Researchers find acupuncture effective for the treatment of carpal tunnel syndrome (CTS), a local entrapment neuropathy affecting the wrist and hand that causes pain, numbness, and dysfunction. The research team documents acupuncture’s beneficial influence on the morphology of the median nerve and improvement of clinical symptoms.

According to researchers conducting the investigation, “while previous studies investigated the effect of acupuncture on clinical symptoms and electromyographic studies, to the best of our knowledge, its effect on median nerve morphology was not investigated before.” [1] This study demonstrates that acupuncture influences morphology of the median nerve, which opens up a host of possible future studies that may build upon this foundation of knowledge.

Median nerve compression in the carpal tunnel region of the wrist results in pain, numbness, and tingling in the fingers or hand, as well as possible weakness and atrophy of the hand muscles innervated by the median nerve. [2] More prevalent among women, it is correlated with overuse, diabetes mellitus, rheumatoid arthritis, hypothyroidism, and pregnancy. [3]

Diagnostically and prognostically, musculoskeletal ultrasound imaging has been growing in popularity for monitoring this condition because of its ease and cost effectiveness. Musculoskeletal ultrasound shows the cross-sectional area (CSA) in the wrist level of the median nerve and this study documents correlations between median nerve cross-sectional areas and electrophysiological changes within the CTS affected limb.

A total of 27 female patients (45 limbs) with CTS were diagnosed with electromyographic tests for the purposes of this investigation. The patients were similar in age, BMI (body mass index), duration of disease, and severity of CTS. Exclusionary criteria were the following: radicular pain, polyneuropathy, radial or ulnar nerve diseases, severe CTS, trauma history, prior hand surgery.

In patients with bilateral CTS, both extremities were included in the same group. All patients were informed about the study and provided consent. They were randomly divided into two groups (acupuncture and control). The mean duration of the disease was 18.3 months and 19.3 months respectively. Both groups used night wrist splints for CTS for 4 weeks, while only the acupuncture group received acupuncture treatments. The following nine acupoints were selected for the study:

• Daling (PC7)
• Ximen (PC4)
• Neiguan (PC6)
• Laogong (PC8)
• Qingling (HT2)
• Shenmen (HT7)
• Shaofu (HT8)
• Taiyuan (LU9)
• Quchi (LI11)

The median nerve cross-sectional area was measured at the proximal carpal tunnel with musculoskeletal ultrasound, with the scaphoid and pisiform bones used as bony landmarks for the proximal tunnel where the cross section was measured. [4] Needles of size 0.25 × 25 mm were inserted into the points and were retained for 25 minutes per acupuncture session. Treatments were conducted two or three days per week for four weeks, totaling ten sessions.

Results
The median nerve cross-sectional area was measured by using musculoskeletal ultrasound on the patients while seated and positioned similarly (elbow at 90 degree flexion with the forearm in supination position). Cross-sectional areas of size 9 mm or greater had previously been determined as a possible diagnostic measure for CTS. [5]

Pain severity, hand function, and musculoskeletal ultrasound measurements were taken before and after treatments. The visual analog scale (VAS: 0–10 cm) measured pain severity. The Duruoz Hand Index (DHI) and Quick Disabilities of the Arm, Shoulder and Hand (DASH) scores were used to assess hand functions and disability. All electrophysiological tests were performed by using a Nihon Cohden Neuropack machine.

Compound muscle action potential (CMAP: normal >6.8 mV) measured the reaction of the abductor pollicis brevis muscle to stimulation at the wrist and elbow. Sensory nerve action potential (SNAP: normal >10 uV) measured the reaction of wrist stimulation to signals traveling in the opposite direction of normal signals in the nerve fiber (antidromic) of the second finger. Motor distal latency (normal <3.8 ms), sensory nerve conduction velocity (SNCV: normal >40.4 m/sec), and motor nerve conduction velocity (M-NCV: normal >49.4 m/sec) were also measured before and after treatment.

Acupuncture group positive outcomes proved significant. The median nerve cross-sectional area decreased from 11.6 to10.6 mm, motor distal latency decreased from 4.3 to 4.1 ms, and SNAP increased from 16.7 to17.6 uV. Also in the acupuncture group, VAS decreased from 9 to 4.8, CMAP increased from 12.9 to 14.8 mV, DHI decreased from 47 to 37, Quick DASH decreased from 67.2 to 56.8, S-NCV increased from 31 to 33.2 m/sec, and motor nerve velocity increased from 57.4 to 59 m/sec.

The improvement within the acupuncture group when comparing baseline values with the results highlights the success of acupuncture in decreasing clinical symptoms of CTS. It also highlights its ability to transform median nerve morphology such that acupuncture can reduce the cross-sectional area. The results within the control group were not as significant as the acupuncture group, highlighting the efficacy of acupuncture in treating neuropathic disorders compared with night splint monotherapy.

The researchers cited several investigations showing acupuncture’s positive influence on CTS. Recent studies have used magnetic resonance imaging to show how acupuncture may alter brain activity and the limbic system of CTS patients. [6,7,8] Acupuncture produces anti-inflammatory effects in the median nerve within the carpal tunnel, as well as effects that can be compared to ibuprofen, night splints, and oral or injected steroids. [9,10,11]

Summary
Acupuncture generates beneficial morphological changes in the median nerve of patients with carpal tunnel syndrome and reduces or eliminates symptoms. Based on the scientific evidence, acupuncture is a reasonable treatment option. Consult with a local licensed acupuncturist to learn more.

References:
1 Ural, Fatma Gülçin, and Gökhan Tuna Öztürk. “The acupuncture effect on median nerve morphology in patients with carpal tunnel syndrome: an ultrasonographic study.” Evidence-Based Complementary and Alternative Medicine 2017 (2017).

2. S. Tanaka, D. K. Wild, P. J. Seligman, V. Behrens, L. Cameron, and V. Putz-Anderson, “The US [musculoskeletal ultrasound] prevalence of self-reported carpal tunnel syndrome: 1988 national health interview survey data,”American Journal of Public Health, vol. 84, no. 11, pp. 1846– 1848, 1994.

3. R. J. Spinner, J. W. Bachman, and P. C. Amadio, “The many faces of carpal tunnel syndrome,” Mayo Clinic Proceedings, vol. 64, no. 7, pp. 829–836, 1989.

4. Ural, Fatma Gülçin, and Gökhan Tuna Öztürk. “The acupuncture effect on median nerve morphology in patients with carpal tunnel syndrome: an ultrasonographic study.” Evidence-Based Complementary and Alternative Medicine 2017 (2017).

5. J. T. Mhoon, V. C. Juel, and L. D. Hobson-Webb, “Median nerve ultrasound as a screening tool in carpal tunnel syndrome: correlation of cross-sectional area measures with electrodiagnostic abnormality,” Muscle and Nerve, vol. 46, no. 6, pp. 871–878, 2012.

6. A. U. Asghar, G. Green, M. F. Lythgoe, G. Lewith, and H. MacPherson, “Acupuncture needling sensation: the neural correlates of deqi using fMRI,” Brain Research, vol. 1315, pp. 111–118, 2010.

7. V. Napadow, J. Liu, M. Li et al., “Somatosensory cortical plasticity in carpal tunnel syndrome treated by acupuncture,” Human Brain Mapping, vol. 28, no. 3, pp. 159–171, 2007.

8. V. Napadow, N. Kettner, J. Liu et al., “Hypothalamus and amygdala response to acupuncture stimuli in carpal tunnel syndrome,” Pain, vol. 130, no. 3, pp. 254–266, 2007.

9. M. Hadianfard, E. Bazrafshan, H. Momeninejad, and N. Jahani, “Efficacies of acupuncture and anti-inflammatory treatment for carpal tunnel syndrome,” Journal of Acupuncture and Meridian Studies, vol. 8, no. 5, pp. 229–235, 2015.

10. Ho, Chien-Yi, Hsiu-Chen Lin, Yu-Chen Lee, Li-Wei Chou, Ta-Wei Kuo, Heng-Wei Chang, Yueh-Sheng Chen, and Sui-Foon Lo. “Clinical effectiveness of acupuncture for carpal tunnel syndrome.” The American journal of Chinese medicine 42, no. 02 (2014): 303-314.

11. Yang, Chun-Pai, Nai-Hwei Wang, Tsai-Chung Li, Ching-Liang Hsieh, Hen-Hong Chang, Kai-Lin Hwang, Wang-Sheng Ko, and Ming-Hong Chang. “A randomized clinical trial of acupuncture versus oral steroids for carpal tunnel syndrome: a long-term follow-up.” The Journal of Pain 12, no. 2 (2011): 272-279.

Dalian Hospital of Traditional Chinese Medicine researchers confirm that acupuncture combined with herbal medicine is effective for the treatment of insomnia in Parkinson’s disease patients. In a controlled clinical trial, a combination of scalp acupuncture and a modified version of the herbal formula Gui Pi Tang were tested. Using the Pittsburgh Sleep Quality Index (PSQI) as a quantitative measure, Parkinson’s disease patients demonstrated significant improvements in sleep. [1]

The PSQI scale rates subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medications, and daytime dysfunction. Higher numbers indicate worse overall quality of sleep. PSQI questionnaires completed before and after the treatment period showed a statistically significant improvement in sleep quality in the two Chinese medicine groups. Group one received acupuncture and herbal medicine and group two received only herbal medicine.

Participants in the acupuncture plus herbs group showed a greater improvement in sleep quality with PSQI scores reduced from a mean of 14.9 before treatment to 4.5 following treatment. Improvements in the herbal medicine monotherapy group were comparatively lower, reducing from a mean of 15.1 to 8.7 following treatment. The results indicate that although herbal medicine is effective, the addition of acupuncture to the treatment protocol significantly increases positive patient outcomes for Parkinson’s disease patients suffering from insomnia.

Insomnia is a common Parkinson’s disease complication, with between 70% and 95% of Parkinson’s sufferers affected. Symptoms such as tremors, stiffness, pain, and restless leg syndrome all make getting a good night’s sleep difficult. Also, common Parkinson’s disease medications (e.g., levodopa) have a stimulatory effect and can cause sleep problems if taken late in the evening.

A total of 50 patients with Parkinson’s disease were recruited for the study and were randomized to either the herb monotherapy group (n=25) or the acupuncture plus herbs group (n=25). The herb monotherapy group received a modified Gui Pi Tang formula, while the acupuncture plus herbs group received the identical modified Gui Pi Tang herbal formula plus scalp acupuncture points. Both groups were statistically similar in terms of demographics, with 13 males and 12 females in each group. The mean age of the herb monotherapy group was 69.7 years and the mean age of the acupuncture plus herbs group was 69.6 years.

Inclusion criteria for the study included tremors or mobility problems, stiffness of the limbs affecting the gait, and having undergone an MRI scan to rule out cerebral bleeding. According to Chinese medicine principles, the patients were diagnosed with a pattern of heart and spleen deficiency. This pattern is a combination of heart qi and blood deficiency with spleen qi deficiency. Common indications for the presence of this pattern are insomnia, forgetfulness, palpitations, dream disturbed sleep, poor appetite, and loose stools. The tongue is typically pale with a white coating and the pulse is deep and weak.

For heart and spleen deficiency, the treatment principle is to tonify the heart and spleen. The diagnostic inclusion parameter of heart and spleen deficiency matches the classical application of Gui Pi Tang within Traditional Chinese Medicine (TCM) for the treatment of this condition. In many clinical scenarios, Gui Pi Tang is used for patients that are light sleepers and wake frequently throughout the night. This is distinguished from other forms of sleep disorders. For example, if patients wake between 1–3 am and have stress, anxiety, tight jaws or grinding, and other manifestations of liver qi stagnation, an herbal formula such as Xiao Yao Wan or Dan Zhi Xiao Yao Wan are usually prescribed instead.

Exclusion criteria included reduced liver and kidney function, gastrointestinal bleeding, organ failure, abnormal cerebral function, stroke or cerebral bleeding, and psychological diseases. All of the participants were on various medications including antibiotics, blood pressure medications, or blood sugar regulatory drugs. All participants were prescribed oral levodopa (0.25mg, three times per day). The modified Gui Pi Tang formula consisted of the following herbs:

• Bai Zhu 15g
• Ren Shen 10g
• Dang Gui 15g
• Fu Ling 15g
• Yuan Zhi 10g
• Suan Zao Ren 15g
• Mu Xiang 10g
• Long Yan Rou 10g
• Da Zao 10g

These ingredients were decocted to 150ml of liquid to be taken orally twice per day. Each course lasted 15 days and a total of four courses were administered to both the herb monotherapy and the experimental groups. In addition to the modified Gui Pi Tang formula, the acupuncture plus herbs group also had scalp acupuncture treatments. The following points were selected for all participants:

• Baihui (GV20)
• Touwei (ST8)
• Sishencong (MHN1)
• Toulinqi (GB15)

The acupoints were stimulated manually using a reinforcing method and treatment was administered once per day. Each acupuncture course lasted 15 days (one treatment session per day) and a total of four courses were administered. The results demonstrate significant improvements from the herb monotherapy; however, the addition of acupuncture produces greater clinical results.

Related Research
Federal University of Pernambuco (Recife, Brazil) researchers had similar findings. In this study, 22 patients diagnosed with Parkinson’s disease by a neurologist were recruited and randomized to receive either acupuncture (n=11) or no intervention (n=11). Both groups included seven male and four female participants. The mean age in the acupuncture group was 65 years compared with 56 years in the control group. Despite this difference in age, both groups had similar clinical characteristics.

Inclusion criteria included a diagnosis of idiopathic Parkinson’s disease according to the UK Parkinson’s Disease Society Brain Bank criteria, stage I–III Parkinson’s disease according to the Hoehn-Yahr scale, and ages ranging between 35–80 years. Exclusion criteria included the presence of comorbid neurological diseases, cognitive impairment, or having undergone physiotherapy. All participants had been on a stable dose of Parkinson’s medications for at least 2 months prior to the study. The following acupuncture points were selected for the study on the basis of previous research:

• Taichong (LV3)
• Sanyinjiao (SP6)
• Hegu (LI4)
• Waiguan (TB5)
• Shenmen (HT7)
• Neiguan (PC6)
• Quchi (LI11)
• Fengchi (GB20)

Needles were retained for 30 minutes per session and treatments were administered weekly for a total of eight weeks. The results were analysed using the Parkinson’s Disease Sleep Scale (PDSS), a self-administered scale which comprises 15 items including overall quality of sleep, sleep onset and maintenance, nocturnal restlessness, nocturnal psychosis, nocturia (excessive waking for urination at night), nocturnal motor symptoms, sleep refreshment, and daytime dozing. There were no significant differences in PDSS scores between the groups prior to the study.

Following treatment, there was a significant improvement in PDSS scores in the acupuncture group in the domains of general sleep quality, nocturnal psychosis, and nocturnal motor symptoms. [2] There was a tendency towards improvement in sleep onset and maintenance, nocturnal agitation, nocturia, relaxing sleep, and daytime sleepiness, but these improvements were not as pronounced as the aforementioned improvements. The control group did not show significant improvements at the end of the study period. Based on the data, the researchers confirm that acupuncture improves sleep for patients with Parkinson’s disease.

References:
1. Li L. “Clinical Observation on Guipi Decoction Combined with Acupuncture and Moxibustion in the Treatment of Insomnia Patients with Parkinson” Guangming Journal of Chinese Medicine; July 2018. Vol 33.

2. De Amorim Aroxa, Fábio Henrique, Ihana Thaís Guerra de Oliveira Gondim, Elba Lúcia Wanderley Santos, Maria das Graças Wanderley de Sales, Amdore Guescel C. Asano, and Nadja Maria Jorge Asano. “Acupuncture as Adjuvant Therapy for Sleep Disorders in Parkinson’s Disease.” Journal of acupuncture and meridian studies 10, no. 1 (2017): 33-38.

Please join me next Friday, Aug. 17th for this informative lunch n’ learn. If you know of anyone who might benefit please share this post. This event is free but reservations are recommended as most of my events sell out. #cscla #cancersupportla

The first prescription medication extracted from the marijuana plant is poised to land on pharmacists’ shelves this fall. Epidiolex, made from purified cannabidiol, or CBD, a compound found in the cannabis plant, is approved for two rare types of epilepsy.

Its journey to market was driven forward by one family’s quest to find a treatment for their son’s epilepsy.

Scientific and public interest in CBD had been percolating for several years before the Food and Drug Administration finally approved Epidiolex in June. But CBD — which doesn’t cause the mind-altering high that comes from THC, the primary psychoactive component of marijuana — was hard to study, because of tight restrictions on using cannabis in research.

Sam Vogelstein’s family and his doctors found ways to work around those restrictions in their fight to control his seizures.

Sam’s seizures started in 2005 when he was four years old. It’s a moment his mother, Evelyn Nussenbaum, will never forget. The family was saying goodbye to a dinner guest when Sam’s face suddenly slackened and he fell forward at the waist.

“He did something that looked like a judo bow after a match,” says Nussenbaum.

Two months passed before Sam had another seizure, but then he started having them every week. Eventually he was suffering through 100 seizures a day.

“When they were bad, they were once every three minutes,” Nussenbaum says.

A roller-coaster ride

Sam was diagnosed with epilepsy with myoclonic-absences, which is characterized by an abrupt unresponsiveness and then sudden body jerks. The episodes were quick, but dangerous.

The electricity in Sam’s brain would misfire for about five to 20 seconds, enough time to fall down stairs, plunge face first into a dinner plate, or crack his head on a window.

“I don’t remember a lot of it really,” says Sam.

He does remember the barrage of medications his doctors put him on. Some helped briefly. Others triggered hallucinations, full body rashes and uncontrolled anger.

“Sam is a pretty gentle person, ” his mother says. “We put him on one medication and it made him angry, and he started punching kids. And it was like, ‘Oh my God, this is not my kid.’ “

More than 3.4 million Americans have epilepsy, according to the Centers for Disease Control and Prevention, but treating the disease is often a riddle doctors find difficult to solve.

Sam struggled to read, to write, to solve math problems and Nussenbaum watched her son fall further and further behind in school.

Life for Sam was like a bad cell phone connection: Every few moments the signal dropped out.

“It was scary,” Nussenbaum says. “I would often cry in my shower or I would drive up to the top of Grizzly Peak [in Berkeley] and sit in my car and scream.”

Pushing for access

In 2011, Nussenbaum came across an article in a British medical journal about a small seizure study on rats. The researchers successfully treated the rodents with CBD.

“I thought, ‘My son needs access to that,’ ” says Nussenbaum.

But, seven years ago, pure CBD was not easy to get. Many states have since legalized medical marijuana and CBD is widely available at dispensaries and on the internet, but it is still classified as a Schedule 1 drug by the U.S. Drug Enforcement Administration which means it’s illegal under federal law.

Then, Nussenbaum learned about a British pharmaceutical company – GW Pharmaceuticals — that was making a medicine derived from highly-concentrated CBD to treat multiple sclerosis patients. After months of phone calls and emails from Sam’s parents, the company agreed to let Sam try the drug, in the U.K., under a doctor’s supervision for two weeks. The family flew to London shortly after.

“After one day his seizures were down to 30,” says Nussenbaum. “After two days they were down to ten. After three days he had one seizure.”

Sam didn’t suffer any side effects.

Back in the U.S. Sam’s parents needed to find a way to keep getting the drug. They collaborated with Dr. Roberta Cilio, a neurologist at UC San Francisco. They petitioned the FDA to allow Sam to use the drug under a compassionate use program. Four months and hundreds of pages of documents later, the FDA allowed Sam to enroll in his own one-person trial at UCSF.

The DEA was a little more cautious. One day two agents knocked on Cilio’s office door. After hours of questioning, the two men requested she store the medication in a giant safe weighing close to 1,000 pounds.

According to GW Pharmaceuticals, Sam was the first patient in the world to receive Epidiolex.

An expanded trial and varying results

Inspired by Sam’s success, Cilio, and other clinicians, started trying Epidiolex on other patients. In 2015, she and several co-authors published a study in Lancet Neurology that included 214 patients with treatment-resistant epilepsy, all children and young adults.

For most patients the results were not as dramatic as they had been for Sam. Seizures dropped in 36.5 percent of patients, which is about the same success rate as other seizure medications, Cilio says.

And some patients experienced side effects like fatigue, diarrhea and convulsions. Cilio doesn’t know why CBD transforms some lives and other patients don’t respond at all.

“The studies that are out are mostly short term,” says Cilio. “We need to learn who the best responders are. Of course, we know this is not a miracle drug.”

There have been other trials of CBD oil for epilepsy, which have shown that the substance is helpful for a portion of patients. Several states have legalized CBD oil specifically for the treatment of intractable epilepsy or seizure disorders.

And as NPR has reported, CBD has gained popularity with consumers as a remedy for a variety of other ailments. But the products that are available over the counter or in medical cannabis dispensaries, aren’t regulated the way pharmaceutical drugs are, so the consistency and dose can vary widely.

The FDA’s decision to approve Epidiolex means that epilepsy patients will have access to a pharmaceutical-grade drug, which delivers a high-quality, consistent dose of CBD, says Robert Carson a pediatric neurologist at Vanderbilt University who treats patients with epilepsy.

Unanswered Questions

Epidiolex still has to get over one regulatory hurdle. The DEA needs to reclassify CBD so it is no longer considered a Schedule 1 substance. Drugs in this category are considered to have no medical use and a high potential for abuse. The FDA’s approval of Epidiolex means CBD no longer fits that category and the reclassification is expected some time in the fall.

Patients will need a prescription to get the drug. GW Pharmaceuticals has not released a price yet. And Sam’s mom, Evelyn Nussenbaum worries that some insurance companies might not cover it.

In the meantime, Sam still gets his drugs from the investigational pharmacy at UCSF. One day he hopes he’ll be prescribing the medication to patients like him.

“I want to be an epilepsy doctor,” Sam says.

First he’s working on his driving license. Dr. Cilio just cleared Sam to get behind the wheel. He’s 17 now and hasn’t had a seizure in more than two years.