Chan Sze-ling (陈诗玲)

Chinese Medicine Service of Pok Oi Hospital, Hong Kong, Hong Kong 999077, China

Critical Review

Survey on acupuncture treatment of neurogenic dysphagia and analysis of regularity of acupoint selection

Chan Sze-ling (陈诗玲)

Chinese Medicine Service of Pok Oi Hospital, Hong Kong, Hong Kong 999077, China

Objective:To understand the general situation of clinical study on acupuncture for neurogenic dysphagia and the regularity of acupoint selection by literature analysis.

Acupuncture Therapy; Dysphagia; Literature; Point Selection

Dysphagia can be seen in many neurological diseases, such as cerebral apoplexy, vascular dementia and Parkinson’s disease, etc. Dysphagia is one of the most common complications. It is reported in domestic and international literature that its incidence rate can reach as high as 50%-73%[1]. The patients with dysphagia often suffer from obstruction of the respiratory tract or aspiration pneumonia due to inhalation of foreign materials. Some patients may present with complications of malnutrition, metabolic disorder and dehydration due to insufficient food ingestion, leading to the increased mortality and decreased quality of life, and directly influencing the patient’s self-care ability, and rehabilitation and prognosis of disease, and bringing about heavy economic and mental burden to the family and society[2-5]. Therefore, it is importantly significant to seek the safe and effective therapy for dysphagia.

It has been shown by clinical tableside evaluation that the total effective rate in acupuncture treatment of neurogenic dysphagia is 80%-100%[6]. Acupuncture is a simple, safe and cheap therapy for dysphagia[7]. In this study, the literatures on clinical study in the recent fifteen years were collected, and the information about acupuncture for neurogenic dysphagia was comprehensively analyzed, in order to explore the regularity of acupoint and meridian selection, in a hope to provide reference to the clinical treatment.

1 Data

1.1 Inclusion criteria of literature

The type of literature was clinical study, including the analyzed results about the therapeutic effects of the treatment group and at least one control group. The research target was dysphagia caused by neurologic diseases (such as cerebral apoplexy, vascular dementia and Parkinson’s disease) based upon the diagnostic criteria of Chinese medicine or the diagnostic criteria of modern medicine. In the therapeutic measures, the treatment group was mainly treated by acupuncture therapy [simple acupuncture or electroacupuncture (EA)] in predominance, possibly in combination with herbal drugs, Western medications, and swallowing training. The control group was only managed by swallowing training or herbal drugs or Western medications. The routine treatment was same in the two groups. The language of the published literature was Chinese or English.

1.2 Exclusion criteria of literature

Repeatedly published literature; literature about other acupuncture methods besides simple body acupuncture and EA; literature about comparison of therapeutic effects between different needling techniques or acupoints, or about acupuncture therapy as the control group; literature about discussion of individual cases and literature survey; literature published without full text or published by abstract.

1.3 Literature sources and searching method

All Chinese and English literature about acupuncture treatment of neurogenic dysphagia, published from 1999-2014, was searched from China National Knowledge Infrastructure (CNKI), Wanfang Database and Ovid Gateway. The searching subject terms included wind stroke, apoplexy, Parkinson’s disease, Alzheimer’s disease, neurological diseases, dysphagia, swallowing difficulty, plus keywords of needle, acupuncture, and EA.

2 Methods

2.1 Literature screen and database establishment

I screened, read and analyzed the literature in accordance with the inclusion criteria and exclusion criteria, established the data table of the literature on acupuncture treatment of neurogenic dysphagia by Microsoft Excel 2010, and input the data of the collected literature, including the average age of the patients, diagnosis, acupoint selection, acupuncture situation, average therapeutic time, therapeutic effects, and follow-up checks.

2.2 Data management

All the collected literature was comprehensively analyzed. SPSS 17.0 statistical software was used to calculate the data, expressed with frequency, means ± standard deviationaPvalue and percentage (%). The terms of acupoints were referred toNomenclature and Location of Acupuncture Points[8].

3 Results

3.1 Basic data

Totally, 94 articles of relevant literature were searched out, and 51 articles were brought into the study after screened by the inclusion criteria and exclusion criteria[9-59]. Totally, the clinical data of 4 606 patients were brought into data analysis. The average age was (61.2±3.8) years old and there was no statistical difference in the ratio between males and females (P＜0.05). Among them, 33 articles presented that post-stroke dysphagia was caused by cerebral infarction or cerebral hemorrhage.

3.2 General situation of clinical study

In the inclusion 51 articles, it was mentioned in 50 articles that the patients participating in the study were randomly divided into the treatment group and control group. But, the random grouping method was not described in 30 articles. In 9 articles, the patients were grouped by the visit order. In 9 articles, the patients were grouped by the random digital table or grouped randomly by computer random numbers. In 1 article, the patients were grouped by the patient’s will. In 1 article, the patients were grouped by the therapeutic methods.

In the enrolled 51 articles, 48 articles described the course of the treatment, with the average treatment time of (24.82±6.19) d. Forty-five articles described the retaining time of the needles, with the average retaining time of (26.22±4.79) min. Forty-one articles described the situation of the needling sensation during the acupuncture treatment, mainly pointing out that the patients had sour, numb, distending and heavy sensation, or shock sensation in the areas of acupuncture.

There were 41 articles in which the treatment group was treated by EA. Among them, wave type of EA was described in 7 articles, including sparse-dense wave in 3 articles, continuous wave in 3 articles, anddiscontinuous wave in 1 article. The frequency of EA was described in 8 articles, including low frequency of 1.25-15 Hz in 4 articles, and frequency of 100-200 Hz in 4 articles.

Of the 51 articles, swallowing training was combined with the treatment in the treatment groups in 4 articles, in the control groups in 2 articles, and both in the treatment groups and control groups in 31 articles. The therapeutic frequency of swallowing training was mentioned in 23 articles, about 1-3 times per day and for 20-30 min on average.

In the 51 articles, the therapeutic effects were described in 45 articles, mostly based upon water drinking test and the scale designed by technicians as the criteria of therapeutic effects. The average effective rate was (91.15±0.06) % in the treatment group and (65.77±0.17) % in the control group. The total effective rate was better in the treatment group than in the control group (P＜0.05).

In 51 articles, there was only one article in which follow-up check and long-term evaluation of therapeutic effect were processed three months after the study[18].

3.3 Acupoint selection in acupuncture treatment

In the analysis of the collected articles, there were statistically 51 acupuncture prescriptions, 36 meridian acupoints and 20 extraordinary acupoints, and the total frequency of acupoints was 306 times. By the order of times and frequency, the top ten commonly used meridian acupoints and extraordinary acupoints in acupuncture treatment of neurogenic dysphagia could be seen in Table 1 and Table 2. Lianquan (CV 23), Fengchi (GB 20), Fengfu (GV 16) and Yifeng (TE 17) were the most commonly used meridian acupoints for dysphagia, with a frequency of 111 times, accounting for 63.4% of total frequency. Jinjin (EX-HN 12) and Yuye (EX-HN 13) were the most commonly used extraordinary acupoints, with a frequency of 39 times, accounting for 45.9% of total frequency.

3.4 Selection of meridian acupoints in acupuncture treatment

It could be seen from Table 3 that the acupoints were selected generally from fourteen meridians in acupuncture for neurogenic dysphagia. The total usage rate of yang meridians was 59.3% and the total usage rate of yin meridians was 40.7%. The top three meridians by the times of frequency were the Conception Vessel, Gallbladder Meridian of Foot Shaoyang and Stomach Meridian of Foot Yangming, accounting for 63.3% of the usage rate. It could be seen from selection of meridians that the meridian acupoints in the area of the neck were used at the highest frequency, totally 158 times, accounting for 73.5% of total frequency. The number of used acupoints was 16. The top three acupoints by the usage rate were Lianquan (CV 23), Fengchi (GB 20), and Fengfu (GV 16).

Table 1. Top 10 commonly used meridian acupoints for neurogenic dysphagia

Table 2. Top 10 commonly used extraordinary acupoints for neurogenic dysphagia

3.5 The usage of specific acupoints in acupuncture treatment of dysphagia

In acupuncture treatment of dysphagia, the total usage times were 50, the usage rate of Luo-Connecting points, Five Shu-Transmitting points and the Confluent points of Eight Extraordinary Meridians was the highest, accounting for 66.0%. The specific points of the highest usage rate were Hegu (LI 4), the Yuan-Primary point of the Large Intestine Meridian, and Zusanli (ST 36), the Lower He-Sea point of the stomach, used for five times respectively (Table 4).

3.6 Combination of acupoints in acupuncture treatment of dysphagia

In acupuncture for dysphagia, the combination of acupoints with a frequency of five times or above was summed up. Based upon Lianquan (CV 23) and Fengchi (GB 20) as the basic treatment, the total frequency of acupoints was 34 times, accounting for 77.3% (Table 5).

Table 3. Selection of meridians and acupoints for acupuncture treatment of dysphagia

Table 4. Specific acupoints used in acupuncture treatment of dysphagia

Table 5. Combination of acupoints in acupuncture treatment of dysphagia

4 Discussion

The pathological position of neurogenic dysphagia is mainly related to the mouth, tongue, throat and esophagus[60]. Its main pathogenic factors include kidney yin deficiency, insufficiency of marrow sea, pathogenic wind and phlegm or obstruction of meridians by blood stasis[33]. Its pathogenesis is related to disharmony between yin and yang of the human body, uprush of qi and blood to the brain, obstruction of the tongue root by wind, phlegm and blood stasis, and blockage of qi dynamics, leading to dysphagia.

Dysphagia has been recorded in ancient literature of Chinese medicine. In this study, the literature of modern clinical research about acupuncture treatment of neurogenic dysphagia is comprehensively analyzed. In accordance with the analysis of the collected literature in this study, the frequently-used acupoints inacupuncture treatment of neurogenic dysphagia are successively Lianquan (CV 23), Fengchi (GB 20), Yifeng (TE 17), Jinjin (EX-HN 12) and Yuye (EX-HN 13), which are all located in the neck, tongue and throat. It has been proven in modern medicine that Lianquan (CV 23), Jinjin (EX-HN 12) and Yuye (EX-HN 13) are situated in the controlling scope of the sensory fibers of the glossopharyngeal nerve, vagus nerve and hypoglossal nerve. The stimulation produced by acupuncture can be transmitted upward to the motor neuron, so as to regulate the controlling effect to the swallowing reflux from the deglutition center in the cerebral cortex and reticular structure of the brain stem, harmonize the sense and motion of the swallowing muscle, and promote the restoration of the damaged peripheral nerves, giving a better effect to the restoration of the pathologic situation[61-62]. In acupuncture treatment of dysphagia, the common combination of the acupoints is mainly processed by Lianquan (CV 23), Fengchi (GB 20) with Fengfu (GV 16), Jinjin (EX-HN 12) and Yuye (EX-HN 13) as a major acupuncture prescription. Hegu (LI 4) and Zusanli (ST 36) are commonly combined distal acupoints.

It can be seen from the meridians of the acupoints used in the treatment of the disease that the top three meridians of the frequently used fourteen meridians are in turns the Conception Vessel, Gallbladder Meridian of Foot Shaoyang and Stomach Meridian of Foot Yangming. The pathways of those three meridians are all related to the tongue and throat, in conformity with acupuncture therapeutic feature that ’an acupoint can treat the disorders where its meridian distributes’.

It has been indicated by the findings from this study that the therapeutic effects are affirmative in acupuncture treatment of neurogenic dysphagia, with the total effective rate of (91.15±0.06) % and the average course of (24.82±6.19) d. During acupuncture treatment, EA can be combined, with high and low frequency used similarly.

It has been shown in the systematic review and study that acupuncture has the therapeutic effect for neurogenic dysphagia[60], but in most studies there is insufficiency in detailed description about random grouping method, in standardized criteria of therapeutic effects, and in long-term observation of the therapeutic effects, and in random clinical double blind test of multiple center and large samples. Therefore, the available literature can only present short-term therapeutic effects in acupuncture treatment of neurogenic dysphagia, and the evidence grades need to be elevated. How to enhance the design of clinical study on acupuncture treatment of neurogenic dysphagia and to enhance the quality of the relevant theses should be emphasized by the research staff[63].

Conflict of Interest

There was no conflict of interest in this article.

Received: 6 March 2015/Accepted: 15 April 2015

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Translator:Huang Guo-qi (黄国琪)

针刺治疗神经性吞咽困难临床研究概况与选穴规律分析

目的：通过文献分析了解针刺治疗神经性吞咽困难的临床研究概况及选穴规律。方法：从中国期刊全文数据库、万方学术期刊全文数据库及Ovid Gateway中检索1999-2014年间所有与针刺治疗神经性吞咽困难相关的中英文文献。把纳入文献的数据, 如患者平均年龄、选穴、疗程、疗效及随访等情况录入Microsoft Excel 2010数据表。结果：共纳入51篇文献, 涉及4 606位患者。针刺治疗神经性吞咽困难平均疗程24.8 d, 平均留针时间26.2 min, 平均总有效率91.2%。廉泉、风池、风府和翳风为最常用的经穴, 占经穴总数的63.4%。金津、玉液为最常用的经外穴, 占经外穴总数的45.9%。使用频次较高的经脉依次是任脉、足少阳胆经及足阳明胃经, 占涉及经脉的63.3%。结论：针刺对神经性吞咽困难的疗效良好, 选穴以廉泉、风池、风府为主, 多位于任脉、胆经及胃经这些与咽喉项部紧密联系的经脉上。

针刺疗法; 吞咽困难; 文献; 选穴

R246.6 【

】A

Author: Chan Sze-ling, M.Phil.

E-mail: c-ling@alumni.cuhk.net

Methods:By searching the relevant Chinese and English literature on acupuncture treatment of neurogenic dysphagia from 1999 to 2014 in China National Knowledge Infrastructure (CNKI), Wanfang Database and Ovid Gateway, the data of the recruited literature, including average age of the patients, acupoint selection, course, therapeutic effects and follow-up information, were input into the data table of Microsoft Excel 2010.

Results:Totally, 51 articles were input, involving 4 606 patients. The average course of acupuncture treatment for neurogenic dysphagia was 24.8 d. The average retaining time of the needles was 26.2 min. The average total effective rate was 91.2%. Lianquan (CV 23), Fengchi (GB 20), Fengfu (GV 16) and Yifeng (TE 17) were the most commonly used acupoints from the regular meridians, accounting for 63.4% of the totally-used acupoints. Jinjin (EX-HN 12) and Yuye (EX-HN 13) were the most commonly used acupoints from the extraordinary meridians, accounting for 45.9% of the totally-used extraordinary acupoints. The frequently-used meridians in turns were the Conception Vessel, Gallbladder Meridian of Foot Shaoyang and Stomach Meridian of Foot Yangming, accounting for 63.3% of the involved meridians.

Conclusion:The therapeutic effect of acupuncture treatment for neurogenic dysphagia was satisfactory. The acupoints were Lianquan (CV 23), Fengchi (GB 20) and Fengfu (GV 16) in predominance, and they were mostly selected from the Conception Vessel, Gallbladder Meridian and Stomach Meridian those are in close relationship with the throat and neck.