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Effectiveness and Safety of Acupuncture for Poststroke Dysphagia: Study Protocol for a Pragmatic Multicenter Nonrandomized Controlled Trial.

1. Background

Dysphagia, sometimes as part of pseudobulbar palsy, is one of the most common complications of stroke among patients. The prevalence of poststroke dysphagia ranges widely from 29% to 81% due to various methods of diagnosis, time after stroke, and the types of lesions [1-3]. Dysphagia may naturally resolve in many patients over the first 7 days after the cerebrovascular event and about 10% of them may develop swallowing problems six months after stroke [4,5]. Dysphagia is known to be associated with an increased risk of pneumonia, malnutrition, disability, and mortality [2,6,7]. Many dysphagia management options are available today, including texture-modified diets, swallowing therapy programmes, nonoral feeding, medications, and physical stimulation. However, clinical evidence to establish their roles in the management of poststroke dysphagia is limited [8,9].

Acupuncture is widely employed in management of poststroke complication in Asia and Pacific region. According to a report which was published by World Health Organization (WHO) in 2003, stroke is one of indications of acupuncture (Chmielnicki, 2014) [10]. Moreover, some clinical trials have been conducted to evaluate the effectiveness and safety of acupuncture for poststroke dysphagia. A study conducted by Ding et al. 1996 compared the acupuncture group and conventional western medication treatment. It demonstrated that the average recovery time of acupuncture group is shorter than conventional western medication group [11].

A systematic review which included about 35 randomized controlled trials of acupuncture for dysphagia has shown that acupuncture may improve swallowing function [12]. Some mechanistic studies had also illustrated that acupuncture is able to regulate the cortex and the swallowing center of the reticular structure of the brain stem to control swallowing reflection and coordinate motor movement of the swallow-related muscles, as well as directly improving the recovery of the injured peripheral nerves [13,14]. Other studies had also found that acupuncture treatment could attenuate the plasma endothelin and nitric oxide (NO) level, regulate the imbalance between prostacyclin and thromboxane A2, and improve blood viscosity, thereby collectively contributing to the therapeutic effect for poststroke dysphagia [15-17].

Nevertheless, several limitations of these studies may potentially bias the result and render the findings inconclusive. Xie et al. had undertaken a systematic review which was published in Cochrane Library [18], demonstrating that there is no enough evidence to make any conclusion about treatment effect of poststroke dysphagia. Some flaws in methodology existed in the previous study to hinder the conclusive finding, such as small sample size and lack of blinding in assessment [19]. In addition, most previous studies are open-labelled trials. Blinding was usually not applied to the outcome assessors. The lack of blinding would seriously weaken the credibility of the study. Therefore, a high quality and well-designed randomized controlled trial is urgently required.

The previous studies, together with our previous experience, suggest that there is a need to conduct a well-designed pilot study for assessing the effectiveness and safety of acupuncture for poststroke dysphagia. The early conclusion of this pilot study is able to provide evidence for conducting a full-scale rigorously designed clinical trial in future.

2. Objective

This study is to evaluate the effectiveness and safety of acupuncture for the treatment of dysphagia as a complication of stroke.

3. Methods and Design

3.1. Study Design. This is a multicenter, pragmatic clinical trial comparing real acupuncture intervention with no acupuncture to evaluate the treatment effects of acupuncture on the outpatient population of poststroke dysphagia. Owing to the characteristic of poststroke dysphagia patient and the nature of acupuncture, it is not feasible to implement the sham acupuncture in this study. The patients in acupuncture group and no-acupuncture control group will be in 1:1 allocation ratio. Subjects who are eligible in study and willing to accept acupuncture will be allocated to intervention group, while subjects eligible in study but refuse to have acupuncture treatment will be put on the no-acupuncture control arm. In the real acupuncture group, patients will receive acupuncture intervention in addition to conventional treatment. Real acupuncture group is defined as the group in the study that receives a series of sessions of acupuncture treatment which is being tested. The study will be conducted in several Chinese medicine clinics including The Pok Oi Hospital, The Chinese University of Hong Kong Clinical Center for Teaching and Research in Chinese Medicine (Shatin and Yuen Long), and The Yan Oi Tong, The Chinese University of Hong Kong Clinical Center for Teaching and Research in Chinese Medicine (Tuen Mun). Acupuncture treatment may also be conducted at the affiliated mobile clinics of these centers. This project is approved by both the Joint Chinese University of Hong Kong-New Territories East Cluster Clinical Research Ethics Committee (CRE-2012.236-T) and New Territories West Cluster Clinical Research Ethics Committee (NTWC/CREC/1281/14). Written informed consent is obtained from each participant. The study will be conducted according to ICH-GCP Guidelines. The study design is described in Figure 1.

3.2. Subject Recruitment. The patients may be recruited from The Pok Oi Hospital, The Chinese University of Hong Kong Clinical Center for Teaching and Research in Chinese Medicine (Shatin and Yuen Long), and The Yan Oi Tong, The Chinese University of Hong Kong Clinical Center for Teaching and Research in Chinese Medicine (Tuen Mun), as well as speech therapy clinics at Prince of Wales Hospital, Shatin Hospital, and Tuen Mun Hospital. The suitable poststroke dysphagia patients will be referred to by the speech therapists of the Speech Therapy Department from above hospitals. The Research Assistant will go to each of speech therapy outpatient clinics of all above three hospitals once or twice a week to explain to those potentially suitable patients (or their relatives/caretakers) the details of the research. All potential participants will be informed of the study such as objective, scope, procedure, and potential benefit and risks of the trial. A paper-formed voluntarily signed written inform consent will be obtained from participants. Under some circumstances, oral informed consent is acceptable, for instance, if participants cannot read. One hundred and forty eligible participants will be recruited from above sites according to the inclusion and exclusion criteria.

3.3. Inclusion Criteria

(1) Age between 30-90 years old

(2) With an ischemic or haemorrhagic stroke confirmed by a CT scan

(3) Within 12 months after the first-time stroke (ischemic or haemorrhagic)

(4) On modified diet due to dysphagia fulfilling RBHOMS with 2-8 points

(5) Able to give informed consent (by patient himself/herself or by caretaker)

3.4. Exclusion Criteria

(1) Dysphagia caused by head injury or neurological disease other than stroke

(2) Patients who suffered from recurrent stroke (not the first-time stroke)

(3) Unstable cardiac arrhythmia

(4) Life-threatening infection

(5) Unconsciousness or severe cognition deficits

(6) Oral or throat diseases that display dysphagia

(7) Patients with bleeding tendencies or thrombocytopenia, who are taking anticoagulants or have advanced malignancy

(8) Patients with tracheostomy

3.5. Withdrawal Criteria

(1) Participant's decision to drop out from study at any time for any reason

(2) Noncompliance with the treatment protocol

(3) Occurrence of any unexpected serious side effects

4. Blinding

Throughout the whole study process, the outcome assessor will be kept blind. As this is a single-blind controlled designed study, it is unfeasible to keep the patient and acupuncturist blind. The primary outcome measure will be carried out by registered speech therapist hired by the project. They will not be informed any information about the patient allocation and will be instructed to keep minimum interaction with patients during the whole study.

5. Intervention

Patients in both acupuncture and no-acupuncture control group will receive the conventional supportive and rehabilitative treatment, such as swallowing therapy programmes, nonoral feeding, medications, and physical stimulation [8,9]. On top of the supportive treatment, patients in the acupuncture group will receive real acupuncture treatment, while patients assigned to the control group will receive no-acupuncture treatment during the study. Baseline assessment will be conducted for all eligible participants. The participants who agree to accept acupuncture treatment will be allocated to treatment group, while those who refuse to accept acupuncture treatment will be allocated to control arm.

All acupuncture treatment sessions will be performed by two to three acupuncturists who are registered Chinese Medicine Practitioners in Hong Kong and have at least 3 years of clinical experience in acupuncture practice. Interventions will be conducted according to STRICTA and ICH-GCP guidelines. To ensure the consistency of skill of various acupuncturists, two to three training workshops will be provided to acupuncturists who have participated in the study prior to the commerce of the study. The acupuncture experts panel of School of Chinese Medicine, The Chinese University of Hong Kong, will provide technique training on the selection of acupuncture points and needling techniques. The workshops will be videotaped for education purpose.

6. Treatment Principle and Acupuncture Point Selection

Based on TCM theory, the pathogenesis of dysphagia after stroke is due to the insufficiency of the liver and kidney, the stagnant qi and blood that fail to nourish the tongue, and pathogenic factors, notably wind and phlegm, that further obstruct the meridians and the throat, resulting in swallowing difficulty. The participants will be further classified into two subtype patterns by registered Chinese Medicine Practitioner involved in the study, that is, (1) pathogenic wind phlegm syndrome and (2) liver yang rebellion syndrome. Those patients with dizziness and thin tongue coating belong to the liver yang rebellion syndrome, while those who are with greasy tongue coating belong to the pathogenic wind phlegm syndrome. All patients in acupuncture group will receive acupuncture at acupuncture points such as GB12 (Wan Gu, bilateral), GB20 (Feng Chi, bilateral), CV23 (Lian Quan), DU20 (Bai Hui), and LI4 (He Gu, bilateral) and HT5 (Tong Li, bilateral), Hangsang, Shanglianquan, and Lower 2/5 of the motor zone of scalp acupuncture.

Besides the above regular acupuncture points, additional acupuncture points will be used for patients' clinical syndrome subtypes. These additional points include ST40 (Fenglong, bilateral) for pathogenic wind phlegm subtype and LR3 (Taichong, bilateral) for liver yang rebellion type.

7. Manipulation Procedure

Sterile disposable stainless steel needles of various lengths and diameters willbe used in the study. The standardized needling manipulation methods on different acupuncture points are described as follows: GB12, GB20 (a depth of 0.8-1.2 cun with the needle tip pointing towards the throat will be punctured, and needles will be rotated with reinforcing techniques); CV23 (about 1.0 cun towards the root of the tongue will be inserted obliquely, and mild lifting and thrusting technique will be applied for about 1min); DU20 (at an angle of 30 degrees, angle to a depth of 0.5 to 0.8 cun will be inserted obliquely, and the needle will be rotated about 30 seconds before withdrawing the needle); LI4 (puncture perpendicularly for 0.5 to 1.0 cun, and apply for 30 seconds reinforcing technique with the lifting and thrusting movement); HT5 (a depth of 0.5 cun will be punctured perpendicularly, reinforcing technique with the lifting and thrusting movement will be applied for 30 seconds); Hangsang (a needle of 75 mm in length will be applied to prick the posterior wall of the throat at the depth of about 0.15 cun for 4 times without retaining the needle); Shanglianquan (a depth of 1.0-1.5 cun towards the root of the tongue will be inserted obliquely, and mild lifting and thrusting technique will be applied for 30 seconds); Lower 2/5 of the motor zone of scalp acupuncture (the needle will be inserted transversely at an angle of 15 degrees to the skin surface and push the needle to about 1.0 cun in depth, and twirling method will be applied for about 30 seconds); ST40 (the needle will be punctured perpendicularly for 1.5 cun, and reducing technique by lifting and thrusting the needle will be applied); LR3 (the needle will be inserted perpendicularly for 0.5-1.0 cun, and reducing techniques by lifting and thrusting the needle for 30 seconds will be applied) (Table 1).

The acupuncture treatment will be administered once every two days, three times a week, and the whole treatment period will last for 2 months. A total of 24 acupuncture treatment sessions will be carried out on each patient.

Participants who are allocated to nonacupuncture controlled group will receive routine care without acupuncture treatment.

8. Primary Outcome

Royal Brisbane Hospital Outcome Measure for Swallowing (RBHOMS) is a valid bedside scale for monitoring difficulties in daily swallowing function based on clinical indicators of swallowing, but not on texture-modified diets [20]. RBHOMS is a 10-point ordinal scale that ranges over four stages of oral intake: stage A, nil by mouth (levels 1-3); stage B, commencing oral intake (level 4); stage C, establishing oral intake (levels 5-7), and stage D, maintaining oral (levels 8-10). Both acupuncture group and nonacupuncture control group patient will be conducted three times RBHOMS, with one being conducted at baseline, one at the end of treatment (2 months after inclusion), and the last one at the end of follow-up period (2 months after treatment completion). All RBHOMS will be conducted by a registered speech therapist blinded to group allocation.

9. Secondary Outcomes

The secondary outcome measures include functional oral intake scale [21], swallow quality-of-life questionnaire in Chinese version [22], BMI [7], and adverse event report.

Functional oral intake scale, or known as swallow function scores, is a 7-point scale that describes the severity of swallowing dysfunction.

Swallow quality-of-life questionnaire in Chinese version consists of 12 items. The items covered all physical and psychosocial impact of the patients. Swallow quality-of-life questionnaire in Chinese version is chosen as secondary outcome because it is as sensitive, valid, and reliable as original version [22].

All adverse events as defined by the Ethics Committee will be fully recorded on the Adverse Event Page of the Case Report Form.

All functional oral intake scale, swallow quality-of-life questionnaire in Chinese version, and BMI will be assessed at baseline (before the intervention), the end of treatment (2 months after inclusion), and the end of follow-up period (2 months after treatment completion).

10. Sample Size Estimation

The primary outcome measure is Royal Brisbane Hospital Outcome Measure for Swallowing (RBHOMS), which is a 10-point ordinal scale that ranges over four stages of oral intake from stage "A" (nil by mouth) to "D" (maintaining oral intake). The sample size is estimated to compare the proportion of those who are rated at stage "D." Based on our previous clinical study [23], we estimate that 60 participants in each group will be needed to detect 20% difference of the proportion between the treatment and control group with a false positive error of 5% and power of 80%. To compensate for dropouts during treatment period, we inflate this value by 15% and hence a total of 140 patients will be recruited, with 70 each in the treatment and control group.

11. Data Analysis

All analyses will be conducted according to the intention-to-treat principle. Descriptive statistics will be computed for each of the analyzed variables. For the primary outcome, chi square test will be used. All continuous variables such as swallowing time, swallow quality-of-life, and BMI will be analyzed using i-test where appropriate. Swallow function scores will be analyzed using Mann-Whitney U test. The possible relationship between some baseline data and main outcomes will be explored using multivariable analysis. All statistical tests will be two-sided, and p < 0.05 is considered statistically significant. The statistical software of SPSS (SPSS, SPSS Inc., Chicago, USA) version 20 will be used for the analysis.

12. Discussion

This pilot study is designed to evaluate the effectiveness and the safety of acupuncture for poststroke dysphagia. As the purpose of our pilot study is to assess the effectiveness and safety of acupuncture in managing poststroke dysphagia within the healthcare setting in Hong Kong, the pragmatic design is deemed appropriate. A routine supportive and rehabilitative treatment group without acupuncture is designed as a control group instead of sham acupuncture, as it is unrealistic to ask the stroke patients to receive sham acupuncture.

Due to the safety consideration and feasibility, RBHOMS is to be selected as the primary outcome. RBHOMS is widely used as bedside assessment in dysphagia patient. It is a noninvasive investigation, and the time required to perform this test is about 10 minutes. As it will not bring too much burden to the patients, it is anticipated that the compliance of patients in the control arm would be high.

The functional oral intake scale, coupled with swallow quality-of-life questionnaire in Chinese version, BMI, and adverse events report are to be used as secondary outcome. The functional oral intake scale is an ordinary rate scale to assess the swallowing function of a patient. It is an auxiliary instrument to assess swallowing function of the patients. Previous study [20] illustrated that swallow quality-of-life questionnaire in Chinese version is a valid, effective, and sensitive tool to assess the physical and psychosocial impact in dysphagia patient of Chinese population.

The strength of our pilot study design is the pragmatic approach. This study mimics the real-world clinical situation based on Hong Kong healthcare setting. Standard acupuncture treatment protocol is obtained by the consensus of our acupuncture expert panel. Although, in real-world setting, most acupuncturists will individualize their acupuncture points selection and manipulation based on TCM theory. However, considering the consistency and replicability of the trial, a standardize acupuncture treatment protocol is chosen. Even that standardized regular acupuncture points are adopted, all enrolled participants will be classified into two subtype syndromes according to diagnosis criteria and different additional acupuncture points will be punctured individually.

Blinding is a crucial measure to assure the quality of the trial. All outcome assessor and statistician will be kept blind throughout the whole process. We will minimize the interaction between the patients and outcome assessors. Neither the RBHOMS assessor nor the staff who administer the questionnaire knows the group allocation of the participants.

One main limitation of this study is lack of randomization. Randomization is a key procedure to minimize the selection bias and ensure the comparability of all parameters between the intervention group and control group. However, concerning the timeframe and budget of our pilot study, nonrandomization approach will be utilized. To reduce the selection bias of our study, subjects will be recruited from different sources, including hospitals, speech therapy outpatient clinics, and Chinese medicine clinics. Moreover, all the prognostic factors and baseline characteristics of participants such as gender, age, occupation, life style, and onset time of stroke will be controlled in both acupuncture group and nonacupuncture control group. All data will be collected to examine the baseline comparability and explore the possible sources of dissimilarity and make proper statistical adjustment later.

As for all clinical trials, subject recruitment is one of the most critical factors for the trial's successful implementation. In our study, various venues and approaches will be utilized to augment the subject recruitment process. Free Chinese medicine consultation will be provided to control arm participants as an incentive. In addition, we will also hold promotional talks in the Chinese medicine clinics to facilitate the recruitment process. Moreover, we may also place advertisements on local newspapers and contact the stroke patients association to boost subject recruitment if recruitments from hospitals and Chinese medicine clinics turn out to be undesirable.

Nonetheless, most of potential subjects of this study are stroke sufferers. They always have other complications, such as immobility. In order to reduce the dropout rate and to enhance the compliance of patients, some treatment sessions may be conducted at affiliated mobile clinics.

This pilot study is the first large scale, multicenter controlled trial focusing on the acupuncture for poststroke dysphagia, which is one of the common complications of stroke patient. Although there is some limitation of the study, the findings of this project are able to provide an early evidence for the effectiveness of acupuncture treatment in enhancing swallowing function and life quality of poststroke dysphagia patients.
Abbreviations

BMI:      Body mass index
RBHOMS:   Royal Brisbane Hospital Outcome
          Measure for Swallowing
TCM:      Traditional Chinese medicine.


http://dx.doi.org/10.1155/2017/2349794

Additional Points

Trial Status. This trial is currently ongoing.

Competing Interests

All authors declare that they have no competing interests.

Authors' Contributions

Zhi-Xiu Lin, Yu Tat Chan, Hong Wei Zhang, and Yuan Qi Guo conceived the study and drafted the initial protocol. Yu Tat Chan recruited patients and conducted assessment. Zhi-Xiu Lin, Yu Tat Chan, and Hong Wei Zhang revised the protocol. Yuan Qi Guo developed the treatment plan. All authors read and approved the final manuscript.

Acknowledgments

The trial is funded by Chinese Medicine Department, Hospital Authority of Hong Kong. The authors would like to express their sincere gratitude to Dr. Eric Tat-Chi Ziea and Dr. NG, Bacon Fung Leung.

References

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[2] R. Martino, N. Foley, S. Bhogal, N. Diamant, M. Speechley, and R. Teasell, "Dysphagia after stroke: incidence, diagnosis, and pulmonary complications," Stroke, vol. 36, no. 12, pp. 2756-2763, 2005.

[3] N.-H. Meng, T.-G. Wang, and I.-N. Lien, "Dysphagia in patients with brainstem stroke: incidence and outcome," American Journal of Physical Medicine & Rehabilitation, vol. 79, no. 2, pp. 170-175, 2000.

[4] D. H. Barer, "The natural history and functional consequences of dysphagia after hemispheric stroke," Journal of Neurology, Neurosurgery & Psychiatry, vol. 52, no. 2, pp. 236-241, 1989.

[5] D. G. Smithard, P. A. O'Neiil, R. E. England et al., "The natural history of dysphagia following a stroke," Dysphagia, vol. 12, no. 4, pp. 188-193, 1997.

[6] M. Paciaroni, G. Mazzotta, F. Corea et al., "Dysphagia following stroke," European Neurology, vol. 51, no. 3, pp. 162-167, 2004.

[7] N. C. Foley, R. E. Martin, K. L. Salter, and R. W. Teasell, "A review of the relationship between dysphagia and malnutrition following stroke," Journal of Rehabilitation Medicine, vol. 41, no. 9, pp. 707-713, 2009.

[8] N. Foley, R. Teasell, K. Salter, E. Kruger, and R. Martino, "Dysphagia treatment post stroke: a systematic review of randomised controlled trials," Age and Ageing, vol. 37, no. 3, pp. 258-264, 2008.

[9] P. M. W. Bath, F. J. Bath-Hextall, and D. Smithard, "Interventions for dysphagia in acute stroke," Cochrane Database of Systematic Reviews, no. 1, 2009.

[10] B. Chmielnicki, "Evidence based acupuncture: WHO official position," http://www.evidencebasedacupuncture.org/who-official-position.

[11] World Health Organization, "Acupuncture: review and analysis of reports on controlled clinical trials," http://apps.who.int/iris/ bitstream/10665/42414/1/9241545437.pdf.

[12] J. He, M. Zheng, C.-Q. He et al., "Systematic assessment of acupoint stimulating therapy for deglutition disorders after apoplexy," Chinese Acupuncture & Moxibustion, vol. 29, no. 1, pp. 66-71, 2009.

[13] W. Zhang, Z. S. Liu, S. C. Sun, M. Huang, and Y. S. Liu, "Study on mechanisms of acupuncture treatment for moderate-severe dysphagia at chronic stage of apoplexy," Chinese Acupuncture & Moxibustion, vol. 22, no. 6, pp. 405-407, 2002.

[14] L. Bai, J. Tian, C. Zhong et al., "Acupuncture modulates temporal neural responses in wide brain networks: evidence from fMRI study," Molecular Pain, vol. 6, article no. 73, 2010.

[15] X. H. Chen and X. S. Lai, "herapeutic effect of acupuncture for apoplectic pseudobulbar palsy and its mechanism," Journal of Guangzhou University of Traditional Chinese Medicine, vol. 22, no. 5, pp. 369-372, 2005.

[16] X. H. Chen and X. S. Lai, "The influence of acupuncture on blood viscosity in apoplectic pseudobulbar paraysis," Shanghai Journal of Acupuncture and Moxibustion, vol. 24, no. 2, pp. 7-8, 2005.

[17] X. H. Chen and X. S. Lai, "Effect of acupuncture on plasma endothelin and NO Levels in apoplectic pseudobulbar paralysis patients," Acupuncture Research, vol. 30, no. 3, pp. 171-173, 2005.

[18] Y. Xie, L. Wang, J. He, and T. Wu, "Acupuncture for dysphagia in acute stroke," Cochrane Database of Systematic Reviews, no. 3, Article ID CD006076, 2008.

[19] T. Seki, K. Iwasaki, H. Arai et al., "Acupuncture for dysphagia in poststroke patients: a videofluoroscopic study," Journal of the American Geriatrics Society, vol. 53, no. 6, pp. 1083-1084, 2005.

[20] Royal Brisbane Hospital, Royal Brisbane Hospital Outcome Measure for Swallowing: Technical and Administration Manual, Speech Pathology Department, Royal Brisbane Hospital, Herston, Australia, 1998.

[21] M. A. Crary, G. D. Carnaby Mann, and M. E. Groher, "Initial psychometric assessment of a functional oral intake scale for dysphagia in stroke patients," Archives of Physical Medicine and Rehabilitation, vol. 86, no. 8, pp. 1516-1520, 2005.

[22] P. M. Lam and C. K. Y. Lai, "The validation of the Chinese version of the Swallow Quality-of-Life Questionnaire (SWALQOL) using exploratory and confirmatory factor analysis," Dysphagia, vol. 26, no. 2, pp. 117-124, 2011.

[23] S. L. Chan, A phase II study on the therapeutic effect of acupuncture for neurogenic dysphagia [Mphil thesis], The Chinese University of Hong Kong, Hong Kong, 2010.

Yu Tat Chan, (1) Hong Wei Zhang, (1) Yuan Qi Guo, (2) and Zhi-Xiu Lin (1)

(1) School of Chinese Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong

(2) Pok Oi Hospital, The Chinese University of Hong Kong Chinese Medicine Centre for Training & Research, Shatin, Hong Kong

Correspondence should be addressed to Zhi-Xiu Lin; linzx@cuhk.edu.hk

Received 10 September 2016; Accepted 5 January 2017; Published 29 January 2017

Academic Editor: Ching-Liang Hsieh

Caption: Figure 1: Study flow chart.
Table 1: Locations, indications, and manipulations of
the acupoints selected for the project.

Points          Location

GB20            In the depression between m.
(Feng Chi)      sternocleidomastoideus and m.
                trapezius, level with Fengfu (DU
                16) point (on the Du meridian,
                1 cun above the posterior
                hairline). [If the hairline is not
                easily determined, the level of
                bilateral earlobe tip connection
                will be used.]

GB12            On the head, in the depression
(Wangu)         posterior-inferior to mastoid
                process.

CV23            With the patient's head slightly
(LianQuan)      tilting backward, the point is
                directly above the Adam's apple
                and at the midpoint of the upper
                border of the hyoid bone.

Shanglianquan   1 cun above CV23 (with the
                patient in a sitting position and
                the patient's head slightly tilting
                backward, the point is directly
                above the Adam's apple, and on
                the midpoint of the upper border
                of the hyoid bone).

Hangsang        On the posterior wall of the
                throat.

Lower 2/5       The motor zone is a line
of the          connecting the following two
motor zone      points: the first is 0.5 cm
of the          posterior to the midpoint of the
scalp           anteroposterior midline over the
                vertex; the second is the
                intersection of the lateral
                eyebrow-occiput line with the
                anterior border of the hairline at
                the temple. The motor zone can
                be divided into 5 portions.

DU20            7 cun above the midpoint of the
(Bai Hui)       posterior hairline, or at the
                junction of the midline at the
                vertex with the line joining the
                two ear apexes.

LI4             On the dorsum of the hand,
(HeGu)          between the first and second
                metacarpal bones, approximately
                in the middle of the second
                metacarpal bone on the radial
                side.

HT5             1 cun above the shenmen point,
(Tongli)        which is at the medial end of the
                transverse crease of the wrist, in
                the depression on the radial side
                of the tendon of the flexor carpi
                ulnaris.

ST40            8 cun above the external
(Fenglong)      malleolus, 2 cun lateral to the
                anterior crest of the tibia.

LR3             On the dorsum of the foot, in the
(Taichong)      depression distal to the junction
                of the 1st and 2nd metatarsal
                bones.

KI3             At the depression between the
(Taixi)         medial malleolus and the tendon
                calcaneus.

UB23            Level with the lower border of
(Shen Shu)      the spinous process of the 2nd
                lumbar vertebra, 1.5 cunlateral to
                the posterior midline.

Points          Indications

GB20            Headache, stiff neck, red and
(Feng Chi)      painful eyes, nose bleeding,
                tinnitus, stroke, swallowing
                difficulty, deviated mouth, and
                eyes.

GB12            Headache, neck stiffness,
(Wangu)         toothache, facial palsy.

CV23            Swelling and pain in the tongue,
(LianQuan)      excessive salivation, stroke with
                stiffness of the tongue, sudden
                loss of voice, difficulty in
                swallowing.

Shanglianquan   Alalia, sore throat, difficulty in
                swallowing, difficulty in speech

Hangsang        Sore throat, difficulty in speech.

Lower 2/5       Facial paralysis, swallowing
of the          difficulty.
motor zone
of the
scalp

DU20            Headache, tinnitus, vertigo,
(Bai Hui)       stroke with difficulty to speak.

LI4             Swollen and sore throat,
(HeGu)          headache, toothache, deviated
                mouth and eye, fever, delayed
                labour.

HT5             Painful and swollen throat,
(Tongli)        sudden loss of voice, stiff tongue
                with difficulty in speech.

ST40            Headache, cough and stroke with
(Fenglong)      phlegm as the pathogenic cause.

LR3             Headache, dizziness, blurred
(Taichong)      vision, deviated mouth, stroke.

KI3             Sore throat, deafness, coughing
(Taixi)         blood, impotence, frequent
                urination and lumbar pain.

UB23            Blurred vision, deafness, tinnitus,
(Shen Shu)      edema and lower back pain.

Points          Manipulation

GB20            Puncture at a depth of
(Feng Chi)      0.8-1.2 cun with the needle tip
                pointing towards the throat.
                After obtaining needling
                sensation, rotate the needles with
                reinforcing techniques (rotating
                180[degrees] -270[degrees]
                at 30 times/min for 30
                seconds) till the needling
                sensation radiating to the whole
                tongue and throat.

GB12            Similar to GB20
(Wangu)

CV23            Insert obliquely for about 1.0 cun
(LianQuan)      towards the root of the tongue,
                followed by applying mild lifting
                and thrusting technique for
                about 1 min till soreness and
                distending sensation (de qi) is
                felt in the tongue and throat.

Shanglianquan   Insert the needle obliquely to a
                depth of 1.0-1.5 cun towards the
                root of the tongue.Then followed
                by mild lifting and thrusting the
                needle for around 30 seconds
                until soreness and distending
                sensation is felt in the tongue and
                throat.

Hangsang        Patient is asked to open the
                mouth, with the tongue pressed
                by a tongue depressor to expose
                the posterior wall of the throat
                clearly. Then a needle of 75mm
                in length will be applied to prick
                the posterior wall of the throat at
                the depth of about 0.15 cunfor 4
                times. After the needle is
                withdrawn, the patient is asked
                tomove the tongue in and out for
                10 times.

Lower 2/5       Insert the needle transversely at
of the          15[degrees] angle to the skin
motor zone      surface and push the needle to
of the          about 1.0 cun in depth, then use
scalp           twirling method (rotating
                180[degrees] -270[degrees]
                about 200 times/min) to
                manipulate the needle for about
                30 seconds.

DU20            Puncture obliquely at an angle of
(Bai Hui)       30 degrees to a depth of 0.5 to
                0.8 cun, then use rotating motion
                (rotating 180[degrees]
                -270[degrees] at about 200
                times/min) to manipulate the
                needle for about 30 seconds
                before withdrawing the needle.

LI4             Puncture perpendicularly for 0.5
(HeGu)          to 1.0 cun, then apply for 30
                seconds reinforcing technique
                with the lifting and thrusting
                movement (strong thrusting and
                gentle lifting for short duration
                with small amplitude and low
                frequency).

HT5             Puncture perpendicularly to a
(Tongli)        depth of 0.5cun, then apply
                reinforcing technique with the
                lifting and thrusting movement
                for 30 seconds.

ST40            Puncture perpendicularly for
(Fenglong)      1.5 cun, then apply reducing
                technique by lifting and
                thrusting the needle (gentle
                thrusting and strong lifting with
                large amplitude and high
                frequency) 30 seconds.

LR3             Puncture perpendicularly for
(Taichong)      0.5-1.0 cun, then apply reducing
                techniques by lifting and
                thrusting the needle for 30
                seconds.

KI3             Insertion perpendicularly for
(Taixi)         0.5-1.0 cun, then apply for 30
                seconds reinforcing technique
                with the lifting and thrusting
                movement.

UB23            Straight insertion for 0.5-1.0 cun,
(Shen Shu)      then apply for 1 min reinforcing
                technique with the lifting and
                thrusting movement.
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Article Details
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Title Annotation:Research Article
Author:Chan, Yu Tat; Zhang, Hong Wei; Guo, Yuan Qi; Lin, Zhi-Xiu
Publication:Evidence - Based Complementary and Alternative Medicine
Article Type:Report
Geographic Code:9HONG
Date:Jan 1, 2017
Words:5253
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