EA enhances the performance of the motor training tasks [15]. Similar study is carried out and the conclude that muscle spasticity can be reduced by the combination of EA (twice per week) and muscle training exercise for 6 weeks using a quantitative measurement in chronic strokes patients [16]. Our previous studies indicated acupuncture for 20 min at Baihui (GV 20) and the spirit acupoints on ischemic stroke patients, who lesion locate at hemisphere, and stroke is first attack, the reduction of displacement area is greater than control group. Therefore, acupuncture can produce an immediate effect to improve balance function [17].
Rorsman and Johansson (2006) conducts a study, the 54 strokes patients with moderate or several function impairment are randomized divided into three groups
acupuncture including EA, TENS and control with subliminal TENS, acupuncture starts from 5 to 10 days after stroke onset, 30 min, twice/week and for 10 weeks, the results that are no significant treatment effect is seen in acupuncture treatment on emotional status and cognitive function at 3 or 12 months after treatment [18]. In contrast to the results are reported that 1 Hz EA apply to acupuncture PC6 and HT7 for 20 min, twice /week, for 8 weeks, has a positive effect on cognition and life quality in stroke patient with cognitive impairment in Taiwan [19].
To sum up above-mentioned, the beneficial effect of acupuncture start in the acute stage on the motor function, DAL, and cognitive function in post-stroke patients seemly is controversy. While acupuncture including EA plus strength training treatment start from subacute or chronic stage after stroke onset can produce a positive effect of motor function including balance function, reduction of wrist joint muscle spasticity, active wrist extension range of motion and Fugl-Meyer upper-limb scores. A subliminal with superficial acupuncture stimulation also possibly produces effect has known [20], thus, resulting in hide of real acupuncture
effectiveness. In addition, the results do not support that acupuncture can produce a beneficial effect for the treatment of stroke patients, the motor function in all the subjects are moderately to severe impairment. The 30-day mortality rate is about 20% in ischemic stroke patients had been reported [21], therefore, the bias is also
possibly generation results in a different results. A usage rate of acupuncture study find that the acute ischemic stroke patients select acupuncture as supplement
treatment about is 3.4 fold in moderately severe, and 4.1 fold in severe stroke greater usage in an academic medical centre in Korea [22]. Acupuncture or EA at different frequencies can facilitate the neuropeptide release in central nervous system, and this neuorpeptide can produce neurobiological effect [23]. EA reduces brain injury via increase cerebral blood flow in middle cerebral artery occlusion rats had been known [24]. Together with, suggesting that acupuncture including is a valuable additional treatment for stroke patients.
3. Acupuncture in degenerative disorders 3.1 Alzheimer’s disease and vascular dementia
Alzheimer’s disease (AD) is a chronic progressive degeneration disease, and it is the most common dementia in old people. Several systemic review articles do not support the effectiveness of the acupuncture for AD [25] and vascular dementia [26, 27] that always occurs in poststroke, whereas a using functional magnetic resonance imaging recording study in 26 patients with AD, electric-stimulation apply to Shenmen (HT7) as a anode and Zusanli (ST36) as a cathode, and Fenlong (ST40) as a anode and Taixi (K13) as a cathode induced the activation of hippocampal gyrus and insula of right hemisphere, and temporal lobe, parietal lobe of left hemisphere,
these activation regions are closely cognitive function such as memory, language, suggest that acupuncture may produce beneficial effect for AD [28]. In addition, Yang et al., (2007) acupressure on the Fengchi (GB20), Baihui (GV20), Shenmen (HT7) , Neiguan (PC6), and Sanyinjiao (SP6), each acupoint for two min after 5 min warm activity, twice/day, five days/week for four week in 20 patients with dementia who has agitated behavior. The result indicated that acupressure reduces agitation behavior of dementia [29]. Taken together, the beneficial effect of acupuncture for dementia including AD and vascular dementia needs further study, such as larger sample size, randomized double blinded-controlled study etc.
3.2 Parkinson’s disease
Parkinson’s disease (PD) is a chronic progressive disease due to dopamine paucity of substantia nigra of mid brain. About 62.8 % of patients with Parkinson’s disease (PD) in Korean [30], and 25% in Singapore [31] use acupuncture as a
complementary therapy. Several systematic review articles do not support that acupuncture is effectiveness for PD [32, 33, 34]. In addition, a double-blind randomized pilot study using 4 Hz EA for 20 min, five sessions, over a 2-weeks period in stage II or III PD patients. The results indicated that the unified PD rating scale (UPDRS), PD questionnaire, ADL score of PDQ-39 etc. in acupuncture group
is similar to non-acupuncture group [35]. Eng et al. (2006) use acupuncture and Yin Tui Na weekly to treat patients with PD for 6 months, and the results indicated that UPDRS motor score is worse at 6 month than at baseline [36]. Shulman et al. (2002) using acupuncture at body or scalp acupoints to treat 17 patients with PD, each session is 1 hr, twice/week for 5-8 weeks. The results find that acupuncture improves sleep and rest only [37]. Acupuncture at Yanglingquan (GB34) can activate putamen and primary motor cortex, and also can improve motor function of affective hand in a functional magnetic resonance image study [38]. Scalp acupuncture and Madopa for 5 weeks can increase glucose metabolism in 5 patients with PD in a positron emission tomography study [39]. EA at scalp and levodopa for 5 weeks can increase hemispheric regional blood flow, but cannot affect basal ganglion striated dopamine transporter[40]. Taken together, although acupuncture including EA cannot improve motor function and ADL of patients with PD, whereas acupuncture can improve blood flow and glucose metabolism of brain tissue in patients with PD, therefore, suggesting acupuncture possibly is beneficial to delay intellectual decline for patients with PD. This suggestion need further study.
4. Acupuncture in headache 4.1 Migraine
controversies, and this efficacy of the acupuncture is results from a non specific psychogenic effect because expectancy and repetition of placebo can mediates via the dopaminergic mesolimbic system to activate pre-frontal, anterior cingular, accumbens and .periacqueduct grey neuron [41]. Schiapparelli et al. (2011) review a number of articles and conclude that acupuncture is an effect and a cost-effect treatment for migraine [42]. Zheng et al. (2010) base on the review articles
recommend that treating migraine is most efficacy acupuncture at Fenchi (GB20), Taiyang (EX-HN5), twice a week, 30 min in duration, at least over a 10 weeks period [43]. Acupuncture may provide as first-line treatment for migraine pain relief has been supported [44]. Several studies that use needle contact test (NCT) to detect most efficacy ear point for migraine, the results find that the anterior-internal part of the antitragus ipsilateral to pain is most effective zone for migraine pain. The semi-permant needles insert this zone can relief migraine pain within 30 min and persist to 24 h [45] or persist to 2 h [46].
A multicenter, single blind randomized controlled trial, the 480 patients with migraine was studied. The results find that acupuncture including electrical
stimulation significantly reduces the days of migraine pain than control during weeks 13-16, thus, they consider acupuncture can produce a minor effect for migraine prophylaxis than sham [47]. The Cochrane review conclude that
acupuncture is effective than drug treatment in migraine prophylaxis [48] and a similar conclusion also is reported [49, 50]. In addition, acupuncture treatment apply to Cuanzhu (BL2), Taiyang (EX-HN5), Yintang (Ex-HN-3) and Fengchi (GB20) can reduce migraine days and has less adverse events than topiramate treatment in chronic migraine prophylaxis [51], and similar results suggest that the acupuncture is more effect in reducing migraine days than flunarizine treatment [52]. Taken
together, the acupuncture treatment is beneficial for the reduction of migraine pain, particularly, in the prophylaxis of migraine.
4.2 Tension type headache
A Cochrane review 11 trial with 2317 patients with tension type headache, their conclusion is that acupuncture treatment is valuable for patients suffer frequent episode or chronic tension type headache [53]. Similar conclusion in a systematic review also is reported that acupuncture is better in improving intensity and
frequency of headache than sham acupuncture [54]. In addition, acupuncture treating tension type headache is superiority over sham acupuncture in short-term and long-term outcome [55]. Therefore, acupuncture is beneficial for frequent episode or chronic tension type headache.
Epilepsy is a chronic brain disorders, and its characteristic is results from a group neurons, excessive and synchronization discharges, productive behavioral changes, and repeat attack. A Cochrane review does not support acupuncture is efficacy for the treatment of epilepsy due to the trials are low quality and the methods are without adequate randomization [56]. A study conducts 15 patients with chronic intractable epilepsy (15 patient with real acupuncture, and 14 patients with sham acupuncture), the acupuncture is applied to bilateral Taichon (LR3), Hegu (LI4) and Baihui (GV20), 30 min in duration, 3 times/week for 7.5 weeks with a 4 day break in middle. The results indicated that the reduction of seizure frequency is not
significantly difference between two groups, thus, they do no support that acupuncture is beneficial for chronic intractable epilepsy [57]. A similar study is carried out in 34 patients with intractable epilepsy (18 patients received real acupuncture, the others16 patients received sham acupuncture)
, the results also do not supported that the acupuncture lack effect on health-related quality of life in patients with intractable epilepsy [58]. To sum up mentioned-above, no evidence to demonstrate that acupuncture is efficacy for the treatment of epilepsy under randomized, controlled trial.
Vagal nerve stimulation (VNS) had been applicable to the treatment of intractable epilepsy [59], The VNS and EA are consider that the anti-inflammation
and neuroprotection through the nucleus of solitary tract via VNS because he acupuncture or EA apply to scalp, face, auricular and body produce afferent signals via trigeminal, vagal and spinal nerve, respectively into the nucleus of solitary tract [60]. Our previous studies find 2 Hz and 100 Hz EA at bilateral Zusanli (ST36) can reduce pulse rate, therefore, EA at Zusanli (ST36) can induce a greater
parasympathetic activity [61]. Auricular acupuncture can activate parasympathetic activity, and the activity through nucleus of solitary tract to interference
desynchronization of electroencephalogram (EEG) epilepsy, and the activity via cholinergic anti-inflammatory pathway to inhibit inflammation. Thus, auricular acupuncture is suggested that has antiepileptic action [62]. Taken together, acupuncture including EA applies to several specific acupoints that can induce a parasympathetic activity maybe has antiepileptic effect. Further study is need in future.
6. Acupuncture in peripheral neuropathy 6.1 Bell’s palsy
Bell’s palsy is acute idiopathic facial nerve palsy, and is the most common unilateral peripheral facial nerve palsy. Although herpes virus infection is high suspected, whereas its etiology is still unclear until now [63]. The patients suffered from Bell’s palsy usually research for an additional acupuncture treatment except corticosteroids
in the acute stage period [64]. A Cochrane review considers that acupuncture improving Bell’s palsy, the evidence is inadequate and needs more high quality trail research [65]. A multiple , single-blind, stratified, randomized controlled trial, a total of 480 patients with Bell’s palsy is studied, the acupuncture at Dicang (ST4), Jiache (ST6), Hegu (LI4), Yangbai (GB14), Xiaguan (ST7)and Yifeng (TE17), 30 min including moxibustion for 5 min, 5 times/week for 4 weeks. The results indicated acupuncture and moxibustion improves facial nerve palsy [66]. In addition,
acupuncture treatment improves a patient with Bell’s palsy for 7 years history [67], and improves a pregnant patient with Bell’s palsy [68]. Taken together, although the evidence-based for efficacy of the acupuncture treating Bell’s palsy remains needs obtaining the support of more high quality trial, the acupuncture in patients with Bell’s palsy is a safety and valuable additional therapy.
6.2 Carpal tunnel syndrome
Carpal tunnel syndrome (CTS) is the median nerve is compressed with carpal tunnel, is the most common of the entrapment neuropathies. Surgical decompression is considered the definite treatment. The conservative treatment of CTS includes steroid injection, splinting etc. [69]. The acupuncture had been used to treat CTS as an adjunct. Sim et al. (2011) review 11 electronic research reports including 6
randomized controlled trials; the conclusion is that the acupuncture for symptomatic treatment of CTS is encouraging, but no adequate evidence to support its efficacy [70]. Yao et al. (2012) design a double-blinded, randomized controlled study in 34 patients with CTS, the results indicated that verum acupuncture is not superior to placebo acupuncture due to two groups improve the symptom of CTS 3 months after treatment, but no significant difference between them [71]. The fMRI is conducted to study somatosensory cortical plasticity in 13 adult patients with CTS and 12 age-and sex-matched healthy adults, the results indicate that acupuncture changes digit cortical representation of CTS patients 5 weeks after acupuncture treatment, whereas no similar result noted in healthy adults [72], and the verum acupuncture also induces a greater activity in the hypothalamus and deactivation in the amygdale in patient with CTS than healthy adults, therefore, acupuncture can coordinate limbic network between hypothalamus and amygdale [73]. The acupuncture apply to Daling (PC7) and Neiguan (PC6), twice/week for 4 weeks, produces a similar effect of prednisolone improving the symptoms and sign of patients with CTS [74], and these effects of the acupuncture maintain longer effect than prednisolone [75]. To sum up, although the evidence in the efficacy of the acupuncture for CTS needs more research and more rigorous study for support, the acupuncture as an alternative therapy for conservative treatment.
7. Conclusion
The acupuncture treatment of nervous system disorders is popular in Taiwan; the evidence-based demonstrate that the acupuncture treatment is beneficial including subacute and chronic stage of stroke for muscle spasticity, migraine prophylaxis, tension type headache, Bell’s palsy and carpal tunnel syndrome; the efficacy of the acupuncture need more evidence including acute stage of stroke for motor function, dementia including Alzheimer’s disease, vascular dementia, Parkinson’s disease, epilepsy etc.
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