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Acupuncture application for neurologicaldisorders

Hyangsook Lee Hi-Joon Park1 Jongbae Park Mi-Ja Kim1MeeSuk Hong1 JongSoo Yangamp SunMi Choi and Hyejung Lee1

Acupuncture and Meridian Science Research Center Department of Meridian and Acupuncture Collegeof Korean Medicine and 1TKM Research Group Kyung Hee University Seoul 130-701 Korea

Department of Meridian and Acupoint College of Korean Medicine Sang Ji University Wonju 220-702Korea

Division for Research and Education in Complementary and Integrative Medical Therapies HarvardMedical School Osher Institute Landmark Center 401 Park Drive Suite 22A-West Boston MA 02215

USADepartment of Medical Research Korea Institute of Oriental Medicine Daejeon 305-811 Korea

ampDepartment of Small and Medium Business Innovation Center ITEP Seoul 135-080 Korea

Background Acupuncture has been widely used for a range of neurological disorders Despite itspopularity the evidence to support the use of acupuncture is contradictoryMethods This review was designed to summarize and to evaluate the available evidence ofacupuncture for neurological disordersResults Most of the reviewed studies suffer from lack of methodological rigor Owing to paucityand poor quality of the primary studies no firm conclusion could be drawn on the use ofacupuncture for epilepsy Alzheimerrsquos disease Parkinsonrsquos disease ataxic disorders multiplesclerosis amyotrophic lateral sclerosis and spinal cord injury For stroke rehabilitation theevidence from recent high-quality trials and previous systematic reviews is not convincingConclusion More rigorous trials are warranted to establish acupuncturersquos role in neurologicaldisorders [Neurol Res 2007 29 S49ndashS54]

Keywords Acupuncture electroacupuncture randomized clinical trial neurological disorders

INTRODUCTIONAcupuncture has long been widely practised in ChinaJapan Korea and other Asian countries Althoughacupuncture has been used for years within immigrantcommunities in the West it was not least due totelevision reporting in the 1970s of patients undergoingsurgery without conventional analgesia that acupunc-ture received much attention and generated intensiveresearch Over the past two decades acupuncture hasenjoyed its growing popularity in the United States andEurope and a recent survey demonstrated thatAmericans pay more than five million visits a year toacupuncture practitioners1

Acupuncture involves inserting fine needles intospecific locations in the body called acupuncturepoints The needles are usually manipulated to elicit acharacteristic needle sensation (Deqi) which is believedto be essential to obtain better therapeutic effects Inaddition to manual needling a variety of methods areused to stimulate acupuncture points eg electricitylaser ultrasound and moxibustion (burning the powderof dried leaves of Artemisia vulgaris or mugwort)

Despite the historical usage and present popularity ofacupuncture the current evidence supporting its use islargely inconclusive Systematic reviews have shownthat acupuncture is more effective than placebo forchemotherapy-induced nausea and vomiting2 earlypost-operative nausea in adults3 and for acute dentalpain4 Evidence is inconclusive for a range of condi-tions low back pain56 neck pain7 headache8fibromyalgia9 osteoarthritis1011 stroke12 labor pain13tinnitus14 and asthma15 For smoking cessation16 andweight loss17 present evidence suggests that acupunc-ture is no better than placebo

For neurological disorders there have not been manyhigh-quality studies of acupuncture from which firmconclusions can be drawn In this review we aimed atsummarizing the current evidence available foragainstacupuncture for neurological disorders and suggestingresearch strategies for further investigation in this field

SCIENTIFIC EVIDENCE OF ACUPUNCTUREIt has not been fully explained how acupuncture workswithin the framework of Western Medicine Since gate-control theory by Wall and Melzack in 196518 basicscientific research has focused on acupuncturersquos modeof action from a neurobiologic perspective One of themost intensely researched areas is the involvement ofendogenous opioid peptides in acupuncture-induced

Correspondence and reprint requests to Hyejung Lee KMD PhDDepartment of Meridian and Acupuncture College of KoreanMedicine Kyung Hee University 1 Hoegi-dong Dongdaemoon-guSeoul 130-701 Korea [hjleekhuackr]

2007 W S Maney amp Son Ltd Neurological Research 2007 Volume 29 Supplement 1 S49101179016164107X172211

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analgesia Researches have revealed that endogenousopioids in the central nervous system (CNS) play anessential role in mediating the analgesic effect ofelectroacupuncture Further studies have shown thatdifferent kinds of neuropeptides are released byelectroacupuncture with different frequencies 2 Hzelectroacupuncture selectively induces the release ofenkephalin b-endorphin and endomorphin while100 Hz electroacupuncture increases the release ofdynorphin19 More recent study demonstrated thatalternative 2 and 100 Hz (2100) electroacupunctureincreased the release of both dynorphin and endomor-phin whilst 2 z 100 Hz electroacupuncture increasedonly the release of dynorphin not endomorphin Theresults suggest that a proper combination of differentfrequencies of electroacupuncture may produce a maxi-mal release of various opioids possibly for bettertherapeutic effects20 This finding from laboratoryanimals was studied in post-operative patients and thedata revealed that the alternative mode stimulation (2100 Hz) reduced the morphine requirement by 53while a constant 2 or 100 Hz produced only 32 or 35decrease respectively21

Functional magnetic resonance imaging techniquehas also been used to investigate the neural mechanismof acupuncture in healthy volunteers correlationsbetween acupuncture stimulation on the vision-relatedacupuncture point (BL67) and activation of the visualcortex were investigated22 and acupuncture stimulationon LI4 point might modulate the activity of limbicsystem and subcortical structures23

CLINICAL EVIDENCE OF ACUPUNCTURE FOR CNSDISEASESThe basic idea of acupuncture treatment is that disordersresult from inadequate flow of Qi through the meridianand can be prevented or corrected by stimulating the

relevant acupuncture points While time has witnessedbeneficial effects of acupuncture systematic reviewsfrom rigorous randomized clinical trials (RCTs) do notseem to make firm conclusions whether acupuncture iseffective or not for neurological disorders

Seizure and epilepsyEndogenous opioids serotonin and c-butyric acid

have been implicated in the mechanism of acupuncturein suppressing epileptic seizures in animal models24Kloster et al25 compared 8 week acupuncture treatmentwith sham acupuncture in 29 patients with chronicintractable epilepsy Fifteen patients in the acupuncturegroup received real acupuncture consisting of manualacupuncture and electroacupuncture three times a weekfor 8 weeks with a week rest in the middle For thecontrol group (n514) acupuncture on non-acupuncturepoints without electric stimulation was given No inter-group difference was reported in seizure frequency andthe number of seizure-free weeks increased significantlyin the control group not in the acupuncture group(p50006) The same team reported no beneficial effectof acupuncture in health-related quality of life from thesame trial26 (Table 1)

Cerebrovascular disordersIn 1997 the National Institute of Health Consensus

Development Panel on Acupuncture suggested thatacupuncture might be a useful adjunct for strokerehabilitation27 However high-quality RCTs and sys-tematic reviews on the effectiveness of acupuncture forstroke rehabilitation do not support this claim122829 Arecently published meta-analysis also reports no addi-tional effect of acupuncture on motor recovery whengiven with rehabilitation therapy30

Several high-quality RCTs have been published sincePark et al12 systematically reviewed the literature

Table 1 Characteristics and results of randomized clinical trials of acupuncture for seizure and epilepsy

Author (year) Study design and qualitySample size(acupuncture) Intervention Outcome measures Results

Kloster (1999)25 Sham-controlled(1 z 1 z 1 z 1 z 155)

29 (15) AP MA z EA three timesweekfor 7 weeks with 1 week rest inthe middle LR3 LI4 GV20 z 1ndash 2 individualized points 3 Hz3ndash20 mA

Seizure frequency8 weeks post-APSeizure-free weeksduring treatmentand follow-up

NSsignificant benefitfor CON group(p50006)

CON sham AP non-AP pointsminimal manipulation and noelectrical stimulation

Stavem (2000)26 Sham-controlled(1 z 1 z 1 z 0 z 154)

34 (18) AP MA z EA three timesweekfor 7 weeks with 1 week rest inthe middle LR3 LI4 GV20 z 1ndash 2 individualized points 3 Hz3ndash20 mA

QOLIE-89 scores8 weeks post-AP

NS

CON sham AP non-AP pointsminimal manipulation and noelectrical stimulation

Study quality was assessed using the modified Jadad score753 randomization 1 point z appropriate randomization method 1 point (zinappropriate randomization method 21 point) z patient-blinding 1 point z evaluator-blinding 1 point z describing withdrawals and dropouts 1point5maximum 5 points AP acupuncture EA electroacupuncture MA manual acupuncture NS not significantly different between groupsQOLIE-89 89-item quality of life in epilepsy questionnaire

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(Table 2) Johansson et al31 conducted a multi-centerevaluator-blinded RCT involving 150 patients within 5ndash10 days of stroke onset Only patients with moderate orsevere functional impairment at randomization wereincluded Barthel index (70 points in combinationwith inability to walk 10 m without mechanical orpersonal support Patients were allocated by stratifiedrandomization to receive (1) a combination of manualacupuncture and low-frequency electroacupuncture(n548) (2) high-intensity low-frequency transcuta-neous electric nerve stimulation (TENS) (n551) (3)low-intensity high-frequency TENS (control groupn551) Twice-a-week treatment for 10 weeks was givenand if necessary patients received conventional phy-siotherapy occupational therapy and speech therapyirrespective of group allocation Walking (time neededto walk 10 m) motor function (Rivermead mobilityindex) activities of daily living (Barthel index) andquality of life (Nottingham health profile) were mea-sured at randomization three months and 12 monthsfollow-ups after the onset of stroke The resultsdemonstrated no significant differences between groupsin any of outcome measures and authors concludedthat acupuncture combined with electroacupuncture orTENS-induced muscle contraction could not be recom-mended as a standard treatment for patients withmoderate or severe stroke in the subacute stage

In another evaluator-blinded RCT with 106 strokepatients within 3ndash15 days of the onset of strokeadditional manual acupuncture to standard treatmentwas compared with standard treatment only32 Patientswere stratified into Group I (admission Barthelindex11) and Group II (admission Barthel indexgt11)to avoid chance imbalance of severity of disabilitybetween the acupuncture arm and the control arm andalso because the severe group required longer inpatientrehabilitation than the moderate group Group I patientsreceived 5 weeks (iexcl1 week) of inpatient rehabilitationfollowed by 5 weeks (iexcl1 week) of day hospitalrehabilitation while Group II patients receivedthree weeks (iexcl1 week) of inpatient rehabilitationfollowed by 7 weeks (iexcl1 week) of day hospitalrehabilitation Patients in Groups I and II were thenseparately randomized to either acupuncture group orcontrol group (n553) Acupuncture treatment wascarried out 5 times per week for inpatients three timesper week to the end of the eighth week and then twiceper week for the remaining two weeks for day hospitalpatients Therefore the total intervention lasted for10 weeks The primary end points were the Fugl-Meyerassessment of physical performance-motor subsection(FMAM) median score at week 10 and FMAM medianscore change over time Median scores of Barthel indexand functional independence measure were alsoassessed Acupuncture intervention failed to showsignificant benefit in any of the outcome measures atweek 10 or outcome changes over time

A most recent placebo-controlled trial28 tested theeffect of 4 week manual acupuncture treatment forreduction of leg spasticity in chronic post-stroke patients(mean time from ischemic stroke 654 iexcl 483 months)

Participants were randomized to receive either 8sessions of manual acupuncture (n513) or placeboacupuncture where sham acupuncture needles wereused (n512) Modified Ashworth scale score wasmeasured as the primary end point There was nosignificant difference between acupuncture group andplacebo acupuncture group

The message from the current evidence is clear Thereis a paucity of RCTs and the most recent high-qualitystudies283031 confirm the finding of the systematicreview by Park et al12 that methodologically weakerstudies were likely to generate positive outcomes Aswith acupuncture studies in other areas most studies onacupuncture for stroke rehabilitation suffer from meth-odological flaws Control groups are heterogeneous andfew studies adopt placebo control to investigate possiblespecific effects of acupuncture As practitioner-blindingis virtually impossible in acupuncture trials at leastevaluator of outcome measures should be blinded tominimize measurement bias However most studieswere found to fail to blind outcome assessor313337Acupuncture interventions vary across studies in termsof stimulation method choice of acupuncture pointsnumber of treatment sessions and treatment periodHeterogeneous inclusion criteria across trials and smallsample sizes also preclude estimation of acupunctureeffect for any subgroup of stroke patients Rigorousresearch is warranted to establish acupuncturersquos role instroke rehabilitation

Alzheimerrsquos diseaseThere are only a few uncontrolled studies of

acupuncture for Alzheimerrsquos disease In a pilot studyinvolving 11 patients 10 with Alzheimerrsquos disease andone with vascular dementia twice-a-week acupuncturetreatment for three months was tested whether it hadany effects on depression and anxiety38 The researchersfound significant improvements in the depression andanxiety scores measured by the Cornell scale fordepression and the Speilberger state anxiety inventoryCognitive functioning (mini-mental status examinationMMSE) remained stable over months of the studyAnother pilot study where eight patients with mild tomoderate Alzheimerrsquos disease were given acupuncturetreatment for a month reported that patients significantlyimproved on measures of verbal orientation and motorcoordination and had higher overall MMSE scores39The findings call for rigorous clinical trials in this area

Parkinsonrsquos diseaseSeveral uncontrolled pilot studies were conducted on

the patients with Parkinsonrsquos disease In the study by Haet al40 7 patients with antiparkinsonian drugs and 12patients without antiparkinsonian drugs completedtwice-a-week acupuncture treatments for eight weeksIn the former group total scores of unified Parkinsonrsquosdisease rating scale (UPDRS) UPDRS II for daily activityand UPDRS IV for side effects improved compared to thebaseline In the latter group total scores for UPDRS andUPDRS III for motor function improved significantly

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Table 2 Characteristics and results of randomized clinical trials of acupuncture for stroke

Author (year) Study design and qualitySample size(acupuncture)

Days afteronset Intervention

Outcomemeasures

Results comparedwith control

Zou (1990)37 Open(1 z 0 z 0 z 0 z 051)

63 (32) 7 AP MA everydayfor 6 weeks

CSRM Significant benefit(p0001)

CON standardmedication

Naeser (1992)35 Patient-blinded(1 z 0 z 1 z 0 z 052)

16 (10) 30ndash90 AP EA 1ndash2 Hzfive timesweek for4 weeks

ROM NS

CON sham AP noelectrical stimulationnon-paralyzed armsand leg

Johansson (1993)31

and Magnusson(1994)54

Open(1 z 0 z 0 z 0 z 152)

78 (38) 10 AP EA 2ndash5 Hz twiceweek for 10 weeks

Walking Motorfunction balanceand Barthel ADL

Significant benefit(p005) exceptmotor function

Significant benefitfor energy mobilityemotion andsocial isolation(p005)

CON rehabilitation NHPDays spent athospitalnursinghome

Significant benefit(p005)

Hu (1993)34 Open(1 z 0 z 0 z 0 z 152)

30 (15) 15 AP EA 94 Hz threetimesweek for 4 weeksCON Rehabilitation

SSSBarthel ADL

Significant benefit(p5002)NS

Sallstrom (1996)55

and Kjendahl(1997)56

Evaluator-blinded(1 2 1 z 0 z 1 z 152)

49 (24) median40

AP MAzEA or Moxaeveryday for 6 weeks2ndash4 HzCON rehabilitation

Motor function

Sunnaas ADLNHP

Significant benefit(p50002)NSSignificant benefit(p50009)

Zhang (1996)36 Open(1 z 0 z 0 z 0 z 051)

64 (31) 8 AP EA 2 Hz 6ndash7 timesweek for 2 weeks

CSRM NS

CON rehabilitation

Gosman-Hedstrom(1998)29

Patient-blinded Evaluator-blinded (1 z 1 z 1 z 1 z155)

104 (37 34) 7

AP deep EAzMA 2 Hztwiceweek for 10 weeksAP2 superficial AP nomanipulation and noelectrical stimulationCON Rehabilitation

SSS Barthel ADLand Sunnaas ADLNHP

NSSignificant benefitfor CON2 (p005)

Si (1998)57Evaluator-blinded(1 z 0 z 0 z 1 z 052) 42 (20) 7

AP EA 545 Hz fivetimesweek for 3ndash7 weeks CSS

Significant benefit(p001)

CON standard medication

Duan (1998)33 Open(1 z 0 z 0 z 0 z 051)

92 (47) Acute AP MA everyday for4 weeks

CSRM Significant benefit(p0001)

CON standard medication

Johansson (2001)58 Evaluator-blinded(1 z 1 z 0 z 1 z 154)

150 (48) 5ndash10 AP MAzEA 2 Hztwiceweek for 10 weeksCON1 TENS high-intensity and low-frequencyCON2 subliminal TENSlow-intensity andhigh-frequency

Barthel ADLmotor functionwalking and NHP

NS

Sze (2002)32 Evaluator-blinded(1 z 1 z 0 z 1 z 154)

106 (53) 3ndash15 AP MA 2ndash5 timesweekfor 10 weeks

FMAM BarthelADL and FIM

NS

CON standard treatment

Fink (2004)28 Patient-blinded Evaluator-blinded (1 z 0 z 1 z 1 z154)

25 (13) 5 years AP MA twice week for4 weeksCON sham AP

MAS NS

Study quality was assessed using the modified Jadad score753 randomization 1 point z appropriate randomisation method 1 point (z inappropriaterandomization method ndash1 point) z patient-blinding 1 point z evaluator-blinding 1 point z describing withdrawals and dropouts 1 point5maximum 5points ADL activities of daily living AP acupuncture CSRM Chinese stroke recovery measure CSS Chinese stroke scale EA electroacupuncture FIMfunctional independence measure FMAM Fugl-Meyer assessment of physical performance-motor subsection MA manual acupuncture MAS modifiedAshworth scale NHP Nottingham health profile NS not significantly different between groups ROM range of movement SSS Scandinavian stroke scale

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Shulman et al41 conducted a pilot study in 20patients with Parkinsonrsquos disease All patients weregiven two acupuncture treatment sessions per week for5ndash8 weeks and evaluated before and after acupuncturetreatment with a range of Parkinsonrsquos disease andbehavioral scales Although 85 of patients reportedsubjective improvement of symptoms such as tremorwalking handwriting slowness pain sleep depressionand anxiety the data showed no significant benefit fromacupuncture treatment except improvement in the sleepand rest categories in sickness impact profile Asacupuncture was reported to be one of the mostfrequently used complementary and alternative medi-cine modalities42 further rigorous research is requiredfor this indication

Other diseases of the CNSThere are few RCTs of acupuncture for other impor-

tant disorders of the CNS such as ataxic disorders43multiple sclerosis4445 amyotrophic lateral sclerosis46

and traumatic injuries of the spinal cord47 The effect ofacupuncture for these indications is largely dependentupon anecdotal evidence Considering the prevalenceof acupuncture use4648 well-designed high-qualityRCTs in these populations are needed

FUTURE DIRECTIONSOwing to the dearth of high-quality studies a firmconclusion on the effectiveness of acupuncture forneurological disorders cannot be drawn A carefulanalysis of the negative results however is required todispute acupuncturersquos effect on neurological disordersas most previous studies have been unable to fullyevaluate therapeutic modality of acupuncture Based onthe summarized evidence a few suggestions for futureclinical trials of acupuncture in this field can be made

Patient populationThe patient populations in the previous studies are

heterogeneous The effect of acupuncture can bedifferent in a certain patient group3 Future researchshould clearly define patient inclusion criteria toinvestigate whether acupuncture works for a certainsubgroup of patients under the same condition

Control proceduresA variety of control procedures have been used in

acupuncture research from waiting list to sham needledevice49 First comparison should be made betweenstandard treatment and acupuncture as an adjunct If anadd-on acupuncture treatment is found to be of anyhelp specific effect of acupuncture should be sought ina placebo-controlled trial For the ideal placebo-controlled study of acupuncture placebo should mimicacupuncture treatment without physiologic effectRecently developed sham needle devices are expectedto play an important role in placebo-controlledstudy5051

Acupuncture techniqueEfforts should be made regarding the acupuncture

technique in terms of stimulation method selection ofacupuncture points duration of treatment and appro-priate number of sessions Acupuncturistrsquos proficiencyand clinical experience are also important Rationalefor the acupuncture intervention should be reportedclearly

Outcome measuresWell-validated clinically relevant scales should be

used and adequate follow-up is necessary Reportsshould pre-define the primary and secondary end pointsto avoid data dredging

Methodological rigorLow-quality trials are more likely to overestimate

efficacy52 Previous acupuncture trials have been opento criticism due to poor quality Sample size calculationdescription of adequate randomization method alloca-tion concealment appropriate blinding of patient andoroutcome assessor intention-to-treat analysis and ade-quate statistical analysis should be provided in thereport

CONCLUSIONThe current evidence is not conclusive to support theuse of acupuncture for a range of neurological disordersThe paucity and poor quality of the existing studiespreclude from drawing a firm conclusion whetheracupuncture has any beneficial effect on neurologicaldisorders and stroke rehabilitation More rigorousstudies are needed to define acupuncturersquos role in thisarea

ACKNOWLEDGEMENTThis study was supported by the SRC program of KOSEF (R11-2005-014)Korea

REFERENCES1 Eisenberg DM Davis RB Ettner SL et al Trends in alternative

medicine use in the United States 1990ndash1997 Results of a follow-up national survey JAMA 1998 280 1569ndash1575

2 Vickers AJ Can acupuncture have specific effects on health asystematic review of acupuncture antiemesis trials J R Soc Med1996 89 303ndash311

3 Lee A Done ML The use of nonpharmacologic techniques toprevent postoperative nausea and vomiting A meta-analysisAnesth Analg 1999 88 1362ndash1369

4 Ernst E Pittler MH The effectiveness of acupuncture in treatingacute dental pain A systematic review Br Dent J 1998 184 443ndash447

5 Ernst E White AR Acupuncture for back pain A meta-analysis ofrandomized controlled trials Arch Intern Med 1998 158 2235ndash2341

6 van Tulder M Cherkin DC Berman B et al The effectiveness ofacupuncture in the management of acute and chronic low backpain A systematic review within the framework of the CochraneCollaboration Back Review Group Spine 1999 24 1113ndash1123

7 White AR Ernst E A systematic review of randomized controlledtrials of acupuncture for neck pain Rheumatology 1999 38 143ndash147

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analgesia Researches have revealed that endogenousopioids in the central nervous system (CNS) play anessential role in mediating the analgesic effect ofelectroacupuncture Further studies have shown thatdifferent kinds of neuropeptides are released byelectroacupuncture with different frequencies 2 Hzelectroacupuncture selectively induces the release ofenkephalin b-endorphin and endomorphin while100 Hz electroacupuncture increases the release ofdynorphin19 More recent study demonstrated thatalternative 2 and 100 Hz (2100) electroacupunctureincreased the release of both dynorphin and endomor-phin whilst 2 z 100 Hz electroacupuncture increasedonly the release of dynorphin not endomorphin Theresults suggest that a proper combination of differentfrequencies of electroacupuncture may produce a maxi-mal release of various opioids possibly for bettertherapeutic effects20 This finding from laboratoryanimals was studied in post-operative patients and thedata revealed that the alternative mode stimulation (2100 Hz) reduced the morphine requirement by 53while a constant 2 or 100 Hz produced only 32 or 35decrease respectively21

Functional magnetic resonance imaging techniquehas also been used to investigate the neural mechanismof acupuncture in healthy volunteers correlationsbetween acupuncture stimulation on the vision-relatedacupuncture point (BL67) and activation of the visualcortex were investigated22 and acupuncture stimulationon LI4 point might modulate the activity of limbicsystem and subcortical structures23

CLINICAL EVIDENCE OF ACUPUNCTURE FOR CNSDISEASESThe basic idea of acupuncture treatment is that disordersresult from inadequate flow of Qi through the meridianand can be prevented or corrected by stimulating the

relevant acupuncture points While time has witnessedbeneficial effects of acupuncture systematic reviewsfrom rigorous randomized clinical trials (RCTs) do notseem to make firm conclusions whether acupuncture iseffective or not for neurological disorders

Seizure and epilepsyEndogenous opioids serotonin and c-butyric acid

have been implicated in the mechanism of acupuncturein suppressing epileptic seizures in animal models24Kloster et al25 compared 8 week acupuncture treatmentwith sham acupuncture in 29 patients with chronicintractable epilepsy Fifteen patients in the acupuncturegroup received real acupuncture consisting of manualacupuncture and electroacupuncture three times a weekfor 8 weeks with a week rest in the middle For thecontrol group (n514) acupuncture on non-acupuncturepoints without electric stimulation was given No inter-group difference was reported in seizure frequency andthe number of seizure-free weeks increased significantlyin the control group not in the acupuncture group(p50006) The same team reported no beneficial effectof acupuncture in health-related quality of life from thesame trial26 (Table 1)

Cerebrovascular disordersIn 1997 the National Institute of Health Consensus

Development Panel on Acupuncture suggested thatacupuncture might be a useful adjunct for strokerehabilitation27 However high-quality RCTs and sys-tematic reviews on the effectiveness of acupuncture forstroke rehabilitation do not support this claim122829 Arecently published meta-analysis also reports no addi-tional effect of acupuncture on motor recovery whengiven with rehabilitation therapy30

Several high-quality RCTs have been published sincePark et al12 systematically reviewed the literature

Table 1 Characteristics and results of randomized clinical trials of acupuncture for seizure and epilepsy

Author (year) Study design and qualitySample size(acupuncture) Intervention Outcome measures Results

Kloster (1999)25 Sham-controlled(1 z 1 z 1 z 1 z 155)

29 (15) AP MA z EA three timesweekfor 7 weeks with 1 week rest inthe middle LR3 LI4 GV20 z 1ndash 2 individualized points 3 Hz3ndash20 mA

Seizure frequency8 weeks post-APSeizure-free weeksduring treatmentand follow-up

NSsignificant benefitfor CON group(p50006)

CON sham AP non-AP pointsminimal manipulation and noelectrical stimulation

Stavem (2000)26 Sham-controlled(1 z 1 z 1 z 0 z 154)

34 (18) AP MA z EA three timesweekfor 7 weeks with 1 week rest inthe middle LR3 LI4 GV20 z 1ndash 2 individualized points 3 Hz3ndash20 mA

QOLIE-89 scores8 weeks post-AP

NS

CON sham AP non-AP pointsminimal manipulation and noelectrical stimulation

Study quality was assessed using the modified Jadad score753 randomization 1 point z appropriate randomization method 1 point (zinappropriate randomization method 21 point) z patient-blinding 1 point z evaluator-blinding 1 point z describing withdrawals and dropouts 1point5maximum 5 points AP acupuncture EA electroacupuncture MA manual acupuncture NS not significantly different between groupsQOLIE-89 89-item quality of life in epilepsy questionnaire

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(Table 2) Johansson et al31 conducted a multi-centerevaluator-blinded RCT involving 150 patients within 5ndash10 days of stroke onset Only patients with moderate orsevere functional impairment at randomization wereincluded Barthel index (70 points in combinationwith inability to walk 10 m without mechanical orpersonal support Patients were allocated by stratifiedrandomization to receive (1) a combination of manualacupuncture and low-frequency electroacupuncture(n548) (2) high-intensity low-frequency transcuta-neous electric nerve stimulation (TENS) (n551) (3)low-intensity high-frequency TENS (control groupn551) Twice-a-week treatment for 10 weeks was givenand if necessary patients received conventional phy-siotherapy occupational therapy and speech therapyirrespective of group allocation Walking (time neededto walk 10 m) motor function (Rivermead mobilityindex) activities of daily living (Barthel index) andquality of life (Nottingham health profile) were mea-sured at randomization three months and 12 monthsfollow-ups after the onset of stroke The resultsdemonstrated no significant differences between groupsin any of outcome measures and authors concludedthat acupuncture combined with electroacupuncture orTENS-induced muscle contraction could not be recom-mended as a standard treatment for patients withmoderate or severe stroke in the subacute stage

In another evaluator-blinded RCT with 106 strokepatients within 3ndash15 days of the onset of strokeadditional manual acupuncture to standard treatmentwas compared with standard treatment only32 Patientswere stratified into Group I (admission Barthelindex11) and Group II (admission Barthel indexgt11)to avoid chance imbalance of severity of disabilitybetween the acupuncture arm and the control arm andalso because the severe group required longer inpatientrehabilitation than the moderate group Group I patientsreceived 5 weeks (iexcl1 week) of inpatient rehabilitationfollowed by 5 weeks (iexcl1 week) of day hospitalrehabilitation while Group II patients receivedthree weeks (iexcl1 week) of inpatient rehabilitationfollowed by 7 weeks (iexcl1 week) of day hospitalrehabilitation Patients in Groups I and II were thenseparately randomized to either acupuncture group orcontrol group (n553) Acupuncture treatment wascarried out 5 times per week for inpatients three timesper week to the end of the eighth week and then twiceper week for the remaining two weeks for day hospitalpatients Therefore the total intervention lasted for10 weeks The primary end points were the Fugl-Meyerassessment of physical performance-motor subsection(FMAM) median score at week 10 and FMAM medianscore change over time Median scores of Barthel indexand functional independence measure were alsoassessed Acupuncture intervention failed to showsignificant benefit in any of the outcome measures atweek 10 or outcome changes over time

A most recent placebo-controlled trial28 tested theeffect of 4 week manual acupuncture treatment forreduction of leg spasticity in chronic post-stroke patients(mean time from ischemic stroke 654 iexcl 483 months)

Participants were randomized to receive either 8sessions of manual acupuncture (n513) or placeboacupuncture where sham acupuncture needles wereused (n512) Modified Ashworth scale score wasmeasured as the primary end point There was nosignificant difference between acupuncture group andplacebo acupuncture group

The message from the current evidence is clear Thereis a paucity of RCTs and the most recent high-qualitystudies283031 confirm the finding of the systematicreview by Park et al12 that methodologically weakerstudies were likely to generate positive outcomes Aswith acupuncture studies in other areas most studies onacupuncture for stroke rehabilitation suffer from meth-odological flaws Control groups are heterogeneous andfew studies adopt placebo control to investigate possiblespecific effects of acupuncture As practitioner-blindingis virtually impossible in acupuncture trials at leastevaluator of outcome measures should be blinded tominimize measurement bias However most studieswere found to fail to blind outcome assessor313337Acupuncture interventions vary across studies in termsof stimulation method choice of acupuncture pointsnumber of treatment sessions and treatment periodHeterogeneous inclusion criteria across trials and smallsample sizes also preclude estimation of acupunctureeffect for any subgroup of stroke patients Rigorousresearch is warranted to establish acupuncturersquos role instroke rehabilitation

Alzheimerrsquos diseaseThere are only a few uncontrolled studies of

acupuncture for Alzheimerrsquos disease In a pilot studyinvolving 11 patients 10 with Alzheimerrsquos disease andone with vascular dementia twice-a-week acupuncturetreatment for three months was tested whether it hadany effects on depression and anxiety38 The researchersfound significant improvements in the depression andanxiety scores measured by the Cornell scale fordepression and the Speilberger state anxiety inventoryCognitive functioning (mini-mental status examinationMMSE) remained stable over months of the studyAnother pilot study where eight patients with mild tomoderate Alzheimerrsquos disease were given acupuncturetreatment for a month reported that patients significantlyimproved on measures of verbal orientation and motorcoordination and had higher overall MMSE scores39The findings call for rigorous clinical trials in this area

Parkinsonrsquos diseaseSeveral uncontrolled pilot studies were conducted on

the patients with Parkinsonrsquos disease In the study by Haet al40 7 patients with antiparkinsonian drugs and 12patients without antiparkinsonian drugs completedtwice-a-week acupuncture treatments for eight weeksIn the former group total scores of unified Parkinsonrsquosdisease rating scale (UPDRS) UPDRS II for daily activityand UPDRS IV for side effects improved compared to thebaseline In the latter group total scores for UPDRS andUPDRS III for motor function improved significantly

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Neurological Research 2007 Volume 29 Supplement 1 S51

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Table 2 Characteristics and results of randomized clinical trials of acupuncture for stroke

Author (year) Study design and qualitySample size(acupuncture)

Days afteronset Intervention

Outcomemeasures

Results comparedwith control

Zou (1990)37 Open(1 z 0 z 0 z 0 z 051)

63 (32) 7 AP MA everydayfor 6 weeks

CSRM Significant benefit(p0001)

CON standardmedication

Naeser (1992)35 Patient-blinded(1 z 0 z 1 z 0 z 052)

16 (10) 30ndash90 AP EA 1ndash2 Hzfive timesweek for4 weeks

ROM NS

CON sham AP noelectrical stimulationnon-paralyzed armsand leg

Johansson (1993)31

and Magnusson(1994)54

Open(1 z 0 z 0 z 0 z 152)

78 (38) 10 AP EA 2ndash5 Hz twiceweek for 10 weeks

Walking Motorfunction balanceand Barthel ADL

Significant benefit(p005) exceptmotor function

Significant benefitfor energy mobilityemotion andsocial isolation(p005)

CON rehabilitation NHPDays spent athospitalnursinghome

Significant benefit(p005)

Hu (1993)34 Open(1 z 0 z 0 z 0 z 152)

30 (15) 15 AP EA 94 Hz threetimesweek for 4 weeksCON Rehabilitation

SSSBarthel ADL

Significant benefit(p5002)NS

Sallstrom (1996)55

and Kjendahl(1997)56

Evaluator-blinded(1 2 1 z 0 z 1 z 152)

49 (24) median40

AP MAzEA or Moxaeveryday for 6 weeks2ndash4 HzCON rehabilitation

Motor function

Sunnaas ADLNHP

Significant benefit(p50002)NSSignificant benefit(p50009)

Zhang (1996)36 Open(1 z 0 z 0 z 0 z 051)

64 (31) 8 AP EA 2 Hz 6ndash7 timesweek for 2 weeks

CSRM NS

CON rehabilitation

Gosman-Hedstrom(1998)29

Patient-blinded Evaluator-blinded (1 z 1 z 1 z 1 z155)

104 (37 34) 7

AP deep EAzMA 2 Hztwiceweek for 10 weeksAP2 superficial AP nomanipulation and noelectrical stimulationCON Rehabilitation

SSS Barthel ADLand Sunnaas ADLNHP

NSSignificant benefitfor CON2 (p005)

Si (1998)57Evaluator-blinded(1 z 0 z 0 z 1 z 052) 42 (20) 7

AP EA 545 Hz fivetimesweek for 3ndash7 weeks CSS

Significant benefit(p001)

CON standard medication

Duan (1998)33 Open(1 z 0 z 0 z 0 z 051)

92 (47) Acute AP MA everyday for4 weeks

CSRM Significant benefit(p0001)

CON standard medication

Johansson (2001)58 Evaluator-blinded(1 z 1 z 0 z 1 z 154)

150 (48) 5ndash10 AP MAzEA 2 Hztwiceweek for 10 weeksCON1 TENS high-intensity and low-frequencyCON2 subliminal TENSlow-intensity andhigh-frequency

Barthel ADLmotor functionwalking and NHP

NS

Sze (2002)32 Evaluator-blinded(1 z 1 z 0 z 1 z 154)

106 (53) 3ndash15 AP MA 2ndash5 timesweekfor 10 weeks

FMAM BarthelADL and FIM

NS

CON standard treatment

Fink (2004)28 Patient-blinded Evaluator-blinded (1 z 0 z 1 z 1 z154)

25 (13) 5 years AP MA twice week for4 weeksCON sham AP

MAS NS

Study quality was assessed using the modified Jadad score753 randomization 1 point z appropriate randomisation method 1 point (z inappropriaterandomization method ndash1 point) z patient-blinding 1 point z evaluator-blinding 1 point z describing withdrawals and dropouts 1 point5maximum 5points ADL activities of daily living AP acupuncture CSRM Chinese stroke recovery measure CSS Chinese stroke scale EA electroacupuncture FIMfunctional independence measure FMAM Fugl-Meyer assessment of physical performance-motor subsection MA manual acupuncture MAS modifiedAshworth scale NHP Nottingham health profile NS not significantly different between groups ROM range of movement SSS Scandinavian stroke scale

Acupuncture and neurological disorders H Lee et al

S52 Neurological Research 2007 Volume 29 Supplement 1

Pub

lishe

d by

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ublis

hing

(c)

W S

Man

ey amp

Son

Lim

ited

Shulman et al41 conducted a pilot study in 20patients with Parkinsonrsquos disease All patients weregiven two acupuncture treatment sessions per week for5ndash8 weeks and evaluated before and after acupuncturetreatment with a range of Parkinsonrsquos disease andbehavioral scales Although 85 of patients reportedsubjective improvement of symptoms such as tremorwalking handwriting slowness pain sleep depressionand anxiety the data showed no significant benefit fromacupuncture treatment except improvement in the sleepand rest categories in sickness impact profile Asacupuncture was reported to be one of the mostfrequently used complementary and alternative medi-cine modalities42 further rigorous research is requiredfor this indication

Other diseases of the CNSThere are few RCTs of acupuncture for other impor-

tant disorders of the CNS such as ataxic disorders43multiple sclerosis4445 amyotrophic lateral sclerosis46

and traumatic injuries of the spinal cord47 The effect ofacupuncture for these indications is largely dependentupon anecdotal evidence Considering the prevalenceof acupuncture use4648 well-designed high-qualityRCTs in these populations are needed

FUTURE DIRECTIONSOwing to the dearth of high-quality studies a firmconclusion on the effectiveness of acupuncture forneurological disorders cannot be drawn A carefulanalysis of the negative results however is required todispute acupuncturersquos effect on neurological disordersas most previous studies have been unable to fullyevaluate therapeutic modality of acupuncture Based onthe summarized evidence a few suggestions for futureclinical trials of acupuncture in this field can be made

Patient populationThe patient populations in the previous studies are

heterogeneous The effect of acupuncture can bedifferent in a certain patient group3 Future researchshould clearly define patient inclusion criteria toinvestigate whether acupuncture works for a certainsubgroup of patients under the same condition

Control proceduresA variety of control procedures have been used in

acupuncture research from waiting list to sham needledevice49 First comparison should be made betweenstandard treatment and acupuncture as an adjunct If anadd-on acupuncture treatment is found to be of anyhelp specific effect of acupuncture should be sought ina placebo-controlled trial For the ideal placebo-controlled study of acupuncture placebo should mimicacupuncture treatment without physiologic effectRecently developed sham needle devices are expectedto play an important role in placebo-controlledstudy5051

Acupuncture techniqueEfforts should be made regarding the acupuncture

technique in terms of stimulation method selection ofacupuncture points duration of treatment and appro-priate number of sessions Acupuncturistrsquos proficiencyand clinical experience are also important Rationalefor the acupuncture intervention should be reportedclearly

Outcome measuresWell-validated clinically relevant scales should be

used and adequate follow-up is necessary Reportsshould pre-define the primary and secondary end pointsto avoid data dredging

Methodological rigorLow-quality trials are more likely to overestimate

efficacy52 Previous acupuncture trials have been opento criticism due to poor quality Sample size calculationdescription of adequate randomization method alloca-tion concealment appropriate blinding of patient andoroutcome assessor intention-to-treat analysis and ade-quate statistical analysis should be provided in thereport

CONCLUSIONThe current evidence is not conclusive to support theuse of acupuncture for a range of neurological disordersThe paucity and poor quality of the existing studiespreclude from drawing a firm conclusion whetheracupuncture has any beneficial effect on neurologicaldisorders and stroke rehabilitation More rigorousstudies are needed to define acupuncturersquos role in thisarea

ACKNOWLEDGEMENTThis study was supported by the SRC program of KOSEF (R11-2005-014)Korea

REFERENCES1 Eisenberg DM Davis RB Ettner SL et al Trends in alternative

medicine use in the United States 1990ndash1997 Results of a follow-up national survey JAMA 1998 280 1569ndash1575

2 Vickers AJ Can acupuncture have specific effects on health asystematic review of acupuncture antiemesis trials J R Soc Med1996 89 303ndash311

3 Lee A Done ML The use of nonpharmacologic techniques toprevent postoperative nausea and vomiting A meta-analysisAnesth Analg 1999 88 1362ndash1369

4 Ernst E Pittler MH The effectiveness of acupuncture in treatingacute dental pain A systematic review Br Dent J 1998 184 443ndash447

5 Ernst E White AR Acupuncture for back pain A meta-analysis ofrandomized controlled trials Arch Intern Med 1998 158 2235ndash2341

6 van Tulder M Cherkin DC Berman B et al The effectiveness ofacupuncture in the management of acute and chronic low backpain A systematic review within the framework of the CochraneCollaboration Back Review Group Spine 1999 24 1113ndash1123

7 White AR Ernst E A systematic review of randomized controlledtrials of acupuncture for neck pain Rheumatology 1999 38 143ndash147

Acupuncture and neurological disorders H Lee et al

Neurological Research 2007 Volume 29 Supplement 1 S53

Pub

lishe

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hing

(c)

W S

Man

ey amp

Son

Lim

ited

(Table 2) Johansson et al31 conducted a multi-centerevaluator-blinded RCT involving 150 patients within 5ndash10 days of stroke onset Only patients with moderate orsevere functional impairment at randomization wereincluded Barthel index (70 points in combinationwith inability to walk 10 m without mechanical orpersonal support Patients were allocated by stratifiedrandomization to receive (1) a combination of manualacupuncture and low-frequency electroacupuncture(n548) (2) high-intensity low-frequency transcuta-neous electric nerve stimulation (TENS) (n551) (3)low-intensity high-frequency TENS (control groupn551) Twice-a-week treatment for 10 weeks was givenand if necessary patients received conventional phy-siotherapy occupational therapy and speech therapyirrespective of group allocation Walking (time neededto walk 10 m) motor function (Rivermead mobilityindex) activities of daily living (Barthel index) andquality of life (Nottingham health profile) were mea-sured at randomization three months and 12 monthsfollow-ups after the onset of stroke The resultsdemonstrated no significant differences between groupsin any of outcome measures and authors concludedthat acupuncture combined with electroacupuncture orTENS-induced muscle contraction could not be recom-mended as a standard treatment for patients withmoderate or severe stroke in the subacute stage

In another evaluator-blinded RCT with 106 strokepatients within 3ndash15 days of the onset of strokeadditional manual acupuncture to standard treatmentwas compared with standard treatment only32 Patientswere stratified into Group I (admission Barthelindex11) and Group II (admission Barthel indexgt11)to avoid chance imbalance of severity of disabilitybetween the acupuncture arm and the control arm andalso because the severe group required longer inpatientrehabilitation than the moderate group Group I patientsreceived 5 weeks (iexcl1 week) of inpatient rehabilitationfollowed by 5 weeks (iexcl1 week) of day hospitalrehabilitation while Group II patients receivedthree weeks (iexcl1 week) of inpatient rehabilitationfollowed by 7 weeks (iexcl1 week) of day hospitalrehabilitation Patients in Groups I and II were thenseparately randomized to either acupuncture group orcontrol group (n553) Acupuncture treatment wascarried out 5 times per week for inpatients three timesper week to the end of the eighth week and then twiceper week for the remaining two weeks for day hospitalpatients Therefore the total intervention lasted for10 weeks The primary end points were the Fugl-Meyerassessment of physical performance-motor subsection(FMAM) median score at week 10 and FMAM medianscore change over time Median scores of Barthel indexand functional independence measure were alsoassessed Acupuncture intervention failed to showsignificant benefit in any of the outcome measures atweek 10 or outcome changes over time

A most recent placebo-controlled trial28 tested theeffect of 4 week manual acupuncture treatment forreduction of leg spasticity in chronic post-stroke patients(mean time from ischemic stroke 654 iexcl 483 months)

Participants were randomized to receive either 8sessions of manual acupuncture (n513) or placeboacupuncture where sham acupuncture needles wereused (n512) Modified Ashworth scale score wasmeasured as the primary end point There was nosignificant difference between acupuncture group andplacebo acupuncture group

The message from the current evidence is clear Thereis a paucity of RCTs and the most recent high-qualitystudies283031 confirm the finding of the systematicreview by Park et al12 that methodologically weakerstudies were likely to generate positive outcomes Aswith acupuncture studies in other areas most studies onacupuncture for stroke rehabilitation suffer from meth-odological flaws Control groups are heterogeneous andfew studies adopt placebo control to investigate possiblespecific effects of acupuncture As practitioner-blindingis virtually impossible in acupuncture trials at leastevaluator of outcome measures should be blinded tominimize measurement bias However most studieswere found to fail to blind outcome assessor313337Acupuncture interventions vary across studies in termsof stimulation method choice of acupuncture pointsnumber of treatment sessions and treatment periodHeterogeneous inclusion criteria across trials and smallsample sizes also preclude estimation of acupunctureeffect for any subgroup of stroke patients Rigorousresearch is warranted to establish acupuncturersquos role instroke rehabilitation

Alzheimerrsquos diseaseThere are only a few uncontrolled studies of

acupuncture for Alzheimerrsquos disease In a pilot studyinvolving 11 patients 10 with Alzheimerrsquos disease andone with vascular dementia twice-a-week acupuncturetreatment for three months was tested whether it hadany effects on depression and anxiety38 The researchersfound significant improvements in the depression andanxiety scores measured by the Cornell scale fordepression and the Speilberger state anxiety inventoryCognitive functioning (mini-mental status examinationMMSE) remained stable over months of the studyAnother pilot study where eight patients with mild tomoderate Alzheimerrsquos disease were given acupuncturetreatment for a month reported that patients significantlyimproved on measures of verbal orientation and motorcoordination and had higher overall MMSE scores39The findings call for rigorous clinical trials in this area

Parkinsonrsquos diseaseSeveral uncontrolled pilot studies were conducted on

the patients with Parkinsonrsquos disease In the study by Haet al40 7 patients with antiparkinsonian drugs and 12patients without antiparkinsonian drugs completedtwice-a-week acupuncture treatments for eight weeksIn the former group total scores of unified Parkinsonrsquosdisease rating scale (UPDRS) UPDRS II for daily activityand UPDRS IV for side effects improved compared to thebaseline In the latter group total scores for UPDRS andUPDRS III for motor function improved significantly

Acupuncture and neurological disorders H Lee et al

Neurological Research 2007 Volume 29 Supplement 1 S51

Pub

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ited

Table 2 Characteristics and results of randomized clinical trials of acupuncture for stroke

Author (year) Study design and qualitySample size(acupuncture)

Days afteronset Intervention

Outcomemeasures

Results comparedwith control

Zou (1990)37 Open(1 z 0 z 0 z 0 z 051)

63 (32) 7 AP MA everydayfor 6 weeks

CSRM Significant benefit(p0001)

CON standardmedication

Naeser (1992)35 Patient-blinded(1 z 0 z 1 z 0 z 052)

16 (10) 30ndash90 AP EA 1ndash2 Hzfive timesweek for4 weeks

ROM NS

CON sham AP noelectrical stimulationnon-paralyzed armsand leg

Johansson (1993)31

and Magnusson(1994)54

Open(1 z 0 z 0 z 0 z 152)

78 (38) 10 AP EA 2ndash5 Hz twiceweek for 10 weeks

Walking Motorfunction balanceand Barthel ADL

Significant benefit(p005) exceptmotor function

Significant benefitfor energy mobilityemotion andsocial isolation(p005)

CON rehabilitation NHPDays spent athospitalnursinghome

Significant benefit(p005)

Hu (1993)34 Open(1 z 0 z 0 z 0 z 152)

30 (15) 15 AP EA 94 Hz threetimesweek for 4 weeksCON Rehabilitation

SSSBarthel ADL

Significant benefit(p5002)NS

Sallstrom (1996)55

and Kjendahl(1997)56

Evaluator-blinded(1 2 1 z 0 z 1 z 152)

49 (24) median40

AP MAzEA or Moxaeveryday for 6 weeks2ndash4 HzCON rehabilitation

Motor function

Sunnaas ADLNHP

Significant benefit(p50002)NSSignificant benefit(p50009)

Zhang (1996)36 Open(1 z 0 z 0 z 0 z 051)

64 (31) 8 AP EA 2 Hz 6ndash7 timesweek for 2 weeks

CSRM NS

CON rehabilitation

Gosman-Hedstrom(1998)29

Patient-blinded Evaluator-blinded (1 z 1 z 1 z 1 z155)

104 (37 34) 7

AP deep EAzMA 2 Hztwiceweek for 10 weeksAP2 superficial AP nomanipulation and noelectrical stimulationCON Rehabilitation

SSS Barthel ADLand Sunnaas ADLNHP

NSSignificant benefitfor CON2 (p005)

Si (1998)57Evaluator-blinded(1 z 0 z 0 z 1 z 052) 42 (20) 7

AP EA 545 Hz fivetimesweek for 3ndash7 weeks CSS

Significant benefit(p001)

CON standard medication

Duan (1998)33 Open(1 z 0 z 0 z 0 z 051)

92 (47) Acute AP MA everyday for4 weeks

CSRM Significant benefit(p0001)

CON standard medication

Johansson (2001)58 Evaluator-blinded(1 z 1 z 0 z 1 z 154)

150 (48) 5ndash10 AP MAzEA 2 Hztwiceweek for 10 weeksCON1 TENS high-intensity and low-frequencyCON2 subliminal TENSlow-intensity andhigh-frequency

Barthel ADLmotor functionwalking and NHP

NS

Sze (2002)32 Evaluator-blinded(1 z 1 z 0 z 1 z 154)

106 (53) 3ndash15 AP MA 2ndash5 timesweekfor 10 weeks

FMAM BarthelADL and FIM

NS

CON standard treatment

Fink (2004)28 Patient-blinded Evaluator-blinded (1 z 0 z 1 z 1 z154)

25 (13) 5 years AP MA twice week for4 weeksCON sham AP

MAS NS

Study quality was assessed using the modified Jadad score753 randomization 1 point z appropriate randomisation method 1 point (z inappropriaterandomization method ndash1 point) z patient-blinding 1 point z evaluator-blinding 1 point z describing withdrawals and dropouts 1 point5maximum 5points ADL activities of daily living AP acupuncture CSRM Chinese stroke recovery measure CSS Chinese stroke scale EA electroacupuncture FIMfunctional independence measure FMAM Fugl-Meyer assessment of physical performance-motor subsection MA manual acupuncture MAS modifiedAshworth scale NHP Nottingham health profile NS not significantly different between groups ROM range of movement SSS Scandinavian stroke scale

Acupuncture and neurological disorders H Lee et al

S52 Neurological Research 2007 Volume 29 Supplement 1

Pub

lishe

d by

Man

ey P

ublis

hing

(c)

W S

Man

ey amp

Son

Lim

ited

Shulman et al41 conducted a pilot study in 20patients with Parkinsonrsquos disease All patients weregiven two acupuncture treatment sessions per week for5ndash8 weeks and evaluated before and after acupuncturetreatment with a range of Parkinsonrsquos disease andbehavioral scales Although 85 of patients reportedsubjective improvement of symptoms such as tremorwalking handwriting slowness pain sleep depressionand anxiety the data showed no significant benefit fromacupuncture treatment except improvement in the sleepand rest categories in sickness impact profile Asacupuncture was reported to be one of the mostfrequently used complementary and alternative medi-cine modalities42 further rigorous research is requiredfor this indication

Other diseases of the CNSThere are few RCTs of acupuncture for other impor-

tant disorders of the CNS such as ataxic disorders43multiple sclerosis4445 amyotrophic lateral sclerosis46

and traumatic injuries of the spinal cord47 The effect ofacupuncture for these indications is largely dependentupon anecdotal evidence Considering the prevalenceof acupuncture use4648 well-designed high-qualityRCTs in these populations are needed

FUTURE DIRECTIONSOwing to the dearth of high-quality studies a firmconclusion on the effectiveness of acupuncture forneurological disorders cannot be drawn A carefulanalysis of the negative results however is required todispute acupuncturersquos effect on neurological disordersas most previous studies have been unable to fullyevaluate therapeutic modality of acupuncture Based onthe summarized evidence a few suggestions for futureclinical trials of acupuncture in this field can be made

Patient populationThe patient populations in the previous studies are

heterogeneous The effect of acupuncture can bedifferent in a certain patient group3 Future researchshould clearly define patient inclusion criteria toinvestigate whether acupuncture works for a certainsubgroup of patients under the same condition

Control proceduresA variety of control procedures have been used in

acupuncture research from waiting list to sham needledevice49 First comparison should be made betweenstandard treatment and acupuncture as an adjunct If anadd-on acupuncture treatment is found to be of anyhelp specific effect of acupuncture should be sought ina placebo-controlled trial For the ideal placebo-controlled study of acupuncture placebo should mimicacupuncture treatment without physiologic effectRecently developed sham needle devices are expectedto play an important role in placebo-controlledstudy5051

Acupuncture techniqueEfforts should be made regarding the acupuncture

technique in terms of stimulation method selection ofacupuncture points duration of treatment and appro-priate number of sessions Acupuncturistrsquos proficiencyand clinical experience are also important Rationalefor the acupuncture intervention should be reportedclearly

Outcome measuresWell-validated clinically relevant scales should be

used and adequate follow-up is necessary Reportsshould pre-define the primary and secondary end pointsto avoid data dredging

Methodological rigorLow-quality trials are more likely to overestimate

efficacy52 Previous acupuncture trials have been opento criticism due to poor quality Sample size calculationdescription of adequate randomization method alloca-tion concealment appropriate blinding of patient andoroutcome assessor intention-to-treat analysis and ade-quate statistical analysis should be provided in thereport

CONCLUSIONThe current evidence is not conclusive to support theuse of acupuncture for a range of neurological disordersThe paucity and poor quality of the existing studiespreclude from drawing a firm conclusion whetheracupuncture has any beneficial effect on neurologicaldisorders and stroke rehabilitation More rigorousstudies are needed to define acupuncturersquos role in thisarea

ACKNOWLEDGEMENTThis study was supported by the SRC program of KOSEF (R11-2005-014)Korea

REFERENCES1 Eisenberg DM Davis RB Ettner SL et al Trends in alternative

medicine use in the United States 1990ndash1997 Results of a follow-up national survey JAMA 1998 280 1569ndash1575

2 Vickers AJ Can acupuncture have specific effects on health asystematic review of acupuncture antiemesis trials J R Soc Med1996 89 303ndash311

3 Lee A Done ML The use of nonpharmacologic techniques toprevent postoperative nausea and vomiting A meta-analysisAnesth Analg 1999 88 1362ndash1369

4 Ernst E Pittler MH The effectiveness of acupuncture in treatingacute dental pain A systematic review Br Dent J 1998 184 443ndash447

5 Ernst E White AR Acupuncture for back pain A meta-analysis ofrandomized controlled trials Arch Intern Med 1998 158 2235ndash2341

6 van Tulder M Cherkin DC Berman B et al The effectiveness ofacupuncture in the management of acute and chronic low backpain A systematic review within the framework of the CochraneCollaboration Back Review Group Spine 1999 24 1113ndash1123

7 White AR Ernst E A systematic review of randomized controlledtrials of acupuncture for neck pain Rheumatology 1999 38 143ndash147

Acupuncture and neurological disorders H Lee et al

Neurological Research 2007 Volume 29 Supplement 1 S53

Pub

lishe

d by

Man

ey P

ublis

hing

(c)

W S

Man

ey amp

Son

Lim

ited

Table 2 Characteristics and results of randomized clinical trials of acupuncture for stroke

Author (year) Study design and qualitySample size(acupuncture)

Days afteronset Intervention

Outcomemeasures

Results comparedwith control

Zou (1990)37 Open(1 z 0 z 0 z 0 z 051)

63 (32) 7 AP MA everydayfor 6 weeks

CSRM Significant benefit(p0001)

CON standardmedication

Naeser (1992)35 Patient-blinded(1 z 0 z 1 z 0 z 052)

16 (10) 30ndash90 AP EA 1ndash2 Hzfive timesweek for4 weeks

ROM NS

CON sham AP noelectrical stimulationnon-paralyzed armsand leg

Johansson (1993)31

and Magnusson(1994)54

Open(1 z 0 z 0 z 0 z 152)

78 (38) 10 AP EA 2ndash5 Hz twiceweek for 10 weeks

Walking Motorfunction balanceand Barthel ADL

Significant benefit(p005) exceptmotor function

Significant benefitfor energy mobilityemotion andsocial isolation(p005)

CON rehabilitation NHPDays spent athospitalnursinghome

Significant benefit(p005)

Hu (1993)34 Open(1 z 0 z 0 z 0 z 152)

30 (15) 15 AP EA 94 Hz threetimesweek for 4 weeksCON Rehabilitation

SSSBarthel ADL

Significant benefit(p5002)NS

Sallstrom (1996)55

and Kjendahl(1997)56

Evaluator-blinded(1 2 1 z 0 z 1 z 152)

49 (24) median40

AP MAzEA or Moxaeveryday for 6 weeks2ndash4 HzCON rehabilitation

Motor function

Sunnaas ADLNHP

Significant benefit(p50002)NSSignificant benefit(p50009)

Zhang (1996)36 Open(1 z 0 z 0 z 0 z 051)

64 (31) 8 AP EA 2 Hz 6ndash7 timesweek for 2 weeks

CSRM NS

CON rehabilitation

Gosman-Hedstrom(1998)29

Patient-blinded Evaluator-blinded (1 z 1 z 1 z 1 z155)

104 (37 34) 7

AP deep EAzMA 2 Hztwiceweek for 10 weeksAP2 superficial AP nomanipulation and noelectrical stimulationCON Rehabilitation

SSS Barthel ADLand Sunnaas ADLNHP

NSSignificant benefitfor CON2 (p005)

Si (1998)57Evaluator-blinded(1 z 0 z 0 z 1 z 052) 42 (20) 7

AP EA 545 Hz fivetimesweek for 3ndash7 weeks CSS

Significant benefit(p001)

CON standard medication

Duan (1998)33 Open(1 z 0 z 0 z 0 z 051)

92 (47) Acute AP MA everyday for4 weeks

CSRM Significant benefit(p0001)

CON standard medication

Johansson (2001)58 Evaluator-blinded(1 z 1 z 0 z 1 z 154)

150 (48) 5ndash10 AP MAzEA 2 Hztwiceweek for 10 weeksCON1 TENS high-intensity and low-frequencyCON2 subliminal TENSlow-intensity andhigh-frequency

Barthel ADLmotor functionwalking and NHP

NS

Sze (2002)32 Evaluator-blinded(1 z 1 z 0 z 1 z 154)

106 (53) 3ndash15 AP MA 2ndash5 timesweekfor 10 weeks

FMAM BarthelADL and FIM

NS

CON standard treatment

Fink (2004)28 Patient-blinded Evaluator-blinded (1 z 0 z 1 z 1 z154)

25 (13) 5 years AP MA twice week for4 weeksCON sham AP

MAS NS

Study quality was assessed using the modified Jadad score753 randomization 1 point z appropriate randomisation method 1 point (z inappropriaterandomization method ndash1 point) z patient-blinding 1 point z evaluator-blinding 1 point z describing withdrawals and dropouts 1 point5maximum 5points ADL activities of daily living AP acupuncture CSRM Chinese stroke recovery measure CSS Chinese stroke scale EA electroacupuncture FIMfunctional independence measure FMAM Fugl-Meyer assessment of physical performance-motor subsection MA manual acupuncture MAS modifiedAshworth scale NHP Nottingham health profile NS not significantly different between groups ROM range of movement SSS Scandinavian stroke scale

Acupuncture and neurological disorders H Lee et al

S52 Neurological Research 2007 Volume 29 Supplement 1

Pub

lishe

d by

Man

ey P

ublis

hing

(c)

W S

Man

ey amp

Son

Lim

ited

Shulman et al41 conducted a pilot study in 20patients with Parkinsonrsquos disease All patients weregiven two acupuncture treatment sessions per week for5ndash8 weeks and evaluated before and after acupuncturetreatment with a range of Parkinsonrsquos disease andbehavioral scales Although 85 of patients reportedsubjective improvement of symptoms such as tremorwalking handwriting slowness pain sleep depressionand anxiety the data showed no significant benefit fromacupuncture treatment except improvement in the sleepand rest categories in sickness impact profile Asacupuncture was reported to be one of the mostfrequently used complementary and alternative medi-cine modalities42 further rigorous research is requiredfor this indication

Other diseases of the CNSThere are few RCTs of acupuncture for other impor-

tant disorders of the CNS such as ataxic disorders43multiple sclerosis4445 amyotrophic lateral sclerosis46

and traumatic injuries of the spinal cord47 The effect ofacupuncture for these indications is largely dependentupon anecdotal evidence Considering the prevalenceof acupuncture use4648 well-designed high-qualityRCTs in these populations are needed

FUTURE DIRECTIONSOwing to the dearth of high-quality studies a firmconclusion on the effectiveness of acupuncture forneurological disorders cannot be drawn A carefulanalysis of the negative results however is required todispute acupuncturersquos effect on neurological disordersas most previous studies have been unable to fullyevaluate therapeutic modality of acupuncture Based onthe summarized evidence a few suggestions for futureclinical trials of acupuncture in this field can be made

Patient populationThe patient populations in the previous studies are

heterogeneous The effect of acupuncture can bedifferent in a certain patient group3 Future researchshould clearly define patient inclusion criteria toinvestigate whether acupuncture works for a certainsubgroup of patients under the same condition

Control proceduresA variety of control procedures have been used in

acupuncture research from waiting list to sham needledevice49 First comparison should be made betweenstandard treatment and acupuncture as an adjunct If anadd-on acupuncture treatment is found to be of anyhelp specific effect of acupuncture should be sought ina placebo-controlled trial For the ideal placebo-controlled study of acupuncture placebo should mimicacupuncture treatment without physiologic effectRecently developed sham needle devices are expectedto play an important role in placebo-controlledstudy5051

Acupuncture techniqueEfforts should be made regarding the acupuncture

technique in terms of stimulation method selection ofacupuncture points duration of treatment and appro-priate number of sessions Acupuncturistrsquos proficiencyand clinical experience are also important Rationalefor the acupuncture intervention should be reportedclearly

Outcome measuresWell-validated clinically relevant scales should be

used and adequate follow-up is necessary Reportsshould pre-define the primary and secondary end pointsto avoid data dredging

Methodological rigorLow-quality trials are more likely to overestimate

efficacy52 Previous acupuncture trials have been opento criticism due to poor quality Sample size calculationdescription of adequate randomization method alloca-tion concealment appropriate blinding of patient andoroutcome assessor intention-to-treat analysis and ade-quate statistical analysis should be provided in thereport

CONCLUSIONThe current evidence is not conclusive to support theuse of acupuncture for a range of neurological disordersThe paucity and poor quality of the existing studiespreclude from drawing a firm conclusion whetheracupuncture has any beneficial effect on neurologicaldisorders and stroke rehabilitation More rigorousstudies are needed to define acupuncturersquos role in thisarea

ACKNOWLEDGEMENTThis study was supported by the SRC program of KOSEF (R11-2005-014)Korea

REFERENCES1 Eisenberg DM Davis RB Ettner SL et al Trends in alternative

medicine use in the United States 1990ndash1997 Results of a follow-up national survey JAMA 1998 280 1569ndash1575

2 Vickers AJ Can acupuncture have specific effects on health asystematic review of acupuncture antiemesis trials J R Soc Med1996 89 303ndash311

3 Lee A Done ML The use of nonpharmacologic techniques toprevent postoperative nausea and vomiting A meta-analysisAnesth Analg 1999 88 1362ndash1369

4 Ernst E Pittler MH The effectiveness of acupuncture in treatingacute dental pain A systematic review Br Dent J 1998 184 443ndash447

5 Ernst E White AR Acupuncture for back pain A meta-analysis ofrandomized controlled trials Arch Intern Med 1998 158 2235ndash2341

6 van Tulder M Cherkin DC Berman B et al The effectiveness ofacupuncture in the management of acute and chronic low backpain A systematic review within the framework of the CochraneCollaboration Back Review Group Spine 1999 24 1113ndash1123

7 White AR Ernst E A systematic review of randomized controlledtrials of acupuncture for neck pain Rheumatology 1999 38 143ndash147

Acupuncture and neurological disorders H Lee et al

Neurological Research 2007 Volume 29 Supplement 1 S53

Pub

lishe

d by

Man

ey P

ublis

hing

(c)

W S

Man

ey amp

Son

Lim

ited

Shulman et al41 conducted a pilot study in 20patients with Parkinsonrsquos disease All patients weregiven two acupuncture treatment sessions per week for5ndash8 weeks and evaluated before and after acupuncturetreatment with a range of Parkinsonrsquos disease andbehavioral scales Although 85 of patients reportedsubjective improvement of symptoms such as tremorwalking handwriting slowness pain sleep depressionand anxiety the data showed no significant benefit fromacupuncture treatment except improvement in the sleepand rest categories in sickness impact profile Asacupuncture was reported to be one of the mostfrequently used complementary and alternative medi-cine modalities42 further rigorous research is requiredfor this indication

Other diseases of the CNSThere are few RCTs of acupuncture for other impor-

tant disorders of the CNS such as ataxic disorders43multiple sclerosis4445 amyotrophic lateral sclerosis46

and traumatic injuries of the spinal cord47 The effect ofacupuncture for these indications is largely dependentupon anecdotal evidence Considering the prevalenceof acupuncture use4648 well-designed high-qualityRCTs in these populations are needed

FUTURE DIRECTIONSOwing to the dearth of high-quality studies a firmconclusion on the effectiveness of acupuncture forneurological disorders cannot be drawn A carefulanalysis of the negative results however is required todispute acupuncturersquos effect on neurological disordersas most previous studies have been unable to fullyevaluate therapeutic modality of acupuncture Based onthe summarized evidence a few suggestions for futureclinical trials of acupuncture in this field can be made

Patient populationThe patient populations in the previous studies are

heterogeneous The effect of acupuncture can bedifferent in a certain patient group3 Future researchshould clearly define patient inclusion criteria toinvestigate whether acupuncture works for a certainsubgroup of patients under the same condition

Control proceduresA variety of control procedures have been used in

acupuncture research from waiting list to sham needledevice49 First comparison should be made betweenstandard treatment and acupuncture as an adjunct If anadd-on acupuncture treatment is found to be of anyhelp specific effect of acupuncture should be sought ina placebo-controlled trial For the ideal placebo-controlled study of acupuncture placebo should mimicacupuncture treatment without physiologic effectRecently developed sham needle devices are expectedto play an important role in placebo-controlledstudy5051

Acupuncture techniqueEfforts should be made regarding the acupuncture

technique in terms of stimulation method selection ofacupuncture points duration of treatment and appro-priate number of sessions Acupuncturistrsquos proficiencyand clinical experience are also important Rationalefor the acupuncture intervention should be reportedclearly

Outcome measuresWell-validated clinically relevant scales should be

used and adequate follow-up is necessary Reportsshould pre-define the primary and secondary end pointsto avoid data dredging

Methodological rigorLow-quality trials are more likely to overestimate

efficacy52 Previous acupuncture trials have been opento criticism due to poor quality Sample size calculationdescription of adequate randomization method alloca-tion concealment appropriate blinding of patient andoroutcome assessor intention-to-treat analysis and ade-quate statistical analysis should be provided in thereport

CONCLUSIONThe current evidence is not conclusive to support theuse of acupuncture for a range of neurological disordersThe paucity and poor quality of the existing studiespreclude from drawing a firm conclusion whetheracupuncture has any beneficial effect on neurologicaldisorders and stroke rehabilitation More rigorousstudies are needed to define acupuncturersquos role in thisarea

ACKNOWLEDGEMENTThis study was supported by the SRC program of KOSEF (R11-2005-014)Korea

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2 Vickers AJ Can acupuncture have specific effects on health asystematic review of acupuncture antiemesis trials J R Soc Med1996 89 303ndash311

3 Lee A Done ML The use of nonpharmacologic techniques toprevent postoperative nausea and vomiting A meta-analysisAnesth Analg 1999 88 1362ndash1369

4 Ernst E Pittler MH The effectiveness of acupuncture in treatingacute dental pain A systematic review Br Dent J 1998 184 443ndash447

5 Ernst E White AR Acupuncture for back pain A meta-analysis ofrandomized controlled trials Arch Intern Med 1998 158 2235ndash2341

6 van Tulder M Cherkin DC Berman B et al The effectiveness ofacupuncture in the management of acute and chronic low backpain A systematic review within the framework of the CochraneCollaboration Back Review Group Spine 1999 24 1113ndash1123

7 White AR Ernst E A systematic review of randomized controlledtrials of acupuncture for neck pain Rheumatology 1999 38 143ndash147

Acupuncture and neurological disorders H Lee et al

Neurological Research 2007 Volume 29 Supplement 1 S53

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(c)

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ited

8 Melchart D Linde K Fischer P et al Acupuncture for recurrentheadaches A systematic review of randomized controlled trialsCephalalgia 1999 19 779ndash786

9 Berman BM Ezzo J Hadhazy V et al Is acupuncture effective inthe treatment of fibromyalgia J Fam Pract 1999 48 213ndash218

10 Ernst E Acupuncture as a symptomatic treatment of osteoarthritisScand J Rheumatol 1997 26 444ndash447

11 Ezzo J Hadhazy V Birch S et al Acupuncture for osteoarthritis ofthe knee A systematic review Arthritis Rheum 2001 44 819ndash825

12 Park J Hopwood V White AR et al Effectiveness of acupuncturefor stroke A systematic review J Neurol 2001 248 558ndash563

13 Lee H Ernst E Acupuncture for labor pain management Asystematic review Am J Obstet Gynecol 2004 191 1573ndash1579

14 Park J White AR Ernst E Efficacy of acupuncture as a treatment fortinnitus A systematic review Arch Otolaryngol Head Neck Surg2000 126 489ndash492

15 McCarney R Brinkhaus B Lasserson T et al Acupuncture forchronic asthma Cochrane Database Syst Rev 2004 1 CD000008

16 White AR Resch KL Ernst E A meta-analysis of acupuncturetechnique for smoking cessation Tob Control 1999 8 393ndash397

17 Ernst E Acupunctureacupressure for weight reduction Asystematic review Wien Klin Wochenschr 1997 109 60ndash62

18 Melzack R Wall PD Pain mechanism A new theory Science1965 150 971ndash979

19 Han JS Acupuncture and endorphins Neurosci Lett 2004 361258ndash261

20 Wang Y Zhang Y Wang W et al New evidence for synergisticanalgesia produced by endomorphin and dynorphin Chin J PainMed 2002 8 118ndash119

21 Hamza MA White PF Ahmed HE et al Effect of the frequency oftranscutaneous electrical nerve stimulation on the postoperativeopioid analgesic requirement and recovery profile Anesthesiology1999 91 1232ndash1238

22 Cho ZH Chung SC Jones JP et al New findings of the correlationbetween acupoints and corresponding brain cortices usingfunctional MRI Proc Natl Acad Sci USA 1998 95 2670ndash2673

23 Hui KK Liu J Makris N et al Acupuncture modulates the limbicsystem and subcortical gray structures of the human brainEvidence from fMRI studies in normal subjects Hum Brain Mapp2000 9 13ndash25

24 Wu D Mechanism of acupuncture in suppressing epilepticseizures J Trad Chin Med 1992 12 187ndash192

25 Kloster R Larsson PG Lossius R et al The effect of acupuncture inchronic intractable epilepsy Seizure 1999 8 170ndash174

26 Stavem K Kloster R Rossberg E et al Acupuncture in intractableepilepsy Lack of effect on health-related quality of life Seizure2000 9 422ndash426

27 NIH Consensus Development Panel Acupuncture JAMA 1998280 1518ndash1524

28 Fink M Rollnik JD Bijak M et al Needle acupuncture in chronicpoststroke leg spasticity Arch Phys Med Rehabil 2004 85 667ndash672

29 Gosman-Hedstrom G Claesson L Klingenstierna U et al Effectsof acupuncture treatment on daily life activities and quality of lifeA controlled prospective and randomized study of acute strokepatients Stroke 1998 29 2100ndash2108

30 Sze FK Wong E Or KK et al Does acupuncture improve motorrecovery after stroke A meta-analysis of randomized controlledtrials Stroke 2002 33 2604ndash2619

31 Johansson K Lindgren I Widner H et al Can sensory stimulationimprove the functional outcome in stroke patients Neurology1993 43 2189ndash2192

32 Sze FK Wong E Yi X et al Does acupuncture have additionalvalue to standard poststroke motor rehabilitation Stroke 2002 33186ndash194

33 Duan G He J Zeng Z et al Comparison of effects of acupunctureon cerebral infarction in different parts World J Acup-Mox 19988 3ndash7

34 Hu HH Chung C Liu TJ et al A randomized controlled trial onthe treatment for acute partial ischemic stroke with acupunctureNeuroepidemiology 1993 12 106ndash113

35 Naeser MA Alexander MP Stiassny-Eder D et al Real versussham acupuncture in the treatment of paralysis in acute stroke

patients A CT scan lesion site study J Neurol Rehab 1992 6 163ndash173

36 Zhang X Yuan Y Kuang P et al The changes of vasoactiveintestinal peptide somatostatin and pancreatic polypeptide inblood and CSF of acute cerebral infarction patients and the effectof acupuncture on them Zhen Ci Yan Jiu 1996 21 10ndash16

37 Zou X Wang D Comparative study of cerebral infarction treatedwith acupuncture at 6 acupoints of yang meridian and calanZhong Xi Yi Jie He Za Zhi 1990 10 199ndash202

38 Lombardo NE Vehvilainen L Ooi WL et al Acupuncture totreat anxiety and depression in Alzheimerrsquos disease andvascular dementia A pilot feasibility and effectiveness trialPresent at World Alzheimerrsquos Conference 2000 WashingtonDC USA

39 Kao H Acupuncture enhancement in clinical symptoms andcognitive-motor abilities of the Alzheimerrsquos disease patientsPresent at World Alzheimerrsquos Conference 2000 WashingtonDC USA

40 Ha J Lee S Yin C et al The effect of manual acupuncture therapyon symptoms of the patients with idiopathic Parkinsonrsquos diseaseJ Korean Oriental Med 2003 24 172ndash183

41 Shulman LM Wen X Weiner WJ et al Acupuncture therapy forthe symptoms of Parkinsonrsquos disease Mov Disord 2002 17 799ndash802

42 Rajendran PR Thompson RE Reich SG The use of alternativetherapies by patients with Parkinsonrsquos disease Neurology 200157 790ndash794

43 Luo JH Guo JM 30 cases of cerebellar ataxia treated by skinacupuncture Shanghai J Acupunct Mox 1996 15 25ndash26

44 Gibson RG Gibson SLM Neural therapy in the treatment ofmultiple sclerosis J Altern Complement Med 1999 5 543ndash552

45 Miller RE An investigation into the management of the spasticityexperienced by some patients with multiple sclerosis usingacupuncture based on traditional Chinese medicineComplement Ther Med 1996 4 58ndash62

46 Wasner M Klier H Borasio GD The use of alternative medicineby patients with amyotrophic lateral sclerosis J Neurol Sci 2001191 151ndash154

47 Wong AMK Leong CP Su TY et al Clinical trial of acupuncturefor patients with spinal cord injuries Am J Phys Med Rehabil 200382 21ndash27

48 Nayak S Matheis RJ Agostinelli S et al The use of complementaryand alternative therapies for chronic pain following spinal cordinjury A pilot survey J Spinal Cord Med 2001 24 54ndash62

49 Vickers AJ Placebo controls in randomized trials of acupunctureEval Health Prof 2002 25 421ndash435

50 Park J White AR Stevinson C et al Validating a new non-penetrating sham acupuncture device Two randomised controlledtrials Acupunct Med 2002 20 168ndash174

51 Streitberger K Kleinhenz J Introducing a placebo needle intoacupuncture research Lancet 1998 352 364ndash365

52 Smith LA Oldman AD McQuay HJ et al Teasing apart qualityand validity in systematic reviews An example from acupuncturetrials in chronic neck and back pain Pain 2000 86 119ndash132

53 Jadad AR Moore RA Carroll D et al Assessing the quality ofreports of randomized clinical trials Is blinding necessary ControlClin Trials 1996 17 1ndash12

54 Magnusson M Johansson K Johansson BB Sensory stimulationpromotes normalization of postural control after stroke Stroke1994 25 1176ndash1180

55 Sallstrom S Kjendahl A Sten PE et al Acupuncture in thetreatment of stroke patients in the subacute stage A randomizedcontrolled study Complement Ther Med 1996 4 193ndash197

56 Kjendahl A Sallstrom S Oslashsten PE et al A one year follow-upstudy on the effects of acupuncture in the treatment of strokepatients in the subacute stage A randomized controlled studyClin Rehabil 1997 11 192ndash200

57 Si Q Wi G Cao X Effects of electroacupuncture on acute cerebralinfarction Acupunct Electrother Res 1998 23 117ndash124

58 Johansson BB Haker E von Arbin M et al Acupuncture andtranscutaneous nerve stimulation in stroke rehabilitation Arandomized controlled trial Stroke 2001 32 707ndash713

Acupuncture and neurological disorders H Lee et al

S54 Neurological Research 2007 Volume 29 Supplement 1