A 56-year-old man diagnosed in 2003 as having Hoehn & Yahr stage III Parkinson's disease (PD) came to our clinic in 2012 with slurred speech, right-sided bradykinesia, erectile dysfunction, rigidity, emotional instability and depression. His PD showed progressive signs with postural instability, moderate bilateral signs, and he rated 80% on the Schwab & England Activities of Daily Living Scale. A modified protocol of electroacupuncture was administered for a period of 5 weeks, six times per week, with each session lasting for 30 min. Assessments were based on the Berg Balance Scale (BBS) and Parkinson's Disease Questionnaire-39 (PDQ-39) items, a disease-specific measure of subjective health status. He showed improvement on the BBS, suggesting improved functional status. His quality of life showed improvement particularly on the ‘activities of daily living’, ‘cognition’ and ‘communication’ dimensions of the PDQ-39. Acupuncture treatments in animal experiments have generated valuable mechanistic insights that could be relevant to PD, for example, demonstrating its neuroprotective potential from stimulation of various neuroprotective agents. The literature also suggests acupuncture may play a role in the improvement of motor function and quality of life in PD. Acupuncture is tolerated well by individuals with PD and should be considered as an integrative approach for their symptomatic management.
Statistics from Altmetric.com
Reports of the use of acupuncture in Parkinson's disease (PD) are scarce; here, we report the case of a patient with PD who showed a measurable response to acupuncture treatment.
Our patient was a 56-year-old man living alone, estranged from his family, diagnosed in 2003 as having Hoehn & Yahr stage III1 PD. His symptoms began with difficulty in walking and initiating movement, tremors, dysphagia and pain in the right hand accompanied with general myalgia. He first visited the outpatient department of the National Institute of Naturopathy (NIN) in September 2012, and presented with slurred speech, right-sided bradykinesia, erectile dysfunction, rigidity, emotional instability and depression. His PD showed progressive signs with postural instability, moderate bilateral signs, and he rated 80% on the Schwab & England Activities of Daily Living Scale. He was physically independent in most chores, however he took more time than normal. He was initially prescribed levodopa 100 mg/25 mg twice daily, trihexiphenidyl 1 mg three times daily and piribedil once daily. Later, his medication was changed to five doses of ropinirole 2 mg daily, carbidopa-levodopa 25 mg/100 mg three times daily along with trihexiphenidyl 1 mg twice daily and amantadine twice daily. Our patient was anxious about such combination treatment, but maintained compliance throughout the course of acupuncture described here. He was able to express his emotions rationally and communicated well. Having separated from his family, consisting of a son and daughter, our patient lived alone with occasional assisted support from a few close relatives.
At the NIN clinic, our patient was given electroacupuncture (EA) by one of the authors (PMKN), monitored by the Department of Acupuncture. PMKN is an institutionally qualified naturopathy practitioner with 3 years of experience in administering therapeutic acupuncture. The Traditional Chinese Medicine (TCM) style of acupuncture was used with our patient. He was informed about the needling sensations, procedure and response sought. A modified protocol of acupuncture was established considering symptomatic management as the primary goal. A combination of scalp acupuncture (‘motor’ area and ‘chorea tremor control’ area) and specific points along the meridians such as Large Intestine, Heart, Small Intestine, Stomach, Gall Bladder and Urinary Bladder were chosen (table 1) seeking de qi. Acupuncture points LI11, LI4 and ST36 were treated with electrical stimulation (5 V; 80 pulses/s) unilaterally, using alternate sides of the body each day, whereas, BL11 was stimulated in each session and paired with LI11. Needles in the other acupuncture points were retained for 30 min without any stimulation. A study using a mouse model of PD suggests that acupuncture-induced enhancement (at GB34) of synaptic dopamine availability may play a critical role in motor function improvement.2 Electrical stimulation of ST36 and SP6 purportedly protects the nigrostriatal system by multiple mechanisms including antioxidation and antiapoptosis3 suggesting that electroacupuncture may protect against oxidative stress in PD.
Additionally, diet and lifestyle counselling was provided to our patient, emphasising water intake and regular physical activity. Our patient was advised to come to the clinic six times a week, and each acupuncture session lasted for 30 min. The total duration of EA was for 4 weeks, that is, 24 sessions, with 7 days rest period after first 12 sessions. This rest for a week is traditionally indicated for improvement and adaptation.4 We used 1 cun filiform locally manufactured stainless steel needles with 0.38 mm diameter and 25 mm length.
A detailed case history was taken after our patient consented to participate in the study. After initial counselling, resting blood pressure and heart rate measurements were recorded. Our patient was assessed on the Berg Balance Scale (BBS)5,6 and PD Questionnaire-39 items (PDQ-39), a disease-specific measure of subjective health status.7 The BBS is widely used as a functional balance measure and consists of 14 items evaluating the ability to maintain balance in different positions, postural changes and movements.8 Scoring of the BBS is based on the ability of the individual to perform each task independently and/or meet certain time or distance requirements. Each item is scored on a five-point ordinal scale ranging from 0 (unable to perform) to 4 (normal performance). The total score range is 0 to 56 with higher scores denoting better balance. The BBS was recently validated for patients with PD.9 Its scores showed significant correlations with indicators of motor functioning, stage of the disease and daily living capacity in patients with PD, supporting the criterion-related validity of the BBS.9 The PDQ-39 produces a profile indicating PD impact in eight areas of health status and is deemed appropriate to test health-related quality of life hypotheses given its extensive usage and adequate clinimetric properties.10 The PDQ-39 summary index (PDQ-39SI), developed from the PDQ-39, provides an indication of the global impact of Parkinson's disease on health status.11 The PDQ-39SI is derived by the sum of the eight PDQ-39 scale scores divided by eight (the number of scales), which yields a score between 0 and 100 (100 indicating more health problems). Pretreatement and post-treatment measures are summarised in table 2. Our patient evidently showed improvement in the quality of life with better balance and postural ability. Resting heart rate and blood pressure seem to have decreased slightly following the acupuncture protocol.
Acupuncture treatments in animal experiments have generated valuable mechanistic insights into PD and shown that acupuncture therapy may function as a neuroprotective treatment that increases various neuroprotective agents such as brain-derived neurotrophic factor, glial cell line-derived neurotrophic factor and cyclophilin A.12 Acupuncture treatment is thought to improve the motor functioning of patients with PD via the basal ganglia-thalamocortical circuit.13 It has also shown to improve the Beck Depression Inventory (BDI) and PDQ-39 total score suggesting an improvement in the depression level and quality of life in PD.14
A 5-week acupuncture protocol is helpful to improve functionality and reduce disease impact on quality of life as demonstrated with a single participant with Hoehn & Yahr stage III PD, with unchanged medication. The improvement of 12 points on the BBS (from 37 to 49) indicates a significant change in the physical function of our patient. There is a shift from ‘medium fall risk’ to ‘low fall risk’ status as observed on the BBS in this single case. In the PDQ-39SI there is a small decrease of 10 points showing that the impact of disease on the quality of life has reduced with acupuncture intervention for 5 weeks. Our patient particularly showed improvement on the ‘activities of daily living’, ‘cognition’ and ‘communication’ dimensions of PDQ-39. Living alone, our patient might have also found solace in visiting the NIN's clinic increasing his compliance to treatment. During the counselling sessions, our patient expressed his subjective happiness and reportedly increased ability to do daily chores faster and independently as compared to before.
To the best of our knowledge this study is the first to show the feasibility of integration of acupuncture in the symptomatic management of PD. A 5-week EA protocol improved the functional status and quality of life of an individual with PD visiting the outpatient department of the NIN's clinic. He showed signs of satisfaction with an increased interest in socialisation, which was affected previously. However, he was not followed-up to see if the effects of EA were sustained, thereby limiting the scope of the study. Even though the results are encouraging, studies need to be carried out on a larger sample size for validation. Acupuncture is tolerated well by individuals with PD and should be considered as an integrative approach for symptomatic management of PD.
Contributors DVA was involved in designing, carrying out literature review, writing of the manuscript and overall conduct of the case report, and is responsible for the content as guarantor. PMKN contributed to identifying the case, taking the participant's consent, acquisition of data, reviewing of the article and carrying out literature review.
Competing interests None.
Patient consent Obtained.
Ethics approval The Institutional Ethics Committee, National Institute of Naturopathy, Pune, India approved the study.
Provenance and peer review Not commissioned; externally peer reviewed.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.