Neuroanatomic and Clinical Correspondences: Acupuncture and Vagus Nerve Stimulation

Acute effects of lumbosacral mobilization on balance and functional activities in idiopathic Parkinson's disease:A randomised controlled trial

BACKGROUND

Decreased axial rotation, impaired coordination between axial segments and axial tone contribute to gait, balance and postural disorders in Parkinson's Disease.

AIMS

The aim of our study was to examine the acute effects of lumbosacral mobilization on balance and functional activities in patients with idiopathic Parkinson's Disease.

METHODS

This study was a randomized controlled clinical trial conducted at Hacettepe University. The study included 28 patients with Parkinson's Disease who were between stage 2-3 according to the Modified Hoehn&Yahr Staging Scale. Participants were randomised to the study group, including 10 minutes of lumbosacral mobilization, or the control group, including no intervention. The Unified Parkinson's Disease Rating Scale (UPDRS), Modified Parkinson's Activity Scale (MPAS), Dynamic Gait Index (DGI), and static posturography test (Modified Clinical Test of Sensory Interaction and Balance - mCTSIB) were all examined twice.

RESULTS

The UPDRS, MPAS, DGI values and the composite score with the soft ground eyes open condition in the mCTSIB were improved in the study group (p < 0.05). DGI and MPAS values reached the level of significance between the groups (p < 0.05).

CONCLUSION

This study is the first to examine the effect of lumbosacral mobilization on balance and functional activities in patients with Parkinson's disease. Lumbosacral mobilization is an effective method in PwPD. Lumbosacral mobilization may be an alternative way for these patients to improve their balance and functional activities.

The increased functional connectivity between the locus coeruleus and supramarginal gyrus in insomnia disorder with acupuncture modulation

Background

Insomnia disorder (ID) seriously affects the quality of people's daily life, and acupuncture is an effective therapy for it. As an essential component of the upward activation system, the locus coeruleus (LC) plays a crucial role in sleep-wake regulation, its aberrant functional connectivity (FC) is found to be involved in ID. The purpose of this study was to explore the modulation effect of acupuncture on the resting state FC of LC in ID patients.

Methods

60 ID patients were recruited and randomly assigned to real acupuncture (RA) or sham acupuncture (SA) treatment. Resting-state functional magnetic resonance imaging (fMRI) data were collected before and after the treatment. With LC as the region of interest, the FC method was adopted to examine acupuncture-related modulation of intrinsic connectivity in ID patients. The Pittsburgh Sleep Quality Index (PSQI), Hyperarousal Scale (HAS), and actigraphy were used to assess sleep quality and cortical hyperarousal states. Associations between clinical outcomes and FC features were calculated using Pearson's correlation analysis.

Results

The improvement in sleep quality and hyperarousal in the RA group was greater than that in the SA group. After treatment, the FC between the LC and left inferior frontal gyrus (IFG) decreased in the RA group. The FC between the LC and left insula and supramarginal gyrus (SMG) was higher in the RA group. The change of LC FC values with the SMG was negatively associated with the change in PSQI scores.

Conclusion

Acupuncture can modulate FC between the LC and IFG, insular gyrus, and SMG. This may imply the potential mechanism of acupuncture treatment for insomnia.

Bibliometric analysis of publication trends and research hotspots in vagus nerve stimulation: A 20-year panorama

Background

As a promising neuromodulation technique, vagus nerve stimulation (VNS) has been utilized to treat diverse diseases and the number of VNS studies has grown prosperously. Nonetheless, publication trends and research hotspots in this field remain unknown. This study aimed to perform a bibliometric analysis to systematically identify publication trends and research hotspots in VNS research within a 20-year panorama.

Methods

The Web of Science Core Collection (WoSCC) database was retrieved to screen eligible VNS-related publications from 2002 to 2021. The online analytic tool of the WoSCC database was used to analyze various bibliometric parameters, such as the number of annual publications, the output of countries/regions, journals, total citations, citations per publication, and the Hirsch index. Bibliometrics (http://bibliometric.com/) and CiteSpace (version 5.6.R3) were used to identify research trends and hotspots.

Results

A total of 7,283 publications were included for analysis. The annual number of publications increased stably but it increased significantly in recent years. The top five prolific countries were the United States, China, Germany, England, and France. The top five productive institutions were the University of California (Los Angeles), Harvard Medical School, Harvard University, University College London, and the University of Texas at Dallas. Notably, there was a geographical imbalance in countries and institutions. In addition, Epilepsy & Behavior, Epilepsia, and Plos One were the top three journals with the largest number of VNS publications. Michael P Kilgard was the most prolific author. Moreover, evolving research hotspots mainly included the effectiveness and mechanism of VNS on epilepsy, the role of VNS as an anti-inflammatory regulator, the application of VNS for psychiatric disorders, and the neuromodulation effect of VNS in headache management.

Conclusion

This study has revealed the overall publication trends and evolving research trends at a global level over a 20-year panorama. The potential collaborators, institutions, hotspots, and future research trends are also identified in this field, which will help guide new research directions of VNS.

The potential for traditional Chinese therapy in treating sleep disorders caused by COVID-19 through the cholinergic anti-inflammatory pathway

Since the outbreak of Coronavirus disease (COVID-19) in 2019, it has spread rapidly across the globe. Sleep disorders caused by COVID-19 have become a major concern for COVID-19 patients and recovered patients. So far, there’s no effective therapy on this. Traditional Chinese therapy (TCT) has a great effect on sleep disorders, with rare side effects and no obvious withdrawal symptoms. The cholinergic anti-inflammatory pathway, a neuroregulatory pathway in the central nervous system that uses cholinergic neurons and neurotransmitters to suppress inflammatory responses, has been reported to be associated with sleep disorders and psychiatric symptoms. Many studies have shown that TCT activates the cholinergic anti-inflammatory pathway (CAP), inhibits inflammation, and relieves associated symptoms. Therefore, we believe that TCT may be a potential therapeutic strategy to alleviate sleep disorders induced by COVID-19 through CAP. In this review, we analyzed the relationship between cytokine storm induced by Coronavirus and sleep disorders, explained the influence of CAP on sleep disorders, discussed the TCT’s effect on CAP, and summarized the treatment effect of TCT on sleep disorders. Based on these practical researches and theoretical basis, we propose potential strategies to effectively improve the sleep disorders caused by COVID-19.

Pharmacological and non-pharmacological therapeutic interventions for the treatment of spinal cord injury-induced pain

Spinal cord injury (SCI) is a complex neurophysiological disorder, which can result in many long-term complications including changes in mobility, bowel and bladder function, cardiovascular function, and metabolism. In addition, most individuals with SCI experience some form of chronic pain, with one-third of these individuals rating their pain as severe and unrelenting. SCI-induced chronic pain is considered to be "high impact" and broadly affects a number of outcome measures, including daily activity, physical and cognitive function, mood, sleep, and overall quality of life. The majority of SCI pain patients suffer from pain that emanates from regions located below the level of injury. This pain is often rated as the most severe and the underlying mechanisms involve injury-induced plasticity along the entire neuraxis and within the peripheral nervous system. Unfortunately, current therapies for SCI-induced chronic pain lack universal efficacy. Pharmacological treatments, such as opioids, anticonvulsants, and antidepressants, have been shown to have limited success in promoting pain relief. In addition, these treatments are accompanied by many adverse events and safety issues that compound existing functional deficits in the spinally injured, such as gastrointestinal motility and respiration. Non-pharmacological treatments are safer alternatives that can be specifically tailored to the individual and used in tandem with pharmacological therapies if needed. This review describes existing non-pharmacological therapies that have been used to treat SCI-induced pain in both preclinical models and clinical populations. These include physical (i.e., exercise, acupuncture, and hyper- or hypothermia treatments), psychological (i.e., meditation and cognitive behavioral therapy), and dietary interventions (i.e., ketogenic and anti-inflammatory diet). Findings on the effectiveness of these interventions in reducing SCI-induced pain and improving quality of life are discussed. Overall, although studies suggest non-pharmacological treatments could be beneficial in reducing SCI-induced chronic pain, further research is needed. Additionally, because chronic pain, including SCI pain, is complex and has both emotional and physiological components, treatment should be multidisciplinary in nature and ideally tailored specifically to the patient.

Memory-directed acupuncture as a neuromodulatory treatment for PTSD: Theory, clinical model and case studies

Posttraumatic stress disorder (PTSD) poses an ongoing challenge to society, to health systems, and to the trauma victims themselves. Today PTSD is often considered an incurable chronic problem that lacks effective treatment. While PTSD is closely related to memory, it also affects many physiological systems. PTSD is usually treated with medications and psychotherapy with moderate success, leaving a substantial proportion of patients with enduring distress and disability. Therefore, a search for better treatment options is vital. In this paper, we propose a model in which a conversation-based technique is integrated with bodily manipulation through acupuncture. This approach first emerged in clinical experience showing intriguing results from treating PTSD patients using acupuncture as a main strategy. Its theoretical foundations derive from the clinic and rely on contemporary neuroscience's understanding of memory consolidation and reconsolidation processes. Research shows that acupuncture can have potentially positive effects at three levels: (a) achieving a balance between sympathetic and parasympathetic neural activity; (b) reducing activation in the limbic system, hence inducing a calming effect; (c) reshaping the functional connectivity map within important and relevant cortical regions that encompass the default-mode network. We suggest that coupling traumatic memory retrieval leading to reconsolidation, combined with acupuncture, offers considerable potential for positive clinical improvement in patients with PTSD. This may explain the positive results of the described case studies and can pave the path for future advances in research and treatment in this field.

Is cervical region tightness related to vagal function and stomach symptoms?

The vagal nerve is a cranial nerve that carries mainly parasympathetic fibers (average 75%) with both sensory and motor functions. The vagal nerve contains a complex neuro-endocrine-immune network. The majority, at least 66%, of the gastric myenteric neurons receive direct cholinergic excitatory stimulation from the pre-enteric vagal nerve. Changes in vagal function may cause stomach problems, although the mechanisms that change the vagal function have not yet been fully illuminated. Considering the course of the vagal nerve in the cervical region, it is thought that conditions such as stiffness, tightness and decreased elasticity in this region may compress the vagal nerve andmay affect vagal function. According to this hypothesis, neuroinflammation and hyperalgesia may occur in the vagal nerve under mechanical pressure, resulting in increased complaints of pain and burning in the stomach increases. However, as the vagal nerve has various effects on the motility of the stomach and vagal dysfunction affects the motor function of the stomach, relaxation techniques applied to the soft tissues of the cervical region will provide mechanical relief in the nerve. Thus, the vagal nerve will be decompressed and be able to function optimally. According to our clinical observations, in patients whose soft tissues in the cervical region are relaxed, gastric symptoms are decreased. Based on research results and clinical experience, cervical region tightness can be considered to cause stomach problems through the vagal nerve, and soft tissue relaxation of the cervical region can be a promising treatment method for stomach symptoms.

Effect of Auricular Acupuncture on Propofol Induction Dose: Could Vagus Nerve and Parasympathetic Stimulation Replace Intravenous Co-Induction Agents?

Objective: Auricular acupuncture, through a combination of several points, can produce sedative and analgesic effects. The aim of this study was to compare the induction dose of propofol required to obtain a loss of response to verbal commands, with and without a preoperative combination of auricular points. Materials and Methods: This study involved American Society of Anesthesiologists physical status I and II patients, ages 18- 65, of either sex, having elective ambulatory surgery (digestive or gynecologic) under general anesthesia. The subjects were allocated to 2 groups: (1) patients treated by auricular acupuncture (group AA), compared with (2) patients not treated by auricular acupuncture (group NA). Propofol injection was initiated in each group, 10 mg, every 5 seconds, in order for the anesthetist to determine the minimum dose until there was a loss of response to verbal commands (the clinical hypnotic endpoint). At this point, the main outcome-the dose of propofol given-was noted. Results: There were 32 patients in this study (16 in each group). Age, height, weight, and body mass index were similar in the groups (P ≥ 0.05). The required induction propofol dose was 17.7% lower in group AA than in group NA-a statistically significant difference (P ≤ 0.05). The mean induction dose indexed to weight was 2.18 mg/kg (range: 1.53-3.13 mg/kg) in group NA and 1.79 mg/kg (range: 1.12-2.11 mg/kg) in group AA. There were no complications. Conclusions: Auricular acupuncture is a method for stimulating the vagus nerve and parasympathetic nervous system. Preoperative auricular acupuncture enabled reductions of induction doses of propofol for general anesthesia without any clinically important side-effects.

A Randomized, Double-Blind, Sham-Controlled Study Assessing Electroacupuncture for the Management of Postoperative Pain after Percutaneous Nephrolithotomy

INTRODUCTION

Percutaneous nephrolithotomy (PCNL) is the gold standard procedure for large renal calculi but postoperative (PO) pain remains a concern. Modifications of the PCNL technique and intraoperative and PO strategies have been tested to reduce pain. PO pain control reducing risk of long-term pain medication and narcotic use is of considerable importance. Acupuncture is a common medical procedure shown to alleviate PO pain. Some benefits are that it is nonpharmacologic, easy to administer, and safe. The purpose of this study was to evaluate the effects of electroacupuncture (EA) on PO pain in patients undergoing PCNL.

MATERIALS AND METHODS

This was a randomized, double-blind, sham-controlled study. The study was Institutional Review Board approved and performed under standard ethical guidelines. Fifty-one patients undergoing PCNL by a single surgeon were randomized to one of the three groups: true EA (n = 17), sham EA (SEA, n = 17), and no acupuncture (control, n = 17). The EA and SEA were performed by a single licensed acupuncturist <1 hour before operation. PCNL was performed without the use of intraoperative nerve block(s) or local anesthetic. Pain scores (visual analog scale [VAS]), narcotic use (morphine equivalents), and side effects were recorded at set intervals postoperatively.

RESULTS

Mean VAS scores for flank and abdomen pain were lower at all time periods in the EA compared with the SEA and control groups. Mean cumulative opioid usage was lower in the EA group immediately postoperatively compared with both SEA and control groups. Two patients in the EA group did not require any PO narcotics. No differences between groups were found for PO nausea and vomiting. No adverse effects of EA or SEA were noted.

CONCLUSIONS

EA significantly reduced PO pain and narcotic usage without any adverse effects after PCNL. This promising treatment for managing PO pain warrants further investigation.

Anatomo-Physiologic Basis for Auricular Stimulation

Introduction: Stimulation of cranial nerves modulates central nervous system (CNS) activity via the extensive connections of their brainstem nuclei to higher-order structures. Clinical experience with vagus-nerve stimulation (VNS) demonstrates that it produces robust therapeutic effects, however, posing concerns related to its invasiveness and side-effects. Discussion: Trigeminal nerve stimulation (TNS) has been recently proposed as a valid alternative to VNS. The ear presents afferent vagus and trigeminal-nerve distribution; its innervation is the theoretical basis of different reflex therapies, including auriculotherapy. An increasing number of studies have shown that several therapeutic effects induced by invasive VNS and TNS, can be reproduced by noninvasive auricular-nerve stimulation. However, the sites and neurobiologic mechanisms by which VNS and TNS produce their therapeutic effects are not clear yet. Conclusions: Accumulating evidence suggests that VNS and TNS share multiple levels and mechanisms of action in the CNS.

Intermittent 96-Hour Auricular Electroacupuncture for Hot Flashes in Patients with Prostate Cancer: A Pilot Study

Objective: The hot flash is a common vasomotor disorder that causes distress in menopausal women and that can be debilitating in men with prostate cancer who are treated with androgen deprivation therapy (ADT). The utility of auricular electroacupuncture (AEA) was tested exclusively for a small cohort of men with ADT-induced vasomotor symptoms while the men underwent a course of curative radiotherapy. Materials and Methods: Prior to and during radiotherapy treatment, men with vasomotor symptoms were given repeated questionnaires regarding severity and frequency of hot flashes, quality of life (QoL), and sleep over a 6-week span of an AEA protocol. Each subject's heart rate variability (HRV) was obtained repeatedly every week in an ambulatory setting with a BlueCardio device (BlueCardio, Miami, FL). The AEA intervention was given with a Neurova device (Nunka Corporation, CM Wellness Clinic, Pompano Beach, FL) that used three needles at Master points Sympathetic, Shen Men, and Point Zero, which were located precisely with a bipolar point finder. Intermittent microcurrent stimulation was given every other week for 96 hours, using a cyclic programmed output of 2 hours on and 2 hours off. Results: Of 10 men completing the 6-week protocol, all responded with significantly lower frequency, duration, and severity of vasomotor symptoms; QoL and sleep scores improved significantly. The HRV analysis showed significantly lower low-frequency/high-frequency power ratios in each individual, compared to baseline, that were consistent with the subjective responses. Conclusions: Vasomotor disturbance, caused by gender hormone withdrawal-either naturally or in patients treated with ADT, as in this study-is a well-defined neurophysiologic condition. This disorder is a constellation of findings that reflect autonomic disturbances of excessive sympathetic and reduced parasympathetic activity. AEA intervention with the Neurova device is simple to administer, is well-tolerated, and appears to be effective for restoring autonomic balance. Further evaluation of AEA for vasomotor disturbances could provide more insight into the mechanisms of AEA neuromodulation and potentially lead to approaches for treating not only these symptoms but also other neurologic conditions with components of autonomic disturbances.

Feasibility study of transfer function model on electrocardiogram change caused by acupuncture

Background

Acupuncture treatments that regulate the heart are used to treat various clinical disorders and conditions. Although many studies have been conducted to measure quantitatively the effects of acupuncture, thus far, models that describe these effects have not been established. The purpose of this study was to derive a transfer function model of acupuncture stimulation within the electrocardiograms based on the periods before, during, and after acupuncture.

Methods

Fourteen healthy subjects were included in this clinical trial. Five-minute electrocardiograms were captured before, during, and after acupuncture at HT7. For each period, signal-averaged electrocardiograms were created from all of the subjects’ 5-min electrocardiograms for that period. Individual transfer functions, which has the highest average goodness of fit, were derived for each period pair. By averaging individual transfer functions, generalized transfer functions were derived.

Results

The transfer function with the highest average goodness of fit was a fraction with 4th order numerator and 5th order denominator. Fourteen individual transfer functions were derived separately for each pair of periods: before and during acupuncture, during and after acupuncture, and before and after acupuncture. Three generalized transfer functions were derived by averaging individual transfer functions for each period pair.

Conclusion

The three generalized transfer functions that were derived may reflect the electrocardiogram changes caused by acupuncture. However, this clinical trial included only 14 subjects. Further studies with control groups and more subjects are needed.

This clinical trial has been registered on the Clinical Research Information Service, Republic of Korea (No. KCT0001944). The first enrolment of subject started at 2 June 2015 and this trial was retrospectively registered at 14 June 2016

Why We Need Minimum Basic Requirements in Science for Acupuncture Education

As enthusiasm for alternatives to pharmaceuticals and surgery grows, healthcare consumers are turning increasingly to physical medicine modalities such as acupuncture. However, they may encounter obstacles in accessing acupuncture due to several reasons, such as the inability to locate a suitable practitioner, insufficient reimbursement for treatment, or difficulty gaining a referral due to perceived lack of evidence or scientific rigor by specialists. Claims made about a range of treatment paradigms outstrip evidence and students in acupuncture courses are thus led to believe that the approaches they learn are effective and clinically meaningful. Critical inquiry and critical analysis of techniques taught are often omitted, leading to unquestioning acceptance, adoption, and implementation into practice of approaches that may or may not be rational and effective. Acupuncture education for both licensed physicians (DOs and MDs) and non-physicians needs to include science (i.e., explanation of its effects based on contemporary explanations of biological processes), evidence, and critical thinking. Erroneous notions concerning its mechanisms such as moving "stuck Qi (Chi)" or "energy" with needles and that this energy stagnates at specific, tiny locations on the body called acupuncture points lead to mistakes in methodologic design. For example, researchers may select sham and verum point locations that overlap considerably in their neural connections, leading to nonsignificant differences between the two interventions. Furthermore, attributing the effects of acupuncture to metaphorical and arcane views of physiology limits both acceptance and validation of acupuncture in both research and clinical settings. Finally, the content and quality of education and clinical exposure across acupuncture programs varies widely, with currently no minimum basic educational requirements in a scientific methodology. Considering the pressures mounting on clinicians to practice in an evidence-based and scientific manner that also demonstrates cost-effectiveness, acupuncture schools and continuing medical education (CME) courses need to provide their students a strong foundation in rational approaches supported by research.

Electrical stimulation of the vagus nerve protects against cerebral ischemic injury through an anti-infammatory mechanism

Vagus nerve stimulation exerts protective effects against ischemic brain injury; however, the underlying mechanisms remain unclear. In this study, a rat model of focal cerebral ischemia was established using the occlusion method, and the right vagus nerve was given electrical stimulation (constant current of 0.5 mA; pulse width, 0.5 ms; frequency, 20 Hz; duration, 30 seconds; every 5 minutes for a total of 60 minutes) 30 minutes, 12 hours, and 1, 2, 3, 7 and 14 days after surgery. Electrical stimulation of the vagus nerve substantially reduced infarct volume, improved neurological function, and decreased the expression levels of tumor necrosis factor-α and interleukin-6 in rats with focal cerebral ischemia. The experimental findings indicate that the neuroprotective effect of vagus nerve stimulation following cerebral ischemia may be associated with the inhibition of tumor necrosis factor-α and interleukin-6 expression.

Electroacupuncture ST36 prevents postoperative intra-abdominal adhesions formation

BACKGROUND

We have recently proved electroacupuncture (EA) ST36 exerted an anti-inflammatory effect in the early phase of intra-abdominal adhesion formation. Evidences indicate that the anti-inflammatory effect of EA ST36 involves a cholinergic anti-inflammatory pathway-dependent mechanism via the vagus nerve. However, the exact effects and accurate vagal modulation of acupuncture in prevention of postoperative intra-abdominal adhesion formation has not been thoroughly evaluated.

MATERIALS AND METHODS

Sprague-Dawley rats subjected to abdominal adhesion lesions operation at the cecum and abdominal wall were randomly divided into six groups as follows: (a) EAN: EA non-channel acupoints; (b) EA: EA ST36 after abdominal lesions; (c) VGX/EA: vagotomy (VGX) after abdominal lesions, then EA ST36; (d) VGX/EAN: VGX after abdominal lesions, then EAN; (e) α-BGT/EA: intraperitoneal injection of α-bungarotoxin (α-BGT, an antagonist of α7 subunit of cholinergic nicotinic receptor) before EA ST36, and (f) α-BGT/EAN group: α-BGT injection before EAN. Seven days after abdominal surgical lesions, the levels of tumor necrosis factor-α (TNF-α) and vascular endothelial growth factor (VEGF) in the adhesive tissue were evaluated, macroscopic observation and histopathologic evaluation of adhesion formation and assessment of angiogenesis by immunohistochemical staining of platelet endothelial cell adhesion molecule-1 (CD31) were performed.

RESULTS

EA ST36 reduced TNF-α and VEGF levels in adhesive tissue homogenates 7 d after surgery, whereas vagotomy or intraperitoneal injection of α-BGT before EA ST36 reversed its suppressive effects. EA at non-channel acupoints with or without vagotomy or intraperitoneal injection of α-BGT before EA had no suppressive effects on TNF-α and VEGF levels. EA ST36 alleviated the adhesion formation, with both of macroscopic and histopathologic adhesion scores significantly lower than those of the EAN group (1.56 ± 0.29 versus 3.00 ± 0.82, 1.35 ± 0.4 versus 3.91 ± 0.8, respectively, both P < 0.05). Compared with the EAN group, EA ST36 significantly decreased angiogenesis evidenced by reduced CD31 positive microvessel density in adhesive tissue.

CONCLUSIONS

EA ST36 might reduce the postoperative local inflammatory response, attenuate the angiogenesis, and alleviate the adhesion formation partly via activating the cholinergic anti-inflammatory mechanism.