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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.
    Austin, Tex: ProEd; 1990:275-317.
  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.
  18. Unschuld PU. Introductory Readings in Ancient Chinese Medicine. Dordrecht, the Netherlands: Kluwer Academic Publishers; 1988:59-63, 69-70.
  19. Oleson T. Auriculotherapy Manual: Chinese and Western Systems of Ear Acupuncture. Los Angeles, Calif: Health Care Alternative; 1990.
  20. Lundy DS, Lu FL, Casiano RR, Xue JW. The effect of patient factors on response outcomes to Botox treatment of spasmodic dysphonia. J Voice. 1998;12:460-466.
  21. Benninger MS, Ahuja AS, Gardner G, Grywalski C. Assessing outcomes
    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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From http://www.michaeljfox.org/newsEvents_mjffInTheNews_moreMJFFNews_article.cfm?ID=507&headertitle=MJFF

By Sara Castellanos, Aurora Sentinel

For those suffering from Parkinson’s disease, most are willing to take a stab at anything to ease the endless days of being tired.

No doubt, the tremors, stiffness and slowness are par for the course. But it’s the general sense of fatigue that’s particularly debilitating.

“People with Parkinson’s disease still have fatigue even when their sleep problems are treated,” said Dr. Benzi Kluger, assistant professor of neurology and psychiatry at the University of Colorado Hospital.

The enervation is so overwhelming, that Kluger himself decided to take a stab at a non-traditional approach to reducing exhaustion. He’s leading a research study to determine whether alternative Eastern medicine, specifically acupuncture, can help alleviate the symptoms of severe fatigue in Parkinson’s patients. He secured $350,000 last year from the Michael J. Fox Foundation for Parkinson’s Research to fund the study, which commenced in November 2010. So far, about 20 Parkinson’s disease patients are participating in the study and Kluger hopes that number will increase to about 100 within two years.

In his study, Kluger is also trying to determine how much of acupuncture’s effects — if there are any — are due to the actual alternative medicine, and how much of its effects are due to placebo.

“It’s possible that both the acupuncture and placebo groups will show improvement,” he said. “Whether the acupuncture groups show greater improvement than the placebo groups is another question.”

For licensed acupuncturist Daisy Dong-Cedar, Kluger’s study is simply trying to prove what she already knows.

Dong-Cedar, who is the chief acupuncturist in the study, has been practicing the method for 26 years. She trained in China and joined the University of Colorado Hospital 10 years ago. In the past five years, the form of alternative medicine has grown more popular among doctors, she said.

“Physicians have started to integrate the medicine,” she said. “The public really demanded alternative medicine.” Acupuncture is covered for some conditions under certain insurance companies, but her clients usually pay out of pocket. The cost ranges from $25 to more than $100 per treatment, with the average treatment costing between $60 and $70 with a $100 initial consultation fee.

But the cost is often worth the results for people who are trying to quit smoking, trying to get pregnant, or trying to reduce pain in the lower back and neck, Dong-Cedar said.

“If you’re older and you have a lot of chronic conditions, the reaction to acupuncture is slower,” Dong-Cedar said. “If a person is young and healthy, and the condition is more acute, the result is much quicker, sometimes within one or two treatments.”

Kluger’s research is being conducted as a double-blind study. Also, the patients are blindfolded while they are receiving acupuncture treatment, and Kluger doesn’t know which patients are receiving acupuncture treatment and which patients are receiving placebo. Without divulging specifics about the study, Kluger said the acupuncturist places needles in acupuncture points on the patient’s face and back. For patients who are in the placebo group, the acupuncturist may place “fake” needles that don’t puncture the surface of the skin in spots that aren’t typical acupuncture spots.

Symptoms of severe fatigue are common in about half of the people diagnosed with Parkinson’s disease. The neuro-degenerative disease affects between 1 percent and 2 percent of people over the age of 65 and is second only to Alzheimer’s in neuro-degenerative illnesses, Kluger said. Those diagnosed with the disease will lose neurons in specific parts of the brain, affecting muscle movement and control. About half of those diagnosed with the disease have sought alternative treatments including acupuncture to help with their symptoms, but until now, there weren’t many evidence-based studies to determine whether acupuncture is, in fact, effective.

“Patients, particularly for symptoms like fatigue and pain, are going to other sources and they’re going to acupuncturists, herbalists and nutritionists,” Kluger said. “Their physicians don’t really have any good information to tell them about it. So that was really one of the major impetuses for doing this study.”

If Kluger finds that acupuncture can be used as an alternative form of medicine to alleviate the symptoms of severe fatigue, which plague nearly 50 percent of those with Parkinson’s disease, insurance companies might be more apt to cover the treatment, he said.

If the study reveals the effects of acupuncture are due mostly to placebo, that could be a major breakthrough as well.

“Placebo is enormously powerful, and really gives us evidence that people have so much capacity to heal but don’t know how to tap into it,” Kluger said.

It may be too soon to tell, but Parkinson’s patient Howard Ewy said he is noticing some results.

“I think it has helped me in that I can walk further and faster and I need fewer naps,” said Denver resident Ewy, 81, and a retired Navy aviator. He was diagnosed with the disease last year and until he decided to participate in Kluger’s study, he had never received acupuncture treatment before this. Ewy said he decided to participate in the study because he’s interested in learning more about all types of therapies available to alleviate the symptoms of his disease, from Western medicine to Eastern medicine.

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Everyday, I answer many questions from visited patients or online inquiries, such as:

For some chronic or difficult-to-treat conditions, such Dystonia, or Parkinson Disease, or diabetes, or a mix of many conditions,

“How many sessions’ acupuncture could cure my condition?”

“How much percentage of cure rate of your treatment?”

“I have infertility, how many sessions’ acupuncture could help me get pregnant?”

And, “If you say you could cure it, I will see you.”

Actually, many conditions or illness,disorders are chronic conditions, many of them are difficult-to-treat also, and patients may use conventional medicine for years too.

Frankly, I say “we could not cure most of them”,  in 8 sessions, even in 16 sessions’acupuncture; Or in one month herbal tea treatment. Many of them need long-term management.

We do see some magic results in some cases; we did cure some patients in a very short-term treatments. In a few cases, we even cure the patients’ condition, which they had that for years, with only one or two sessions’ acupuncture or in one day’s herbal tea treatment!

We did see pregnant only after one acupuncture treatment in a few patients with infertility. We did stop the dystonia in one week.

However, for most of the cases, we could improve them; some patients also did get disappointed with our treatments, because their aims did not become the real in one or two month, or other short period of time.

We do tell patients who have difficult-to- treat illness or disorders, they will see some of improvements over the time, some illness or disorders could not be cured in 100% of patients:  some may get “cure”(this is clinically cure, not absolute cure as patient hoped, sometime may get relapse if patients get some trigger), some get improved, some get slight better(or other condition get better, for example, overall condition better), some no result, some worse (please note, the illness, or disorder will get worse under some conditions by itself, not related to acupuncture or Chinese herbs at all).

We could not imagine how many percentage of the patients get “cure”.  For example, we have over 40 patients get pregnant in recent 4 years. We may say about 40-50% of patients (if they had 2 month or more serious treatments) get pregnant!

However, this is a very rough answer. Why? the condition is very complicated.

In these patients who seek acupuncture/herbs for fertility, patients had different causes of infertility, such as FSH high, POCS, ovulation issue, progesterone issue, tube issue, husband sperm issue, etc; many patients had medications, some of them did acupuncture alone, some of them had Chinese herbs too; some of them followed regular treatment strategy, some of them didn’t follow our strategy very well(due to work, due to personal issue, due to something else–subjective or objective reasons); some of them had IVF, IUI etc(with acupuncture or herbs). We could not tell you very detail in a statistic work.

However, it does work!

For acupuncture and Chinese herbology, to many difficult-to-treat illness or disorders, it works! at least it improves patients’ condition in most of the cases.

Importantly, acupuncture basally has little adverse effect. Chinese herbology also has very less side effect if patients see a trained Chinese medicine doctor.

For most of patients with chronic or difficult-to-treat conditions, no.one thing is adjusting the aim based on understanding their own condition well, don’t see a Chinese medicine doctor – he or she promised you–you will get a cure in several treatments(except for some pain condition). Most of time, patients will need more longer treatments.

Be patient.

For the cost-effectiveness, don’t see a provider who promise you have a good result but you pay very little.Most of well-trained, experienced Chinese medicine doctors offer patients a reasonable, affordable fee schedule. For better result, don’t see a provider who had less training and over low fee.

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I find a website which reports me using my several videos.

http://wn.com/DrArthurFan

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Online literature is very few in Chinese medicine treating Parkinson disease. We published two papers in this scope in Chinese language in 1990s.

After I settle down in America, I did not report my clinical experience in this field.

Recently, I have a successful case in Parkinson disease, using scalp acupuncture and traditional systemic acupuncture, as well as Chinese herbal tea, now patient recovered 70%.  He said he was embarrassed before, now he has confidence to see other people, because in most of time, he no longer shakes.

www.ChineseMedicineDoctor.us

 

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