Neurology

Author: Dr. Wong Lin Ho, MD, MSc 

Forget about your traditional acupoints and acupuncture at Ong Fujian Chinese Physician Hall when you visit us for neurological disorders. At Ong Fujian, Dr. Wong Lin Ho, who is trained in both Western and Traditional Chinese Medicine (TCM), derived a Brain-Acupoint Axis which aims at acupoints targeting specific brain areas during the management of neurological disorders, proven by fMRI studies. Combining his knowledge of Anatomy and Chinese Medicine, he focuses on the management of neurological diseases through the targeting of peripheral nerves. Accuracy of location is also further enhanced with our use of Ultrasound-Guided Electroacupuncture. Electroacupuncture has shown to not only reduce pain, but also improves the healing of peripheral nerves (axonotmesis and neuropraxia). The direct stimulation of peripheral nerves also helps to strengthen related muscles targeted by the individual nerves. Hence the potential benefits outweigh other likely treatment modalities such as TENS and Spinal Cord Stimulation, which is more invasive. Till date, he has successfully improved the quality of life of multiple patients including patients with rare neurological disorders such as Guillain Barre Syndrome, Multiple Sclerosis, Cauda Equina Syndrome, Inflammatory Neuropathies (e.g CIDP) and Amyotrophic Lateral Sclerosis (ALS).

Neurodegenerative diseases (e.g Parkinson’s Disease, Parkinsonian Plus Syndrome, Alzheimer’s Disease)

Neurodegenerative diseases refers to diseases which cause the progressive degenerative of nerve cells which affects movements, sensations, speech, swallowing and mental status. It includes diseases such as Parkinson’s Disease, Alzheimer’s Disease, Dementia, Amyotrophic Lateral Sclerosis, Multiple Sclerosis, Multiple System Atrophy (MSA), Corticobasal Degeneration and Huntington’s Disease. With an ageing population like Singapore, the management of Neurodegenerative diseases is playing an increasing importance in our daily livelihood.

Unlike medical management which shows a relatively limited efficacy in the management of Neurodegenerative disorders, the use of neuro-electroacupuncture mixed chinese medicine provides an important aspect in the maintaining and regeneration for the nervous system. Neuro-electroacupuncture prevents the demyelination (breaking of myelin sheath of nerves) and assists with the regeneration, thus impeding the progression of Neurodegenerative diseases. This can be coupled with Chinese medications such as Gingko Biloba and Ligusticum Chuanxiong which has been shown clinically to reduce the underlying oxidative stressors. In Parkinson’s disease and Parkinsonian plus syndrome, these medicines aid in the release of dopamine within the Central Nervous System (CNS) and reduce tremors and rigidity.

Similarly in Alzheimer’s Disease, Gingko Biloba has been shown in multiple clinical trials to improve the Mini-Mental State Examination (MMSE) of patients with mild cognitive impairment.  In addition, a latest research by researchers in Boston University, Massachusetts, showed that the use of electrical stimulation of the Dorsolateral Prefrontal Cortex (see image below) has shown to improve long term memory while the stimulation of inferior parietal lobe has been proven to improve short term working memory. [1] The combination of both neurostimulation and Gingko Biloba works synergistic to aid in the memory preservation for AD patients.

dlpfc

 

In conditions such as Multiple System Atrophy (MSA) where there is an atrophy (degeneration) of the cerebellum, patients frequently present with signs and symptoms such as broad-based gait, slurred speech, ataxia, inability to perform rapid actions (dysdiadochokinesia). Activities of daily living (ADL) can often be affected as patients have difficulties in performing their daily tasks and may experience frequent falls. Electro-cerebello-acupuncture is the use of electrical stimulation via acupuncture at the cerebellum located on the cranium of the skull. Through the constant stimulation, the cerebellum is activated to release neurotransmitters (GABA) which is often decreased during cerebellum atrophy. Together with GABAnergic stimulating herbs such as Gastrodia elata,  Ziziphi Spinosae Semen and Acorus gramineus, the cerebellum atrophy related symptoms can be managed. Red ginseng, which has been shown to reduce the tau proteins causing MSA will also be given to reduce the rate of deterioration in these neurodegenerative conditions.

Neurovascular diseases (e.g Stroke, Spinal artery occlusion)

According to Singapore’s national stroke registry, there are 257.6 cases of stroke per 100,000 population in 2019. This is up from 188.9 cases per 100,000 population in 2010. The numbers of cases of stroke has still been constantly rising since. This can be attributed to the increase in ageing population, smoking, drinking and dietary habits. Initial stroke is typically managed via “Stroke protocol”. If the ischaemic stroke patient arrives timely within the “Golden Timing” which is usually at 4.5 hours, thrombolectomy (mechanical removal of clot) or thrombolysis (dissolving of clot) is performed. However, beyond the “Golden Timing”, efficacy of such treatment is greatly reduced. Even after thrombolectomy/thrombolysis, many patients are still faced with slurred speech, dysphagia (difficulty swallowing), facial weakness, reduced strength, increased tone and hence reduced mobility at the area that is affected by the stroke. Medical therapy is relatively limited in the management of post stroke and the efficacy of physiotherapy varies amongst individuals. 

Traditional acupoints are fixed set of locations which are located near but not at the nerves, which can reduce the underlying efficacy. Unlike traditional acupoints, Neuroelectroacupuncture directly targets affected peripheral and cranial nerves, and through that modulates the feedback to the brain is a method that has proved to be more effective than traditional acupoints. Patients generally report a reduction of tone, increase in motility and strength immediately after the treatment and the effect remains with the subsequent treatments. The management of slurred speech, dysphagia and facial weakness is achieved via the targeting of lingual, hypoglossal and facial nerves which are located below the tongue, around the chin and directly on the face. Bedside Swallowing Test (BST) is conducted at the end of each treatment to track the progression of swallowing function.

In addition, direct cranial electrical stimulation of the brain has been shown to improve post-stroke aphasia (difficulties in speech).[2]  In a recent trial (NORTHSTAR) published on European Stroke Journal, electrical stimulation of the brain has shown to significantly improve subacute post-stroke aphasia.[3] Through the combination of direct cranial electrical stimulation with the stimulation of peripheral nerves, a faster recovery post stroke can be ensued.

Neuromuscular disorders (e.g Spinal Muscular Atrophy, Dermatomyositis)

Neuromuscular disorders includes Spinal Muscular Atrophy (SMA), Inclusion body myositis, Dermatomyositis, Polymyositis and Myasthenas Gravis. These conditions frequently results in the disruptions between the nerves and the muscles within the body. In congenital disorders such as SMA, it is frequently due to abnormalities of genes known as SMN1 gene. It can be subdivided based on their age of onset as well as their clinical presentation. Patients frequently present with muscle weakness, gower’s sign, difficulty achieving milestones, poor feeding, and poor reflexes. Medical treatment consists of genetic therapies such as Nusinersen, Onasemnogene abeparvovec (Zolgensma) and Risdiplam which costs up to millions of dollars. Cheaper alternatives include the direct neuroelectroacupuncture which stimulates the underlying nervous system, allowing for rennervation of the tissues. Quercetin, a compound found in herbs such as Gingko biloba has been found in some trials to reduce the symptoms of SMA. [4,5] Other herbs such as Brucea javanica, has been shown to boost the production of SMN protein.[6]

Epilepsy and Seizures

Epilepsy occurs when there is a disorder of the brain resulting in abnormal signalling. Causes of seizures includes lack of sleep, infection, trauma, stroke, tumours, certain recreational drugs and low sodium count (hyponatremia).

Seizures can be broadly divided into 2 main types, Generalised and Focal seizures.

Generalised seizure refers to seizures which affects both sides of the brain, consisting of sub-types such as Tonic-Clonic seizure (GTC), myoclonic, atonic, clonic, tonic and absence seizures. Focal seizures refers to seizures which are only localised to a particular area of the brain and may or may not result in the lost of consciousness. Seizures generally last for a few minutes, however, in some severe cases or status epilepticus, it may last for more than 30 minutes.

Diagnosis would require a proper medical consultation and examination, blood test to check for any abnormal electrolytes or sugar level, lumbar puncture, CT/MRI of the brain to check for any tumours or other lesions, EEG to identify the type of seizure involved. In some cases, PET and SPECT scans are also used for more detailed understanding of the abnormalities.

Management of seizures is broadly divided by the type of seizures involved. In general, anti-epileptic medications are given to reduce the abnormal signalling within the brain. Increasingly, the use of neuromodulation where electrical currents can be placed directly on the scalp are used in the management of seizures. They are usually placed in the small brain (cerebellum) and anterior thalamus as they have shown to reduce the frequency of seizures. On average, 54% of the patients have a reduction of 50% of the seizures and 14% remain seizure free for the rest of their life. [7] Other alternatives includes vagus nerve stimulation, where the vagus nerves which controls the parasympathetic nervous system is being stimulated. Clinical trials have found vagus nerve stimulation to reduce complex partial seizures in the majority of patients tested, with 20–40% of patients achieving a greater than 50% reduction in seizure frequency. [8] Neuromodulation via electroacupuncture together with anti-epileptic herbs such as Yanhusuo and Pinelliae Rhizoma, will further increase the efficacy of the reduction of seizures. 

Spinal Cord Injuries (e.g Cauda Equina Syndrome)

Spinal cord injuries refer to the damages of the spinal cord nerves, surrounding tissues or the end of the spinal cord (also known as Cauda Equina Syndrome). It can result from road traffic accidents, sports related injuries, trauma or gunshot wounds. It can result in complete or partial tear of the spinal cord, leading to loss of functions.

As the spinal cord mainly functions to relay information between the brain and the lower body, it can present with a variety of symptoms. Patients who suffer from spinal cord injuries frequently present with paralysis, weakness, numbness, irregular breathing, heart rate, difficulty maintaining bowel or bladder functions as well as sexual dysfunction such as erectile dysfunction. 

Despite surgical intervention, most functions will not return immediately as nerves grow an average of 0.25mm per day. Patients are often left to fend for themselves with the symptoms as conventional therapies are unable to target the underlying symptoms. Vitamin B12 which aims to help with nerve regeneration also provides little relieve to these symptoms.

The use of neuroelectroacupuncture which combines the use of electrical currents and neuroacupuncture aims to stimulate the nerves similar to the normal physiological functioning of the body. It helps to remyelinate the underlying nerves and is especially useful for injuries which damages the axons (axonotmesis) or cause focal demyelination (neurapraxia). It is done via the direct insertion of needles to the epidural space surrounding the nerves within the spinal cord. Research has shown that epidural electrical stimulation aids in the locomotion function in patients with spinal cord injury.  

In addition, neuroelectroacupuncture can be used to target the peripheral nervous system (nerves travelling around the body), such as the pudendal nerves which stimulates the bladder. Through the direct stimulation of pudendal nerves, the bladder receives an active electrical stimulation, allowing it to regain its functions.

Credits: Mr. J who agreed to the sharing of his recovery process with Cauda Equina Syndrome (CES) through neuroelectroacupuncture at OFJ.  As seen in the figure below, the use of neuroelectroacupuncture improved the ability to void post CES substantially. Urine output was measured with the help of a urinary catheter, post voiding ultrasound was also done intermittently via the follow up with Urology.

Percentage of Unassisted Urine Output is calculated by Unassisted urine output(UN)/Total Volume of Urine(TV)   x   100%

Commonly encountered conditions include:
Neuro-traumatic disorders: Stroke, Spinal Cord Injury (eg. Cauda Equina Syndrome), Chronic traumatic encephalopathy and Herniated Nucleus Pulposus (Slipped Disc).

Neurodegenerative Disorders: Alzheimer’s disease, Dementia, Parkinson’s disease, Parkinsonian plus syndrome (Progressive Supranuclear Palsy, Corticobasal Degeneration), Amyotrophic Lateral Sclerosis (ALS), Multiple Sclerosis and Huntington Disease.

Peripheral neuropathies: Mononeuritis Multiplex, Carpal Tunnel Syndrome, Cubital Tunnel Syndrome, Tarsal Tunnel Syndrome, Guillain Barre Syndrome, Meralgia Paresthetica, Diabetes Neuropathy, Inflammatory Neuropathy (e.g. CIDP), claw hand, ape’s hand, wrist drop and foot drop.

Nerve Palsies: Cranial Nerve Palsy including Facial Nerve Palsy (Bell Palsy, Ramsay Hunt Syndrome), Olfactory Nerve Palsy, Optic Nerve Palsy, Oculomotor Nerve Palsy, Trochlear Nerve Palsy and Abducens Nerve Palsy.

Disorder of consciousness: Coma

Neuropsychiatry: ADHD, Autism Spectrum Disorder

Others: Migraine, Trigeminal Neuralgia, Seizures, Transverse Myelitis

References

1. Grover, S., Wen, W., Viswanathan, V., Gill, C. T. & Reinhart, R. M. G. Nature Neurosci. https://doi.org/10.1038/s41593-022-01132-3 (2022).

2. Meinzer M, Darkow R, Lindenberg R, Flöel A. Electrical stimulation of the motor cortex enhances treatment outcome in post-stroke aphasia. Brain. 2016 Apr;139(Pt 4):1152-63. doi: 10.1093/brain/aww002. Epub 2016 Feb 16. PMID: 26912641.

3. Zumbansen A, Black SE, Chen JL, et al. Non-invasive brain stimulation as add-on therapy for subacute post-stroke aphasia: a randomized trial (NORTHSTAR). European Stroke Journal. 2020;5(4):402-413. doi:10.1177/2396987320934935

4. Uzunallı G, Bora-Tatar G, Dayangaç-Erden D, Erdem-Yurter H. Effects of flavonoid quercetin on survival of motor neuron gene expression. Cell Biol Int. 2015 Mar;39(3):350-4. doi: 10.1002/cbin.10395. Epub 2014 Nov 11. PMID: 25319353.

5. Lazo-Gomez, R., Tapia, R. Quercetin prevents spinal motor neuron degeneration induced by chronic excitotoxic stimulus by a sirtuin 1-dependent mechanism. Transl Neurodegener 6, 31 (2017). https://doi.org/10.1186/s40035-017-0102-8

6. Baek J, Jeong H, Ham Y, Jo YH, Choi M, Kang M, Son B, Choi S, Ryu HW, Kim J, Shen H, Sydara K, Lee SW, Kim SY, Han SB, Oh SR, Cho S. Improvement of spinal muscular atrophy via correction of the SMN2 splicing defect by Brucea javanica (L.) Merr. extract and Bruceine D. Phytomedicine. 2019 Dec;65:153089. doi: 10.1016/j.phymed.2019.153089. Epub 2019 Sep 16. PMID: 31563042.

7. Fisher R, Salanova V, Witt T, Worth R, Henry T, Gross R, Oommen K, Osorio I, Nazzaro J, Labar D, Kaplitt M, Sperling M, Sandok E, Neal J, Handforth A, Stern J, DeSalles A, Chung S, Shetter A, Bergen D, Bakay R, Henderson J, French J, Baltuch G, Rosenfeld W, Youkilis A, Marks W, Garcia P, Barbaro N, Fountain N, Bazil C, Goodman R, McKhann G, Babu Krishnamurthy K, Papavassiliou S, Epstein C, Pollard J, Tonder L, Grebin J, Coffey R, Graves N; SANTE Study Group. Electrical stimulation of the anterior nucleus of thalamus for treatment of refractory epilepsy. Epilepsia. 2010 May;51(5):899-908. doi: 10.1111/j.1528-1167.2010.02536.x. Epub 2010 Mar 17. PMID: 20331461.

8. Krahl SE. Vagus nerve stimulation for epilepsy: A review of the peripheral mechanisms. Surg Neurol Int. 2012;3(Suppl 1):S47-52. doi: 10.4103/2152-7806.91610. Epub 2012 Jan 14. PMID: 22826811; PMCID: PMC3400480.

9. Lin CH, Hsieh CL. Chinese Herbal Medicine for Treating Epilepsy. Front Neurosci. 2021 Jul 2;15:682821. doi: 10.3389/fnins.2021.682821. PMID: 34276290; PMCID: PMC8284486.

10. Deng, Cx., Wu, Zb., Chen, Y. et al. Pinellia Total Alkaloids Modulate the GABAergic System in Hippocampal Formation on Pilocarpine-Induced Epileptic Rats. Chin. J. Integr. Med. 26, 138–145 (2020). https://doi.org/10.1007/s11655-019-2944-7

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