전체메뉴
Search
Article Search

JoP

Case Report

Split Viewer

Related articles in JAMS

More Related Articles

Article

Case Report

J Acupunct Meridian Stud 2023; 16(5): 188-192

Published online October 31, 2023 https://doi.org/10.51507/j.jams.2023.16.5.188

Copyright © Medical Association of Pharmacopuncture Institute.

Scalp Acupuncture on the Immediate and Prolonged Motor Recovery in Spinal Cord Injury: a Case Report

Geetha B. Shetty1 , Nanjeshgowda H L2,*

1Department of Acupuncture and Energy Medicine, S.D.M College of Naturopathy and Yogic Sciences, Ujire, India
2Department of Natural Therapeutics, S.D.M College of Naturopathy and Yogic Sciences, Ujire, India

Correspondence to:Nanjeshgowda H L
Department of Natural Therapeutics, S.D.M College of Naturopathy and Yogic Sciences, Ujire, India
E-mail nanjeshgowdahl@gmail.com

Received: June 27, 2023; Revised: August 1, 2023; Accepted: October 10, 2023

This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Spinal cord injury (SCI) is one of the main causes of lifelong motor impairment and is associated with important secondary complications. Thus, multifaceted treatments are needed for early functional recovery. Currently, in cases of SCI, surgery, stem cell treatment, medication, and physical therapy are used to repair and restore neuronal activity. Additionally, encouraging results have been reported on the use of acupuncture to modulate neuronal plasticity. Here, we present an SCI case involving a burst fracture at the L3 level, which was treated for 21 days using scalp acupuncture with residential physical therapy. Activation of the motor area was observed after the 1st day of treatment, with the patient completely regaining power and range of motion in the knees, Additionally, over 21 days, the patient exhibited markedly improved motor recovery and functional outcomes, which had not been observed over the previous six months. This report highlights the importance of complementing scalp acupuncture with intensive physical therapy for better motor recovery.

Keywords: Scalp acupuncture, Spinal cord injury, Motor recovery, Case report

INTRODUCTION

Spinal cord injury (SCI) is a leading cause of disability and in most cases, it causes permanent impairment and movement limitation, resulting in wheelchair dependence or being non-ambulatory. Permanent immobility may increase the risk of secondary health problems [1]. Because of its high financial and social burden [2], SCI significantly diminishes the quality of life [3]. Currently, SCI treatment requires spinal cord decompression and timely vertebral column stabilization, followed by rigorous physical therapy [4]. However, treatments that can achieve significant neurological and functional improvement are limited [5]. Hence, numerous innovative therapies are being tested. Mounting evidence has suggested neuroplasticity and sensorimotor remapping as strategies for improving functional recovery following neurological injury [6]. These discoveries have led to the development of various strategies that combine non-invasive brain stimulation with task-specific training to accelerate neuroplastic changes in the central nervous system [7]. These include acupuncture, and results from studies of its effectiveness have been encouraging [8]. Acupuncture is a therapeutic branch of traditional Chinese medicine in which small needles, or occasionally lasers, are used to pierce specific sites, followed by manual or electrical stimulation [9]. According to a National Institutes of Health consensus panel, acupuncture, which has been used in China and internationally for more than 2000 years, is effective for the treatment of various health challenges. It is thought to improve rehabilitation by promoting neuronal regeneration and plasticity [10], activating cellular metabolism [11], protecting neurocytes and facilitating functional recovery [12], and relieving pain by reducing neuropathic hypersensitivity [13]. Scalp acupuncture, also known as cranial needling therapy, scalp acupoint penetration therapy, or scalp acupuncture therapy, involves the stimulation of specialized areas by inserting filiform needles. This technique is based on a combination of current anatomy, neurophysiology, and bioholographic theory [14]. This case report highlights the need for motor area stimulation using scalp acupuncture during physical rehabilitation.

CASE PRESENTATION

This report adhered to CARE guidelines. Here, we report a case involving a 45-year-old, right-handed male patient, who presented with paraplegia and sensation loss after sustaining SCI to the lower back upon falling from a tree. The patient was diagnosed with incomplete SCI with a burst compression fracture on the L3 vertebral body. Magnetic resonance imaging revealed a fracture of the transverse processes and L3 lamina (Fig. 1). The patient was diagnosed with post-traumatic amnesia and based on the American Spinal Association Impairment criteria, was scored as grade A. The patient also had multiple other injuries, including right medial malleoli open type 3 fracture, right fibula fracture, and right lunate dislocation. At the time of the injury, the patient lost consciousness and exhibited quadriparesis, with altered sensory and motor function.

Figure 1. (A) shows sagittal MRI of the lumbar spine shows burst compression fracture of the L3 vertebral body with retropulsion causing compression of cauda equina with fracture of transverse processes of L2 and L3 and lamina of L3 (white arrows) (B) shows lateral view X-ray of the lumbar spine showing cannulated cancellous screw fixation.

The patient underwent transped fixation, L3 decompression, and screw fixation on 25/01/2022, followed by physical rehabilitation for 6 months, and was admitted to our center on 11/07/2022. After providing signed informed consent, the patient underwent 15 scalp acupuncture sessions for 21 days with residential physical rehabilitation therapy. Fig. 2 shows the timeline of events. The treatment focused on improving the patient’s motor functions, specifically the major movements that he was unable to initiate during physical therapy.

Figure 2. Timeline of the events. BBG = Berg balance scale; 10MWT = 10-meter walk test (m/s); 6MWT = 6-minutes’ walk test (m); WISCI II = Walking Index for Spinal Cord Injury II; FAS = Functional ambulation scale; TUG = time up and go (s); LEMS = lower extremity motor score; SCI = spinal cord injury; SCIM III = Spinal Cord Independence Measure III.

1. Intervention

Acupuncture needle insertion was done by a registered medical practitioner in the motor area, using Jiao’s scalp acupuncture technique. The insertions were done over the cerebral cortex’s anterior central convolution, a line that extends diagonally to the intersection between the eyebrow–occipital line and the anterior border at the corner of the temporal hairline from a position (known as the upper point of the motor region) that lies 0.5 cm posterior to the midpoint of the anterior–posterior midline of the head. Next, 0.25 × 25 mm disposable, single-use stainless steel needles (TX - Pinpai) were inserted bilaterally into the scalp at 15–20 degrees to the subaponeurotic space of the scalp. Rapid manual stimulations, with twirling movements, were then applied for 30 minutes at a minimum speed of 150 revolutions per minute. This was done for 4 minutes after every 10 minutes and the treatment involved 5 sessions a week, for 21 days. No electrical stimulation was applied. When tabulating the acupuncture needling procedure, the Standards for Reporting Interventions in Clinical Trials of Acupuncture guidelines were followed (Table 1). To improve brain plasticity, the patient was instructed to initiate motions that had been difficult during physical therapy.

Table 1

Description of treatment regimen based of STRICTA checklist.

ItemDetails
Style of acupunctureJiao’s scalp acupuncture technique
Rationale for treatmentThe motor area defined in the motor area location in scalp acupuncture is related to the premotor cortex which may help for better motor recovery
Needling detailsBilateral insertion over motor area of the scalp (it is a line that extends diagonally to the intersection of the eyebrow-occipital line and the anterior border of the corner of the temporal hairline from a position that is 0.5 cm posterior to the midpoint of the anterior-posterior midline of the head)
Number of needles10 needles
Needle description and needle type0.25 × 25 mm, filiform disposable stainless steel
Depth of insertion1 cm in depth
Needle stimulation methodManual stimulation
Response elicitedMuscle twitch response
Needle retention time30 minutes at a minimum speed of 150 revolutions per minute for 4 minutes in every 10 minutes
Number of treatment sessions15 sessions
Frequency5 sessions a week for 21 days
Practitioner backgroundRegistered naturopathy and yoga physician of a BNYS degree with MD and having 10 years of experience in diagnosing and treating using the mode of TCM
Other treatmentPhysical therapy
Control or comparatorNot applicable


2. Outcomes

The patient’s left knee range of movement was regained (from 45 to 130 degrees of flexion, with a power increase from 2/5 to 4/5) on day 1, after 30 minutes of treatment. When compared with day 1, at day 21 the patient also exhibited improvement in other functional outcomes, such as the Berg balance scale, the 10-meter walk test, the six-minute walk test, the walking index for spinal cord injury II, the functional ambulation scale, the time up and go, the lower extremity motor score, and the spinal cord independence measure III (Table 2). In both lower limbs, power was also regained from 2/5 to 4/5. Crucially, at discharge, the patient could walk without a cane and could differentiate between hot and cold leg sensations.

Table 2

Functional outcome measures at baseline and after 21 days of scale acupuncture.

VariablesBaselineDay 21
BBS2542
10MWT0.210.33
6MWT80120
WISCI II1719
FAS14
TUG5025
LEMS4045
SCIM III6982


No electromyography and peripheral nerve conduction studies were done after the SCI and scalp acupuncture. The patient complied with the treatment without any discomfort during treatment, which involved five sessions per week. No adverse events were noted.

DISCUSSION

Currently, the most crucial phase of rehabilitation is the restoration of motor and sensory functions following SCI. However, there is little regeneration or functional recovery after SCI, especially in chronic SCI patients whose paralysis may last for more than a year after injury. Moreover, despite extensive research on a variety of therapies, no standard rehabilitation strategy has been identified for promoting recovery.

Because of its relative ease of use, affordability, and safety, acupuncture is frequently used to aid the recovery of motor and sensory functions following SCI. In addition to improving functional outcomes, acupuncture promotes neuronal restoration. By influencing neuronal apoptosis and regulating the expression of key genes, acupuncture can enhance hind-limb motor neurons [15], inhibit astrogliosis, and downregulate platelet-derived growth factor [16]. Studies using a rat model indicate that by raising acetylcholinesterase activity, which increases the transcription of glial cell line-derived neurotrophic factor, acupuncture promotes the recovery of motor neuron function in the afflicted anterior horn after SCI [17]. Evidence also suggests that the effectiveness of acupuncture in treating SCI-associated pain depends on the location, nature, and severity of the injury [18],

In this case, the patient recovered complete knee range of motion with power on day 1, and on day 21, all functional outcomes and temperature sensation had improved. This may be because the motor area as defined by various schools of practice is equivalent to the structure of the precentral gyrus of the cerebral cortex, which is activated via influence from trigeminal nerves, which are innervated into the scalp [19].

Because of inconclusive evidence of brain area activation during incomplete spinal cord injury [20], Sharp KG et al. demonstrated that movement was accompanied by the activation of several brain regions, including the dorsal premotor cortex, the precentral gyrus, and the postcentral gyrus, and that none exhibited decreased activation with increasing time after SCI. Brain activity was highest in those with a quicker gait, indicating that these alterations are beneficial adaptations. This suggests that increased activity in these regions provides additional cortical resources toward sensory processing and cognitive/attention aspects, which may reflect increased movement complexity and effort [21]. To support this, the patient was given movements during scalp acupuncture.

Scalp acupuncture is particularly useful when used at an inpatient facility together with intensive physical therapy, which allows for the activation of the motor area with better patient stabilization. However, although these observations are encouraging, functional magnetic resonance imaging studies are needed to assess neuronal activity during the stimulation of the motor area. Importantly, randomized controlled trials are required to validate the observations from this case, which indicate that complementing scalp acupuncture with physical therapy improves early motor and sensory recovery in patients with SCI.

AUTHORS' CONTRIBUTIONS

Conceptualization: GBS, NHL; Data curation: NHL, GBS; Formal analysis: GBS, NHL; Investigation: NHL, GBS; Methodology: GBS, NHL; Project administration: NHL; Resources: GBS; Supervision: GBS, NHL; Visualization: NHL, GBS; Writing - original draft: NHL; Writing - review & editing: GBS, NHL.

DISCLOSURE STATEMENT

The author affirms that they have no financial or other conflicts of interest regarding the subject of this article.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

Fig 1.

Figure 1.(A) shows sagittal MRI of the lumbar spine shows burst compression fracture of the L3 vertebral body with retropulsion causing compression of cauda equina with fracture of transverse processes of L2 and L3 and lamina of L3 (white arrows) (B) shows lateral view X-ray of the lumbar spine showing cannulated cancellous screw fixation.
Journal of Acupuncture and Meridian Studies 2023; 16: 188-192https://doi.org/10.51507/j.jams.2023.16.5.188

Fig 2.

Figure 2.Timeline of the events. BBG = Berg balance scale; 10MWT = 10-meter walk test (m/s); 6MWT = 6-minutes’ walk test (m); WISCI II = Walking Index for Spinal Cord Injury II; FAS = Functional ambulation scale; TUG = time up and go (s); LEMS = lower extremity motor score; SCI = spinal cord injury; SCIM III = Spinal Cord Independence Measure III.
Journal of Acupuncture and Meridian Studies 2023; 16: 188-192https://doi.org/10.51507/j.jams.2023.16.5.188

Table 1 . Description of treatment regimen based of STRICTA checklist.

ItemDetails
Style of acupunctureJiao’s scalp acupuncture technique
Rationale for treatmentThe motor area defined in the motor area location in scalp acupuncture is related to the premotor cortex which may help for better motor recovery
Needling detailsBilateral insertion over motor area of the scalp (it is a line that extends diagonally to the intersection of the eyebrow-occipital line and the anterior border of the corner of the temporal hairline from a position that is 0.5 cm posterior to the midpoint of the anterior-posterior midline of the head)
Number of needles10 needles
Needle description and needle type0.25 × 25 mm, filiform disposable stainless steel
Depth of insertion1 cm in depth
Needle stimulation methodManual stimulation
Response elicitedMuscle twitch response
Needle retention time30 minutes at a minimum speed of 150 revolutions per minute for 4 minutes in every 10 minutes
Number of treatment sessions15 sessions
Frequency5 sessions a week for 21 days
Practitioner backgroundRegistered naturopathy and yoga physician of a BNYS degree with MD and having 10 years of experience in diagnosing and treating using the mode of TCM
Other treatmentPhysical therapy
Control or comparatorNot applicable

Table 2 . Functional outcome measures at baseline and after 21 days of scale acupuncture.

VariablesBaselineDay 21
BBS2542
10MWT0.210.33
6MWT80120
WISCI II1719
FAS14
TUG5025
LEMS4045
SCIM III6982

References

  1. Patek M, Stewart M. Spinal cord injury. Anaesth Intensiv Care Med 2023;24:406-11.
    CrossRef
  2. Krause JS, Devivo MJ, Jackson AB. Health status, community integration, and economic risk factors for mortality after spinal cord injury. Arch Phys Med Rehabil 2004;85:1764-73.
    Pubmed CrossRef
  3. Migliorini CE, New PW, Tonge BJ. Quality of life in adults with spinal cord injury living in the community. Spinal Cord 2011;49:365-70. https://doi.org/10.1038/sc.2010.102
    Pubmed CrossRef
  4. Fehlings MG, Tetreault LA, Wilson JR, Kwon BK, Burns AS, Martin AR, et al. A clinical practice guideline for the management of acute spinal cord injury: introduction, rationale, and scope. Global Spine J 2017;7(3 Suppl):84S-94S.
    Pubmed KoreaMed CrossRef
  5. Khan FI, Ahmed Z. Experimental treatments for spinal cord injury: a systematic review and meta-analysis. Cells 2022;11:3409. https://doi.org/10.3390/cells11213409
    Pubmed KoreaMed CrossRef
  6. Khan F, Amatya B, Galea MP, Gonzenbach R, Kesselring J. Neurorehabilitation: applied neuroplasticity. J Neurol 2017;264:603-15. https://doi.org/10.1007/s00415-016-8307-9
    Pubmed CrossRef
  7. Boes AD, Kelly MS, Trapp NT, Stern AP, Press DZ, Pascual-Leone A. Noninvasive brain stimulation: challenges and opportunities for a new clinical specialty. J Neuropsychiatry Clin Neurosci 2018;30:173-9.
    Pubmed CrossRef
  8. Jiang K, Sun Y, Chen X. Mechanism underlying acupuncture therapy in spinal cord injury: a narrative overview of preclinical studies. Front Pharmacol 2022;13:875103.
    Pubmed KoreaMed CrossRef
  9. Vickers A, Zollman C. ABC of complementary medicine. Acupuncture. BMJ 1999;319:973-6.
    Pubmed CrossRef
  10. Yan Q, Ruan JW, Ding Y, Li WJ, Li Y, Zeng YS. Electro-acupuncture promotes differentiation of mesenchymal stem cells, regeneration of nerve fibers and partial functional recovery after spinal cord injury. Exp Toxicol Pathol 2011;63:151-6.
    Pubmed CrossRef
  11. Liu Z, Ding Y, Zeng YS. A new combined therapeutic strategy of governor vessel electro-acupuncture and adult stem cell transplantation promotes the recovery of injured spinal cord. Curr Med Chem 2011;18:5165-71.
    Pubmed CrossRef
  12. Choi DC, Lee JY, Moon YJ, Kim SW, Oh TH, Yune TY. Acupuncture-mediated inhibition of inflammation facilitates significant functional recovery after spinal cord injury. Neuro. biol Dis 2010;39:272-82.
    CrossRef
  13. Lau WK, Lau YM, Zhang HQ, Wong SC, Bian ZX. Electroacupuncture versus celecoxib for neuropathic pain in rat SNL model. Neuroscience 2010;170:655-61.
    Pubmed CrossRef
  14. Zhang ZD, Wang RQ, Liu JX, Sun YH, Li XF, Zhang X, et al. [Comparison and analysis on different academic schools of scalp acupuncture]. Zhen Ci Yan Jiu 2021;46:809-14. Chinese.
    Pubmed CrossRef
  15. Ouyang BS, Gao J, Che JL, Zhang Y, Li J, Yang HZ, et al. Effect of electro-acupuncture on tumor necrosis factor-α and vascular endothelial growth factor in peripheral blood and joint synovia of patients with rheumatoid arthritis. Chin J Integr Med 2011;17:505-9. https://doi.org/10.1007/s11655-011-0783-2
    Pubmed CrossRef
  16. Liu F, Zou Y, Liu S, Liu J, Wang T. Electro-acupuncture treatment improves neurological function associated with downregulation of PDGF and inhibition of astrogliosis in rats with spinal cord transection. J Mol Neurosci 2013;51:629-35.
    Pubmed CrossRef
  17. Yang JH, Lv JG, Wang H, Nie HY. Electroacupuncture promotes the recovery of motor neuron function in the anterior horn of the injured spinal cord. Neural Regen Res 2015;10:2033-9.
    Pubmed KoreaMed CrossRef
  18. Nayak S, Shiflett SC, Schoenberger NE, Agostinelli S, Kirshblum S, Averill A, et al. Is acupuncture effective in treating chronic pain after spinal cord injury?. Arch Phys Med Rehabil 2001;82:1578-86. https://doi.org/10.1053/apmr.2001.26624
    Pubmed CrossRef
  19. Wang S, Liu K, Wang Y, Wang S, He X, Cui X, et al. A proposed neurologic pathway for scalp acupuncture: trigeminal nerve-meninges-cerebrospinal fluid-contacting neurons-brain. Med Acupunct 2017;29:322-6. https://doi.org/10.1089/acu.2017.1231
    Pubmed KoreaMed CrossRef
  20. Lundell H, Christensen MS, Barthélemy D, Willerslev-Olsen M, Biering-Sørensen F, Nielsen JB. Cerebral activation is correlated to regional atrophy of the spinal cord and functional motor disability in spinal cord injured individuals. Neuroimage 2011;54:1254-61.
    Pubmed CrossRef
  21. Sharp KG, Gramer R, Page SJ, Cramer SC. Increased brain sensorimotor network activation after incomplete spinal cord injury. J Neurotrauma 2017;34:623-31.
    Pubmed KoreaMed CrossRef