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Archive for the ‘Neurology’ Category

Jun 3, 2014 A Madam e-mail To ArthurFan@ChineseMedicineDoctor.US
Dear Dr. Fan,
I spoke with you recently over the phone about my diagnosis of oromandibular dystonia. You had asked that I send you some background, as well as my address to send an herbal remedy to that you have found works well for dystonia patients.

I was diagnosed around 9 years ago by two neurologists (Lahey Cliinic, Mass General) with task-specific oromandibular dystonia. I was doing radio broadcasting (weather reporting) for a couple of years, which involved repetitive phrases and likely- at least in part- brought on the condition. I first developed symptoms while doing the reports in a recording booth, although my conversational speech was normal (behind the microphone I had symptoms, and stepping away from the microphone I had no symptoms). The symptoms intensified over time and I eventually had to quit the broadcasting. My conversational speech eventually became impaired, and it took at least a year (or more) for the condition to go mostly back into remission. I stayed away from the broadcasting until around 10 months ago, and have only been doing a small amount of broadcasting (two hours or so) a week. I started noticing symptoms returning while working in a research lab (that is my primary job and where I spend most of my time). It was a stressful year for me, as I was trying to get a couple of projects finished so I could publish the work- I had invited a colleague of mine to be a co-first author on this work, and we ended up having many stressful, intense conversations about the work that involved constant voice projection (the lab is loud because of background noises). I’m not sure if it was a combination of stress/anxiety coupled with voice projection, and perhaps also coupled with the little bit of broadcasting I had started doing again that brought the condition back. I was also volunteering for a couple of hours a week at a preschool- which involved more voice projection. I first developed symptoms while in the lab, talking with my colleague.

Years ago when the dystonia first appeared, I received scalp acupuncture treatments based on a protocol published in a Chinese journal that showed success in 19 early Parkinson’s patients. This was successful in relieving my symptoms. I’m on the same protocol again and am receiving treatments three times a week. I had published an article in Natural Solutions Magazine (formerly Alternative Medicine Magazine) in collaboration with my acupuncturist. Below my signature is an excerpt from the article.

I was wondering if you could send me information that I could pass along to my acupuncturist that details the protocol that you use with your dystonia patients? I would also be grateful to receive the herbal remedy that you have found works well for oromandibular dystonia. My address is(omitted in this article):

Thank you kindly for your time.
Best wishes,
E
(Excerpt from the published article):
I had been placed on a Bell’s Palsy acupuncture protocol for several months, since this was- at the time- the only neurological disorder my acupuncturist was familiar with, and unfortunately one that is characteristically very different from dystonia. I was about to quit the acupuncture since it wasn’t bringing me any real benefit, when I asked her if she knew of any protocols used to treat Parkinson’s disease- the closest disorder to dystonia that I knew of. Although researchers have not found a direct link between dystonia and Parkinson’s disease, there is great interest in some of the symptom crossover, and research groups are actively trying to better understand the overlap between the two movement disorders. Since Parkinson’s and Dystonia are both neurological and result in similar signs and symptoms, it was possible that a Parkinson’s acupuncture protocol could be adapted to a dystonia patient.

My acupuncturist found a journal article that outlined a protocol that involves both body and scalp acupuncture, and which is used to treat Parkinson’s patients.1 Acupuncture can help relieve symptoms by altering blood hormone levels. In Traditional Chinese Medicine (TCM), Parkinson’s and dystonia are believed to be caused by genetics, aging, damage from excessive emotions, faulty diet, and chronic disease. Parkinson’s and Dystonia in TCM are seen as an inability of the blood and yin to nourish sinews and vessels, resulting in contraction, stiffness, and rigidity. The liver in TCM is what governs the sinews, and if the blood and yin become deficient, yang can become hyperactive, resulting in liver wind. These disorders mainly take root in the liver, but can lead to more complex presentations such as phlegm accumulation, qi and blood stagnation, and spleen and kidney deficiency. In TCM, you treat the root cause; in this case, treatment would involve settling the liver and extinguishing wind, and the manifestations, such as phlegm, stagnation, and/ or deficiency. One small study, An Acupuncture Protocol for Parkinson’s Disease,2 showed a total amelioration rate of 84.2 percent when scalp acupuncture was incorporated into an acupuncture treatment.

 

Arthur Yin Fan,CMD,PhD,LAc Jun 3,2014(E-mail) To A Madam (e-mailed me above)

Hi, E,

You may still use scalp and body acupuncture you mentioned. Take time. And also use some local points.

For herbal medicine, we have two:
(1) Pattern based herbology, heal tea.
(2) Dystonia focused herbal pills. It is called Liu Jun San capsule (100 capsule/per bottle, use 3#, 3 times a day).
It was a Chinese FDA (local branch) approved for hospital use (my former hospital).

 

A Madam Jun 3,2014 To Arthur Yin Fan,CMD,PhD,LAc

Dear Dr. Fan,

Thank you very much. I would like to try the dystonia focused herbal pills (if this is what you would recommend for my condition). I had seen a Youtube video of a gentleman with oromandibular dystonia that you had helped, whose symptoms looked (and sounded) identical to my own (lower left lip spasms, pursing of the lips, difficulty speaking). Did he take the dystonia focused herbal pills, or the pattern based herbology, heal tea?
Thank you again,

E

From: A Madam To: ArthurFan@ChineseMedicineDoctor.US
Sent: Thursday, July 10, 2014 8:19 AM
Subject: Request for more dystonia-specific herbal capsules

Dear Dr. Fan,
The herbal capsules that I received from you (Liu Jun San, 3 bottles in early June) seem to be working very well for me. My condition within two weeks of taking them went into a near remission. I still have symptoms, however my conversational speech has dramatically improved and I am even still able to do some radio broadcasting each week. I have also been doing scalp acupuncture, which might be synergistic with the capsules. I was also taking herbal teas prepared by my acupuncturist for several weeks prior to taking the capsules- She said there was some overlap in the ingredients in the teas versus what is in the capsules.

I would like to order another shipment of Liu Jun San for next month. I would actually be interested in continuing to take these capsules indefinitely, as I believe they might be effective in suppressing my symptoms. Is it possible for me to receive an automatic shipment every month, with the money taken out of my credit card each month automatically?

Thank you kindly.
Best wishes,
E

  • Jul 11 at 9:46 PM  To  Arthur Yin Fan,CMD,PhD,LAc
Wonderful! Thank you so much!
I was at a party this evening, by the way, and I was discussing my condition with someone. She said she never would have known if I hadn’t told her. I really am doing so much better- Thank you!
E

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Acupuncture helped the mother overcome the migraine and hypertension during pregnancy

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Acupuncture and Chinese herbal medicine is very effective in Guillain-Barre Syndrome’s recovery in some cases.

Here we have a case record in video, I hope patients with Guillain-Barre Syndrome don’t get frustrated, use acupuncture or/and Chinese herbal medicine as early as possible, in most of cases, very good.http://www.youtube.com/watch?v=6Ngu5WrPDcE&feature=youtu.be

http://ahref=

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Recently, I treated the third patient with Vulvodynia with acupuncture. The result is very encouraging.

Ms. D.  a middle age Caucasus woman came to see me because she has been frustrated with various treatments for her IC (Interstitial cystitis), she heard I had treated a IC patient very successfully with acupuncture. She had urinary tract bacteria infection, which was recovered after the extensive antibiotic treatments, however, after that, she still has urinary frequency and strong burning pain when urination. She has been diagnosed as Interstitial cystitis, and then secondary developed Vulvodynia and pelvic bottom dysfunction.

When Ms.D. started to see me, she told me her physical therapist had treated her for several months. She had many trigger points and knots around the tail bone, anus and both sides of vulva(esp. right), both  inner sides of thighs.

After six sessions’ acupuncture, included in local A’shi / trigger point treatments and adjusting liver, spleen, kidney meridians, patient’s pain has been improved 60%, most of trigger points and knots at both thigh and around tail bone disappeared. The urinary frequency still there, but the burning pain decreased. Patient is very happy and still under our treatment, twice a week.

Notes on 08/20/2012: patient’s overall health condition has been improved, the thighs’ pain no longer exist. The pain around tail-bone, anus, and vaginal only 5-10% left. Most of days seem no a lot of pain. The uncomfortable in bladder area, and urine urgency better, but there has not been improved much. This means: her IC issue didn’t get big improvement, but the vulvodynia and leg pain, pain around anus close to clinically cured.

Here is another article from online, for your information.

Vulvodynia and Acupuncture Treatments

By Maryann Child, Acupuncture Physician
www.coralspringsacupuncture.com 

http://www.vulvodyniasupport.com/acupuncture.html

Vulvodynia is a condition, which few in the medical profession have yet to resolve or even understand. Little research exists and little is known about its origins or how best to treat it. What does seem apparent is that for those women who do have it, it is a constant daily dis-ease. Characteristics of Vulvodynia may vary from woman to the next, what is very certain is that there is usually pain and possible burning of the vulva. The level of pain can change from mild to severe. The etiology behind the condition may vary from one woman to the next, so differential diagnosis is essential for individual patient care. This differential diagnosis is what sets Chinese Medicine aside from Western Medical approach. Two women with the same diagnosis may have completely different disharmonies, so treatment is very unique to the patient’s personal body care.

Acupuncture may be a treatment option for Vulvodynia and Vestibulitis. In the proceedings workshop sponsored by the US Dept of Health in collaboration with the National Institutes of Health, National Institute of Child Health and Human Development, Office of Research on Women’s Health, and the National Office of Rare Diseases on April 14-15, 2003, discussion on the lack of understanding and research on the subject of vulvodynia was addressed. Dr. Elizabeth Stewart, of Harvard University had stated that physical therapy might alleviate the vulvar pain that was referred from the ligaments and joints in the spine and pelvis. One study did confirm that patients that used acupuncture to alleviate the pain showed improvement, and over all quality of life. She also did state that surgery for Vestibulitis was highly controversial because of the lack of clear pathophysiology for vulvar pain. There was great concern over cosmetic results. The overall consensus is that there is a relationship to the pudendal nerve being pinched. In Europe and in pain centers in the US, decompression of the nerve is attempted. Acupuncture is a great alternative to relieve compression of this nerve, and to strengthen overall system health.

Acupuncture is part of an ancient system of healing which incorporates all aspects of the physical and non-physical bodies. It is part of a larger doctrine called Oriental Medicine or Traditional Chinese Medicine. The belief is there is a vital energy that surrounds all living things. We call this “qi” or “prana”. It seems that just about every ancient culture has a name for it. We all recognize it as being real and existing. Even allopathic, western medicine has a name for it “vitality”. It is within this energy that the practitioner works his or her art. Constantly changing and creating harmony where there is disharmony, tonifiying what has been depleted and rectifying what has been in exuberance. The I ching states that all things are constantly changing and that nothing stays the same. This is the beauty of life. Every practitioner counts on this change to occur. After every treatment one anticipates the positive change in the body, hoping to rectify its disharmony. Acupuncture points are small areas of energy that spiral round, each with a different action and indication. These small energy spirals travel a pathway, which for the most part connect to an internal body organ. However there are other pathways that do not connect to any organ, these are referred to as extra ordinary pathways. Then lastly there are smaller pathways that diverge from the larger ones and cross the body. These smaller pathways allow for even the smallest communication between energy and body. The insertion of a needle into an acupuncture point creates communication between the function of the point and the body’s energetics. The formulation of points creates a reaction in the body. The body accepts the information and begins a cycle of change. Cycles of change can vary from one body to the next. Gradual improvement of symptoms is what is expected.

In Traditional Chinese Medicine the body is viewed as having patterns of harmony and disharmony. A practitioner pays very careful attention to what the condition of the body is. One examines closely what the blood is doing, what the “qi” is doing, and what it is not. The practitioner further seeks to determine where the patterns of disharmony exist. Differential diagnosis is attained and treatment to restore the body is begins. Women’s bodies are so diverse, that there are no two bodies alike. With treating Vulvodynia, I have noticed that even though there may be some similarities between patient’s symptoms, their etiologies or rather the root cause of the disorder is very different.

I first became aware of this disharmony about five years ago around the year 2000. I began treating a young patient who complained of sheer fire burning of her external genitalia. I remember feeling a bit puzzled because I had not heard of such a condition, so naturally I began to do some research. Very few of my colleagues had even heard of it. No one in my area had ever treated it. With this I began her treatment protocol.

The response that I have seen from my patients, lead me to believe that VV is completely treatable and I will explain why. I will cite two examples of patients that were treated with Acupuncture. What follows are two brief patient cases that were treated with Acupuncture. I’d like to mention that both patient’s are still receiving treatment, and are still obtaining very favorable results.

Mrs. P is a 35-year-old non-smoking married woman who was recently given a name to her burning and stinging of the vulva. For the past two years she has been treated for urinary tract infections. She has a history of low back pain and migraines. Although her migraines were a big concern for treatment, even more so was the constant irritation of the vulva. Mrs. P had a total of four treatments over the course of one month before significant results were obtained. Currently Mrs. P still comes in for treatment one time a month occasionally twice a month. Mrs. P is still undergoing treatment and is about 60 to 70 percent improved. There are many days where she is free from burning and stinging. She can remain free of discomfort for many weeks at a time.

Miss. M is a 49 year old, non-smoking non-married woman who was diagnosed
with Vulvodynia over the summer of 2004. The pain started in 2003, but was recently given a diagnosis. Her major complaint is pain of the vulva. The pain is drawing in nature. The pain is worse while sitting and better lying down. Mrs. was initially treated with Chinese herbal formulas that were modified specifically for her disharmony. Three weeks into treatment she began to feel improvement of her symptoms. Initially her improvement was minimal, then gradually began to feel better. Currently Mrs. M is treated every 4 to 6 weeks.

I wish to express my very concern for the lack of study on VV and treatment. Many women that I have seen have informed me of different experimental procedures that their Dermatologist, Gynecologist and Neurologists have mentioned. I say experimental because there is no significant data to show proof of success. I have even heard of a new use for botox. Injecting botox was the latest that I have heard this week. This is a desperate attempt in the medical world. Although there is no concrete evidence of a cure, in any medical model, all physicians would like to see a resolution of Vulvodynia. I hope if nothing else to bridge the gap between a woman and her options for treatment.

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On November 21, 2011, Dr.Fan got a special call from a patient’s close friend, invited Dr.Fan to see a deep coma patient in INOVA Fairfax hospital neuroscience ICU ward. The visit was approved by that facility and its attending doctor.

The patient is a 67-years old gentleman who is a main minister of a local Indian Sikh temple. He got a hemorrhagic stroke in his brain stem area seven days ago when he did some home repairing.  The hematoma was large and he had an emergency surgery when he was sent to ER by an ambulance. When I saw him, he had no any reflection and no any reaction to strong stimulation. His respiration was irregular and had to use breath machine. He had fever, 102 degree F. He was under antibiotics and respiration stimulating medication.

Considering: Stroke, Bi Pattern(闭证).

I gave him An Gong Niu Huang pills(dissolve in warm water, once every 8 hours, i.g.), and did acupuncture for him.

Acupuncture points were: Ren Zhong, Yin Tang, Feng Chi, He Gu, Qu Chi, Ba Xie, Ba Feng, Zu San Li, Yong Quan. The stimulation was about one hour.

November 22, 2011: seemed have some effects. patient very occasionally move his leg slightly when I stimulated his Yong Quan points.

November 23, 2011: patient had more reaction to acupuncture, the frequency of moving his leg, fingers, head, slight more than one day ago.

November 24, 2011: condition was same as before. The tube from skull to test ICP removed.

November 25, 2011(5th treatment): patient was still in deep coma, responding to acupuncture stimulation more often, seem every 5-10 stimulation he could have a responding.  Stopping use antibiotics and respiration stimulating medication. The iv tube to central vein was removed and only used iv tube in arm vein.

November 26, 2011(6th treatment): patient was moved to Intermediate Unit from ICU. The condition was not good as yesterday. The doctor there discussed patient’s condition with his family members, suggested that this patient was still in very critical condition and his future was not so optimistic. Patient’s family members seemed considering give-up.

I did not give patient more treatments since then.

During six days I involved in his treatments, I feel Chinese medicine, included in An Gong Niu Huang Pills and acupuncture did show some effects, such as some responds to pain stimulation(relection recovered a little bit). However, this patient’s condition is too severe, he didn’t recover from the deep coma.

Although this invitation was by patient’s family and close friends, the facility and doctor in ICU did allow the doctor or practioner in Chinese medicine /acupuncture to see and treat patient. This is much open than a few years ago.

I remember, I saw a coma patient in Johns Hopkins Hospital two years ago, that facility did not allow patient to use Chinese herbal medicine, which needs special approval by hospital administration (the procedure would take half-year).

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Acupuncture For The Treatment Of Adductor Spasmodic Dysphonia
Steven Scheer, MD; Linda Lee, PhD

From http://www.medicalacupuncture.org/aama_marf/journal/vol14_3/article4.html

Vol. 14, #3

ABSTRACT
Background
     Spasmodic dysphonia (SD), a rare neurologic spasm of the vocal folds, results in a chronic voice disorder that can affect patients’ quality of life. Current treatment, including surgery and botulinum toxin injections, produces inconsistent results.
Objective     To investigate the use of acupuncture in the treatment of SD.
Design, Setting, and Participants   Prospective case series of 10 individuals (n=9 women; mean age, 45 years) with adductor SD in a metropolitan Ohio area during 2001.
Intervention     Eight sessions (1 week apart) of acupuncture using the LU-LI distinct meridian; during sessions 2-8, electrical stimulation was applied. Auricular acupuncture to “larynx” points during sessions 4-8
Main Outcome Measures     Self-report of participants’ perception of sound and ease of voice production, as well as changes in vocal quality observed by speech/language pathologists and subjects’ associates.
Results     There was no value in the LU-LI treatment without electrical stimulation. Seven of the 10 participants reported vocal improve-
ment, and 2 others noted improvement during specific times of the investigation. Seven rated satisfaction as 3 or higher on a 5-point scale. Seven individuals reported that others noted vocal improvement.
Conclusions   Most participants reported improvement in vocal quality and speech production following acupuncture treatment. Further research of acupuncture for SD is needed.
KEY WORDS
Spasmodic Dysphonia, Voice Disorder, Acupuncture, Overadduction, Overabduction

INTRODUCTION
he neurologic condition known as spasmodic dysphonia (SD) or uncontrolled spasm of the vocal folds results in a chronic voice disorder.1,2 Believed to be related to the focal dystonias that include blepharospasm, torticollis, and writer’s cramp, SD is defined as an extreme overadduction or overabduction of the vocal folds that interferes with phonatory vibration.3-6 SD does not respond well to conventional voice therapy, behavior modification, or oral antispasmodic medication.5

While SD is rare (current estimates are 1 case in 20,000 persons), for many individuals, it is extremely disabling in life and work.5 The range of onset is from 3 to 85 years, with a mean around 38 years. It occurs more often in women (58%) than in men (42%).6 There are adductor, abductor, and mixed types of the condition, and some patients have symptoms of other focal dystonias as well.6 In the most common form, the adductor type, voice production is characterized by strain and effort, pitch or voice breaks, and there are occasional complete blocks in the ability to sustain the vibratory cycle.7-9 Because of the hyperadduction of the vocal folds and the amount of effort needed to phonate during spasms, many patients complain of physical fatigue, tension in the muscles surrounding the neck, and shortness of breath. Some persons with SD develop fear of speaking that may interfere with holding a job or even maintaining relationships. Use of the telephone is especially difficult for others. Initial thoughts on the possible psychiatric origin of SD have since been discounted.3,4 The presumed central nervous system site of the pathophysiologic disturbance is in the basal ganglia; exactly where is unclear, as is the case with other focal dystonias.10,11

Until recently, persons with this development were forced to resort to either surgical resection of the recurrent laryngeal nerve or the laryngeal muscles, or to the injection of botulinum toxin into one or, rarely, both vocal folds.2,12 Dedo and Izdebski2 established a surgical approach involving unilateral resection of the recurrent laryngeal nerve. While the initial success was reportedly high, subsequent reports suggested that the return of vocal cord dystonia and a worsened vocal quality were as high as 60% in the 3-year follow-up period.12

Another surgical approach, laryngoplasty, caused vocal cord relaxation but with a potential sacrificed loss of pitch and loudness.12 A newer procedure developed by Berke et al12  that prevents reinnervation of the vocal cord adductor muscles appears promising, but is still being investigated.

Use of botulinum toxin was approved by the US Food and Drug Administration (FDA) in 1989 for treatment of blepharospasm (eyelid spasm).7-9 The toxin blocks the release of acetylcholine at nerve terminals. If directed to localized areas of innervated muscle, botulinum toxin can be an effective local paralyzer of unneeded muscle action.

Shortly after its FDA approval for blepharospasm, botulinum toxin was used off-label for the treatment of SD.7 Following injection, the paretic muscle loses its spasm, but the vocal quality after treatment is quite variable: some patients have only a whisper for a number of weeks after injection while others have only a brief remission from the spasm and a return of the entirety of vocal problems within a few months.8,12,13

The procedure is expensive ($500-$750 per injection) and must be repeated every 2-12 months indefinitely.8,12,14 Each injection is followed by occasional difficulty in swallowing.8,12 Over time, botulinum toxin may lose its effectiveness, perhaps due to calcification of the injected muscle.14 Unofficial estimates of the frequency with which botulinum toxin injection is used for disabling SD are approximately 75% of patients with the condition.

A group of academic speech/language pathologists at the University of Cincinnati learned of a limited case study on the use of acupuncture for SD in 1997.15 The patient who underwent acupuncture therapy for SD improved on all measures of voice parameters even after a 6-month follow-up period. The exact nature of the acupuncture treatment was not identified in the report and an attempt to reach the investigative team was unsuccessful.

The first author participated as one of two physician acupuncturists in a pilot study of individuals with adductor SD in metropolitan Ohio. We intended to identify, using a few types of acupuncture treatments, whether a combination of methods could improve acoustic measures of voice and perception of vocal quality. We also hoped to determine which of a battery of measurement procedures best described the effects of treatment.

METHODS
Patient Selection
Ten individuals with adductor SD were investigated during 2001. The participants were drawn from the files of local speech/language pathologists or were recruited through an advertisement in the local SD newsletter. Participants ranged in age from 31 to 70 years (mean 45 years). Nine of the participants were women.

Five individuals had never received botulinum toxin injections, either because they were newly diagnosed or because they had rejected its use. Of the remaining 5 who had received botulinum toxin in the past, we excluded from consideration any persons who been treated within 12 months of the 1st acupuncture session. None of the 10 had undergone surgical treatment for SD. All eligible individuals gave informed consent to participate. The research proposal was reviewed and approved by the institutional review board of the University of Cincinnati.

Speech Evaluation
All clinical testing of speech variables was performed independently by 3 licensed speech/language pathologists from the University of Cincinnati or Miami University of Ohio. Main outcomes included measures of voice analysis (Kay Elemetrics Motor Speech Profile, CSL Model 4300B, Lincoln Park, NJ), and a self-report of participants’ perception of sound and ease of voice production (Voice Handicap Index16). Additional perceptual voice analysis was performed after participants were tape-recorded while reading a standard passage. After the treatments were completed, participants were asked a series of open-ended questions regarding their experience with the protocol, changes in vocal quality noticed by themselves, coworkers, or family members, and future plans regarding acupuncture. Participating physicians did not collect any data so as to minimize observation biases.

Acupuncture Treatment
 The acupuncture protocol (Table 1) was devised by two treating physicians, with input from Dr Joseph Helms and reference to primary texts.17,18 Each participant received 8 treatment sessions, spaced about 1 week apart. For each treatment, participants were placed on a padded plinth in the supine position. Music was played for added relaxation. Session 1 began with a brief description of the procedure to allay anxiety about acupuncture.

In each of the 8 sessions, the protocol required use of the LU-LI meridian17 (Figure 1) plus a focusing point at ST 9, electrically stimulated for all but the 1st session: LU 1 and LI 15 (crossed for negative black clip), LI 18 and ST 9 (crossed for positive red clip). Needles at ST 9
(Figure 1) were directed inward toward the middle of the thyroid cartilage lamina. Stainless steel Seirin 40- and 6-mm needles were used for the LU-LI meridian approaches. During sessions 2-8, a 3-channel electrical stimulator (OMS Medical Supplies Inc, Braintree, Mass) was used at either 80 Hz or 15 Hz. The needles were left in place for approximately 30 minutes. For body tonification points electrically stimulated during the 8th session, 2.5 Hz frequency was chosen. During sessions 2 through 8, attempts were twice made to turn up the intensity of electrical stimulation during each session to enhance the effect.

Ear acupuncture, used initially in session 4, featured double needling of both the French and Chinese “larynx point,” located respectively on the medial surface of the tragus and just posterior to the external auditory meatus on the cavum conchae19 (Figure 2). For ear acupuncture and for the needling of Ting points (LI 1 on the index finger tip, ST 45 on 2nd toe tip), 15-mm plastic-handled Seirin needles were used. Ear tacks 1.5 mm long were placed on the 2 larynx points of both ears for 5 days after session 6.

All participants received exactly the same acupuncture treatment protocol in sessions 1 through 3. Beginning with session 4, the acupuncturists allowed each patient to provide some input as to the efficacy of the previous 2 sessions. For sessions 4-8, the use of either 15 Hz or 80 Hz stimulation frequency was determined by the participants’ individual input as to which of treatments 2 or 3 provided the better week-long improvement. In sessions 7 and 8, participants could choose between use of Ting points (from session 6) or body tonification points (from session 5), again according to their self-perception of improvement.

 Table 1. Acupuncture Protocol by Session

Session

Protocol

1

LU-LI distinct meridian, needles in dispersion, for 30 minutes

2

No. 1 plus electrical stimulation, 80 Hz for 30 minutes

3

No. 1 plus electrical stimulation, 15 Hz for 30 minutes

4

No. 2 or 3 plus double needling of both “larynx points” in each ear, 60 minutes

5

No. 2 or 3 plus body tonification points (LI 4, ST 36, SP 6, LV 3, MH 6) for 20 minutes

6

No. 2 or 3 plus double needling of LI and ST Ting points for 20 minutes; ear tacks placed on bilateral larynx points for 5 days

7

No. 2 or 3 plus choice of Ting or tonification points from sessions 5 or 6

8

No. 2 or 3 plus choice of Ting points or electrical stimulation of LI 4 and SP 6 at 2.5 Hz plus needles in other tonification points: ST 36, ST 43, PC 6, HT 3, LV 3

RESULTS
Participants showed significant improvement in some measures of vocal production and movement from outside to within normal range following treatment for many variables, even when statistically significant differences were not observed. Additionally, patients reported statistically significant improvements in their daily voice use on the Voice Handicap Index.

There was no value in use of the LU-LI Distinct Meridian treatment without electrical stimulation. Some participants were generally satisfied with the use of the Distinct Meridian; however, that was after at least 2 sessions that included electrical stimulation. Participants were equally likely to choose the 15-Hz or 80-Hz frequency setting for sessions 4-8.

Participants disliked the use of Ting points and did not feel they represented added value to the treatment; neither was there positive consensus about use of the body tonification points. Beginning with session 4, some individuals experienced reduction in vocal fold spasms with auricular stimulation at the French and Chinese “larynx” points. By the end of the study, the greatest improvements were noted when electrical stimulation was added to the Distinct Meridian treatment (session 2), and when the ear larynx points were stimulated (sessions 4 and 6). However, objective measures of voice production were more inconsistent in showing a positive response within 10 days after the protocol was completed.

Figure 1. Diagram of the Lung-Large Intestine Distinct Meridian Acupuncture Points
Point 1 (LI 18) is located on the middle belly of the sternocleidomastoid muscle, lateral to point 2. Point 2 (ST 9, slightly displaced) is located at the anterior border of the sternocleidomastoid at the level of the thyroid cartilage. Point 3 (LI 15) is on the upper deltoid, just in front of the acromion. Point 4 (LU 1) is 2 in below the acromial end of the clavicle, in the depression. For electrical stimulation during sessions 2-8, needles at 3 and 4 were crossed and clipped by the negative pole stimulator (black); needles at 1 and 2 were crossed and clipped by the positive pole stimulator.

 

On a post-treatment questionnaire, 7 of 10 participants reported improvement in their voices, and 2 others noted improvement during specific times in the protocol. Seven of 10 individuals rated their satisfaction with treatment for voice quality as a 3 or higher on a 5-point scale. Six rated as 3 or higher their feelings about amount of voice change. Seven stated that family members and friends noticed improvement, and 3 of the 7 who were employed said coworkers noticed improvement.

DISCUSSION
With its significant life effects, persons with SD are frequently desperate to receive treatment for their voice disorder. 20,21 Surgery on the vocal mechanism that will yield consistently good outcomes for persons with SD is still being investigated.12 The usual treatment available in larger medical centers, and sought by patients who must sometimes travel long distances to receive it, is botulinum toxin injections repeated every 2-12 months.7-9,12,13 An available alternative to botulinum toxin injections or a treatment that would extend the period between injections would be well received.

Therefore, we were hopeful to find which of several types of acupuncture could benefit persons with SD. We were aware of only 1 other published account of the use of acupuncture for a single patient with SD.15 The points used and treatment protocol were not identified in that study.

Our decision to use the LU-LI meridian was based on its trajectory and territory of influence that incorporates the trachea,vocal cords, and larynx.17 Use of the focusing point at ST 9 (Figure 1)
is an obvious choice for all laryngeal disorders. Use of ear acupuncture seemed reasonable because muscle sites represented on the ventral surface of the ear will readily relax with stimulation. The larynx points on the ear were commonly quite tender to touch and to needling, as typically occurs in auriculotherapy, in which a pathologic body part can appear to be “hot” in its corresponding ear representation.19 One of our consulting experts recommended use of the Ting points, but a limited trial at session 6 was not well received by our participants for subsequent sessions. Ting points are generally more useful for surface-level problems.19

Figure 2. Ear Acupuncture Points
C indicates Chinese “larynx” point inside tragus; F, French “larynx” point posterior to external auditory meatus.

We chose to use a standard protocol for each individual, allowing only a limited variation determined by participants’ input for the choice of frequency stimulation rate in the LU-LI meridian, and a variation on sessions 7 and 8 depending on the individual’s perception of better effects between sessions 5 and 6. Overall, each individual received generally the same treatment.

Individuals with previous botulinum toxin injections were allowed to participate because we believed that to have a sufficient sample size for our pilot study and for any future research on the use of acupuncture in SD, there was and will be a need to include individuals who have already had these injections.

Some participants reported week-to-week variation in the extent of improvement. The most dramatic and rapid laryngeal response to acupuncture was derived from bilateral needling of the larynx points on the inner surface of the tragus (Chinese larynx point), and the point 3 mm posterior to the external auditory meatus on the cavum conchae (French larynx point). One individual was speaking just as the ear larynx point was needled, and both he and the physician noted a dramatic change in vocal quality as the needle entered the point. The effect on that occasion lasted several days though the needle was removed after 60 minutes. Because of their awareness of the success of ear stimulation, some of our participants continued to use either a “pointer plus” 10-Hz ear point stimulator or a specially developed ear stimulator (provided by Dr Onje Erfan of Denver, Colo) that delivers electrical stimulation of several frequencies simultaneously. One month following the study, 5 of the individuals were self-stimulating the ear for their perceived improvements. At least 1 individual was still using ear stimulation bi-weekly 1 year later.

When asked to characterize their feelings about the effects of acupuncture in open-ended questions, a majority of study participants and frequently, their family members or coworkers, were positive. When asked to characterize the improvements, participants commonly described a reduction in the effort required to speak, and in perceived laryngeal tension while speaking. They commented that their voices, though still not normal, were more “functional” and could be “counted on.”

Future studies of the use of acupuncture for SD should consider scalp acupuncture and Koryo Hand acupuncture. There may be additional acupuncture programs derived from a Traditional Chinese Medicine (TCM) protocol that can be found through a Chinese literature search. A crossover design that uses different acupuncture methods would be beneficial, but a larger population will be needed to show significant differences. Finally, a trial that randomizes SD patients into either botulinum toxin injections or acupuncture treatment would be reasonable.

CONCLUSION
We undertook a pilot study to ascertain whether any of several standardized acupuncture treatments could ameliorate the vocal fold spasm and improve voice quality in persons with adductor SD. We found that a majority of our participants obtained subjective benefits in the ease of producing spontaneous speech through acupuncture treatment. The most useful approach included electrical stimulation with the LU-LI Distinct Meridian and auricular acupuncture on the larynx points. Further investigation of acupuncture for the treatment of adductor SD is warranted.

ACKNOWLEDGEMENTS
We sincerely thank Samantha Daughton, MA, Joseph Stemple, PhD, Barbara Weinrich, PhD, Tracy Miller-Seiler, MA, and Scott Goeller, MD, for their help in conducting this investigation. We also thank Susan Schmidt, PhD, and Aviva Scheer, PhD, for their editorial comments, and John Barrord, MD, for graphics work.

REFERENCES

  1. Frontis E. Results of a National Survey. National Spasmodic Dysphonia Association, reported by the Center for Voice Disorders of Wake Forest University; June 6, 1992.
  2. Dedo HH, Izdebski K. Intermediate results of 306 recurrent laryngeal nerve sections for spastic dysphonia. Laryngoscope. 1983;93:9-16.
  3. Aronson AE, Hartman DE. Adductor spastic dysphonia as a sign of essential (voice) tremor. J Speech Hear Disord. 1981;46:52-58.
  4. .Parnes SM, Lavorato AS, Myers EN. Study of spastic dysphonia using videofiberoptic laryngoscopy. Ann Otol Rhinol Laryngol. 1978;87:322-326.
  5. Colton RH, Casper JK, Hirano M. Understanding Voice Problems: A Physiological Perspective for Diagnosis and Treatment. Baltimore, Md: Lippincott
    Williams & Wilkins; 1996.
  6. Koufman JA, Blalock PD. Classification of laryngeal dystonias. Center for Voice Disorders of Wake Forest University Web site. Link: http://www.thevoicecenter.org/class_ld.html. Verified January 23, 2003.
  7. Blitzer A, Brin MF, Fahn S, Lovelace RE. Localized injections of botulinum toxin for the treatment of focal laryngeal dystonia (spastic dysphonia). Laryngoscope. 1988;98:193-197.
  8. Ludlow CL. Treatment of speech and voice disorders with botulinum toxin. JAMA. 1990;264:2671-2675.
  9. Zwirner P, Murry T, Swenson M, Woodson GE. Acoustic changes in spasmodic dysphonia after botulinum toxin injection. J Voice. 1991;5:78-84.
  10. Cannito MP. Neurobiological interpretation of spasmodic dysphonia.
    In: Vogel D, Cannito MP, eds. Treating Disordered Speech Motor Control.
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  11. Schaefer SD, Finitzo-Geiber TJ, Freeman FJ. Brainstem conduction ab-
    normalities in spasmodic dysphonia. In: Bless DM, Abbs J, eds. Vocal Fold Physiology. San Diego, Calif: College-Hill Press; 1987:393-404.
  12. Berke GS, Blackwell KE, Gerratt BR, Verneil A, Jackson KS, Sercarz JA.
    Selective laryngeal adductor denervation-reinnervation: a new surgical
    treatment for adductor spasmodic dysphonia. Ann Otol Rhinol Laryngol. 1999;108:227-231.
  13. Ford CN, Bless DM, Patel NY. Botulinum toxin treatment of spasmodic
    dysphonia techniques: indications, efficacy. J Voice. 1992;6:370-376.
  14. Lee RE, Tartell PB, Karmody CS, Hunter DD. Association of adhesive macromolecules with terminal sprouts at the neuromuscular junction after botulinum treatment. Otolaryngol Head Neck Surg. 1999;120:255-261.
  15. Crevier-Buchman L, Laccourreye O, Papon JF, Nurit D, Brasnu D. Adductor spasmodic dysphonia: case reports with acoustic analysis following
    botulinum toxin injection and acupuncture. J Voice. 1997;11:232-237.
  16. Jacobson BH, Johnson A, Gryswalski C, et al. The Voice Handicap Index (VHI): development and validation. Am J Speech Language Pathol. 1997;6:
    66-76.
  17. Helms J. The distinct meridian subsystems. In: Acupuncture Energetics: A
    Clinical Approach for Physicians. Berkeley, Calif: Medical Acupuncture Publishers; 1995:189-214.
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    for dysphonic patients. J Voice. 1998;12:540-550.

AUTHORS’ INFORMATION
Dr Steven Scheer’s specialties are Physical Medicine and Rehabilitation, Sleep Medicine, and Medical Acupuncture.

Steven Scheer, MD*
St Luke Hospitals
85 No Grand Ave
Fort Thomas, KY 41075

Linda Lee, PhD, is Professor and Graduate Program Director in the Department of Communication Sciences and Disorders at University of Cincinnati, Cincinnati, Ohio. She teaches and conducts research in the areas of voice disorders, craniofacial anomalies, and respiratory disorders.
Linda Lee, PhD
University of Cincinnati
Dept of Communication Sciences and Disorders
202 Goodman Ave
Cincinnati, OH 45267-0379
E-mail: Linda.lee@uc.edu

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BENIGN ESSENTIAL TREMOR RESOLVED WITH ACUPUNCTURE

 

Cristina S. de la Torre, M.D.

 

 Medical Acupuncture. A Journal For Physicians By Physicians

Fall / Winter 1989 – Volume 1 / Number 1
“Aurum Nostrum Non Est Aurum Vulgi”

 

ABSTRACT– This article reviews the complete resolution of a case of benign essential tremor, in a patient treated with acupuncture, who previously had limited response to drug therapy. Three treatments were given over a three-week period. The patient’s tremor of the head and upper extremities resolved 100%, and she has remained asymptomatic to date (5 months after the last treatment).

 

     In April, 1989, a 38-year-old white female, presented with the chief complaint of intolerable shaking of her head for over one year. From 1987 until then, she was treated for a variety of routine conditions at the practice. She had been diagnosed as having benign essential tremor for many years. Her mother, also a patient of the practice, reported that the patient suffered tremor of the upper extremities since approximately age 2~3, being nicknamed “shaky bones” by her peers. The main medications were propanolol and diazepam, which only provided modest reduction in the intensity of the tremor.
Her condition had been extensively studied at several medical centers, where she was repeatedly told that “she had to learn to live with the tremor, hopefully obtaining some relief by taking prescribed medications”.
The patient’s family history was significant for alcoholism in both parents, a disease which had also afflicted her. She became a heavy drinker between the ages of 21 and 25, and then again between 35 and 37. Other significant medical history included asthma in childhood, excision of an ovarian cyst in 1970, and a twin pregnancy delivery in 1982. The patient is married and owns a successful business.
Marked tremor of the upper extremities (1,2,3), both postural and during voluntary activity, was observed since her first visit in 1987. Around February, 1988, the patient began to notice tremor of her head, which had not been present previously. In May, 1988, she was hospitalized for alcohol detoxification. Soon after discharge, she complained of worsening of her head tremor. She continued sober but increasingly tremulous u ntil April, 1989, when she returned, requesting acupuncture to help her with her head tremor, which by then had become intolerable.
The patient’s constitution was determined to be JUE YIN- Wood, on the East position, according to Dr. Yves Requena’s classification (4). Treatment was then organized following Dr. Maurice Mussat’s “Energy of Living Systems” theory (5,6), specifically the use of triangular equilibration.
Her first treatment, on April 14, 1989, consisted of a JUE YIN triangular equilibration in evolution, using points along the JUE YIN (Lived Master of the Heart), ABSOLUTE YIN (Conception Vessel), and YANG MING (Large Intestine/Stomach).
On her follow-up visit, one week later, she reported great improvement of her head tremor, and mentioned the onset of an unusual craving for sweets. She was then treated with a TAE YIN simple triangular equilibration, with points on TAE YIN (Spleen/ Lung), YANG MING and ABSOLUTE YANG (Governor Vessel).
On her third visit, on April 27, she reported further improvement of her head tremor, and an unexpected complete resolution of her upper extremities tremor. It was then decided to conclude her treatment series with a SHAO YANG simple triangular equilibration (Triple Heater/Gall Bladder), SHAO YIN (Kidney/Hear[), and ABSOLUTE YANG. She was instructed to return 3 weeks later for reassessment.
She did not return until 2 months later, on June 27, when she reported complete resolution of both her upper extremities and head tremor. She was still taking di-azepam, 5 mg twice a day, but had stopped taking propanelei. She was advised to taper off the diazepam, and return for another series of acupuncture treatments, should symptoms recur.
She did not return until 3 months later, on September 28, when she brought in her mother for treatment. At the time, the patient reported no recurrence of her symptoms, being free of tremor for 5 months to date, and without taking any medications. A physical examination, including neurological evaluation, was normal.

 

DISCUSSION 
Tremors may be physiologic or a symptom of neurologic disease, such as tumors, trauma, infections, demyelinating disease, Parkinson’s disease, peripheral neuropathy, and essential tremor (7). Benign essential tremor (called familial or hereditary tremor when there is a positive family history) is thought to be inherited as a Mendelian autosomal dominant trait. No neuropathological lesion has been recognized in post mortem examinations, its neurochemistry is unknown, and its pathophysiology is obscure (8). It may appear at almost any time, often in early adult life, but it may begin in childhood (9}. It is characterized by coarse, rhythmic and symmetric tremor, persisting throughout the range of motion of voluntary activity, increasing in amplitude as the limb approaches an object (finger-to-nose test), or in handling or bringing food or liquid to the mouth.
The frequency of the tremor varies between 6 and 12 Hz, most commonly recording 6-8 Hz (10). The tremor amplitude diminishes with rest and the use of alcohol, and is exacerbated by emotional and physical stress. Tremor increases m amplitude with age, and may eventually interfere with fine movements.
Propanolol (in doses of 40-240 mg/day) and other beta-antagonists which pass the blood-brain barrier and therefore have central and peripheral actions, have been used with varying responses, but no definitive cure (11,12). More recently, primidone has been reported to be as effective as propanolol in treating this condition (13). Alcohol, although the most effective agent, is not recommended. Chronic alcoholism in patients with essential tremor is often a consequence of their attempts to control the symptoms by drinking (14).
The treatment of tremors with acupuncture has 1cng been documented in the classical Chinese medical texts, and continued to be reported in the European and American literature (15), as “problems related to Wind of External and Internal origin”.
For wider clinical applications, the therapeutic response of benign essential tremor to acupuncture needs to be studied in a significant sample of patients with this same condition. However, the complexity of medical acupuncture is such that treatment protocols may be inadequate to incorporate the necessary data into a useful diagnostic and therapeutic formulation (16). The patient’s own diagram of constitutional characteristics, past history, family history, and associated symptoms, eventually determine the most appropriate therapeutic intervention in each case.
With this individualized approach, other functional movement disorders may also be considered as potentially responsive to Medical Acupuncture. Concomitantly, further observations of the effect of acupuncture on tremors may lead to unexpected insights into intrinsic aspects of the motor system.

 

REFERENCES 
1. Critchley E. Clinical manifestations of essential tremor. J. Neurology and Neurosurgery- Psychiatry. 1972; 35: 365-75.

 

2. Critchley M. Observations on essential (heredo-familial) tremor. Brain. 1949; 72: 113-39.

 

3. Marshall J. Observations on essential tremor. J. Neurology and Neurosurgery-Psychiatry. 1962; 25: 122-25.

 

4. Requena Y. Terrains and pathology in acupuncture. Vol I- Correlation with diathetic medicine. Paradigm Publications, Brookline, MA. 1986.

 

5. Mussat M. Energetique des Systemes Vivants. Medecine et Sciences Internationales, Paris. 1982. Transl. by J.M. Helms, 1983.

 

6. Mussat M. Cours d’Energetique des Systemes Vivants Appliquee a la Acupuncture. 1ere, 2eme, et 3eme Annee. Ecole Superieure d’Acupuncture Francaise. 1983.

 

7. Koller W., Lang A. et al. Psychogenic tremors. Neurology 1989; 39: 1094-99.

 

8. Adams R.D., & Victor, M. Principles of neurology- 4th edition. McGraw-Hill Information Services Co., New York. 1989, chapter 5.

 

9. Young R.R. In: Diseases of the nervous system- clinical neurobiology. Edited by Ashbury A.K. et al. W.B. Saunders Co. 1986, Vol 1, chapter 32.

 

10. Weiner W.J. & Goetz C.G. Neurology for the non-neurologist. 2nd edition. J.B.Lippincott Co., Philadelphia. 1989.

 

11. Dupont E., Hansen H.J. et al. Treatment of benign essential tremor with propanolol. Acta NeuroL Scand. 1973; 49: 75-84.

 

12. Winkler G.F., & Young R.R. Efficacy of chronic propanolol therapy in action tremors of the familial, senile or essential varieties. New Eng. J. Med. 1974; 290: 984-88.

 

13. Findley L.I., Cieeves L. et al. Primidone in essential tremor of the hands and head: A double blind controlled clinical study. J. Neurology and Neurosurgery- Psychiatry. 1985; 48: 911-15.

 

14. Growdon J.H., Shahani B.T. et al. The effect of alcohol on essential tremor. Neurology. 1975; 25: 259-62.

 

15. Kaptchuk T.J. The webb that has no weaver- understanding Chinese medicine. Congdon & Weed, New York. 1983.

 

16. UCLA Extension. Medical Acupuncture for Physicians. Santa Monica, California. J.M. Helms, course chairman.

www.ChineseMedicineDoctor.us


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