Xingnao Kaiqiao acupuncture combined with Angong Niuhuang Wan for a patient under persistent vegetative state: a case report

Abstract

Persistent vegetative state (PVS) is a clinical condition wherein the cerebral cortex loses its function although brain stem function remains relatively intact. It has high mortality and disability rates. Although treatment for PVS is extensively studied in developed countries, little breakthrough has been made. In China, many PVS patients who were treated with traditional Chinese medicine (TCM) and acupuncture therapy were reported to have regained consciousness. In our department, we have been investigating TCM diagnosis and treatment methods for PVS for many years and have summarized a set of curative programs. Our patient is a male and 5 years and 3 months of age. He had traumatic brain injury and had been unconscious for three months on admission. Considering his condition, we adopted Xingnao Kaiqiao acupuncture, oral Angong Niuhuang Wan, and Xingnaojing intravenous drip. After the 50-day treatment, his health significantly improved and is nearly similar to that of a healthy child, indicating that the treatment is effective for PVS. Therefore, we decided to report the case and treatment methods.

Keywords

PVS / stubborn disease / Xingnao Kaiqiao / Angong Niuhuang Wan / TCM / acupuncture

Introduction

In recent years, mortality rates among emergency patients have decreased considerably because of the developments in diagnostic techniques and treatment methods. These developments also brought a new medical and social problem that there are a large number of vegetative patients. According to a 1998 statistics, 70 000–100 000 individuals in China were under persistent vegetative state (PVS) [¹], and this number showed an increasing trend. In the US, 10 000–25 000 adults and 4000–10 000 children are PVS patients. PVS has a high mortality and severe disability rates. To date, no effective treatment option for PVS exists, and thus this condition continues to present a huge burden to the families of the patients. Notably, PVS has become one of the serious social problems worldwide. In this regard, the Xi’an Encephalopathy Hospital of Traditional Chinese Medicine has researched PVS for many years. In this study, we reported a case of using Xingnao Kaiqiao acupuncture combined with Angong Niu Huang Wan for PVS treatment. Informed consent was obtained from the guardians of the patient. After the treatment, the patient showed improved level of consciousness.

Presentation of case

The patient is a male, 5 years and 3 months of age, 109 cm tall, and 17.5 kg in weight. His major problem was “unconsciousness three months, after head injury.” On January 28, 2013, he was admitted to our department. He was diagnosed with head injury by traditional Chinese medicine, and severe closed traumatic brain injury by Western medicine. At the time of admission, although he was able to open his eyes, no visual tracking was observed. He did not speak and showed facial expressions. He was unresponsive and unable to follow any command. His right limb had involuntary activity sometimes, whereas the left limb had no activity. He has red tongue with yellow greasy fur. Sublingual venation was tortuous (Fig.1). Pulse was unsmooth and wiry. Physical examination results were as follows: he was in vegetative state; rough lung breath sounds were heard bilaterally; moderate amounts of coarse rales were present; pupils were equal, large, about 3.0 mm in diameter, and round; light reflex was slow; left abdominal reflexes were absent. The patient was unresponsive during the limb muscle strength test and deep and superficial sensation examination. The tendon reflexes of his bilateral biceps and triceps were (++); bilateral radial periosteal reflex, (++); bilateral knee jerk, (++++); and bilateral Babinski sign, (+). Neck muscle weakness was observed and without resistance. Head CT scan showed bilateral frontal lobe contusion, widened hemispheric sulci, and right temporal lobe contusion. The Chinese PVS diagnosis score and effect evaluation standard was 2. The TCM information of four methods of examinations was obnubilation, coma, inactivity, dysfunction of seven orifices, limb apraxia, gatism, facial redness, gurgling with sputum, yellow and ropy sputum, red tongue, tortuous sublingual venation, yellow greasy fur, and thready and slippery pulse.

Diagnosis and treatment

We used two diagnostic criteria (Western medicine and traditional Chinese medicine [TCM]) on the patient. Western medicine conformed to the diagnosis and curative effect evaluation standard of PVS, which was enacted at the meeting in Nanjing in April, 2001 [²]. In TCM, PVS was considered to belong to the “Shenhun” category according to literature. No diagnostic criterion for TCM, but an accepted diagnostic criterion was presented by the experts of the national key specialty preponderant illness. The specific contents of this criterion are the following: obnubilation and coma, lack of response to environmental stimuli, inactivity and limb apraxia, dysfunction of the seven orifices and gatism, and history of head injury, toxicosis, electrical injury, cerebrovascular accident, or sudden death (patients who survived after cardiopulmonary resuscitation but remained unconscious). PVS is diagnosed if the first and second items and one of the third to fifth items are present. For the diagnostic criteria of TCM syndrome, we referred to “Clinical Terminology of Traditional Chinese Medical Diagnosis and Treatment,” which was published by the National Technique Supervision Bureau, and the textbook of higher medical colleges, “Diagnostics of TCM,” to extract syndrome factors and consolidate them [³].

For this patient, the therapeutic principle was Ditan Huayu and Kaiqiao Xingshen. The therapeutic methods used were Xingnao Kaiqiao acupuncture combined with Angong Niuhuang Wan. The description of the methods is as follows:

Intravenous drip of Xingnaojing (5 mL; produced by Henan New Century Pharmaceutical Co., Ltd., state medical permit No. Z41020664) [⁴] was administered for 10 days. Angong Niuhuang Wan (a quarter of a pill; produced by Beijing Tongrentang Co., Ltd., Tongrentang Pharmaceutical Factory, state medical permit No. Z11020076) [⁵] was given through NGT once a day. Three pills were given for the entire course.

TCM inhalation therapy [⁶,⁷] was administered. Its major components were fructus gleditsiae, rhizoma kaempferiae, clove, calculus bovis, and borneol. The method of application was atomized inhalation two times a week.

The acupuncture method was Xingnao Kaiqiao acupuncture [8‒10], and four weeks as one course. The major points were Renzhong (three days later, Yintang), double Neiguan, and Sanyinjiao. The matching acupoints were selected according to the concurrent main symptoms. We used disposable acupuncture needles produced by Beijing Zhongyan Taihe Medical Instrument Co., Ltd. The sequence and technique of the acupuncture are as follows:

First, Neiguan was acupunctured using 0.25 mm × 25 mm needles. We adopted reducing by twirling needle (the range of twirling of the needle was over 180°, and the frequency was 40 to 60 times a minute). Let the left one anti-clockwise twirling and natural return, the right one clockwise and natural return. At the same time, bilateral simultaneous lifting and thrusting was performed for 1 min.

Next, Renzhong was acupunctured using 0.25 mm × 25mm needles. The needles were thrust 0.3–0.5 cun obliquely in the direction of the nasal septum. After the needle pierced the skin, it was turned in one direction for 360° to intertwined muscle fiber round the needle body. The strong stimulation with bird-pecking needling was then performed, with tears or eye moist as a reference to the intensity of stimulation. The needles were then removed.

After acupuncturing Renzhong for three times, Yingtang was performed. For this point, 0.25 mm × 40 mm needles were thrust 0.2–0.3 cun obliquely in the direction of the nasal root. Weak stimulation with sparrow pecking was used, and tear or eye moist was used as reference to the intensity of stimulation. The needles were subsequently removed.

Lastly, Sanyinjiao was obliquely acupunctured 0.1–0.3 cun along the internal angle of the tibia and at a 45° angle to the skin. When the needle tip arrived at the place, lifting–thrusting supplementation method was performed. This method was performed quickly in the forward direction and then slowly in the back direction. A needing sensation from Sanyinjiao to toes was required, with a body twist for 3 times.

Evaluation of therapeutic effect

To evaluate the therapeutic effect, we used efficacy evaluation of TCM syndrome and Western medicine.

A scoring system was employed to evaluate the efficacy TCM syndrome. The calculation method of the TCM syndrome scoring is as follows: the reduction rate of syndrome scoring=[(the scoring before the treatment−the scoring after the treatment) ÷ the scoring before the treatment]×100%.

The efficacy evaluation standard of TCM syndrome was divided into four aspects, namely, “clinical recovery, ” “remarkable effect,” “improved,” and “inefficacy.” The criteria of “clinical recovery” were the resolution of the clinical symptoms and signs, and the reduction rate of syndrome scoring is greater than or equal to 95%. “Remarkable effect” means that the clinical symptoms and signs improved significantly, and the reduction rate of syndrome scoring is greater than or equal to 70% and less than 95%. “Improved” means that the clinical symptoms and signs improved, and the reduction rate of syndrome scoring is greater than or equal to 30% and less than 70%. “Inefficacy” means that the clinical symptoms and signs did not improved significantly or were exacerbated, and the reduction rate of syndrome scoring was less than 30%.

The curative effect of Western medicine was evaluated on the basis of the following aspects: evaluation standard of PVS, whether the patient is in the vegetative state, and other functional score. The curative effect evaluation standard of PVS was enacted at the meeting in Nanjing in April 2001 [²]. Meanwhile, the patient is in a vegetative state when he cannot execute instructions or he exhibits aphasia. He is in the preliminary out-of-vegetative-state when he can execute simple instructions or simply answer. He is in the out-of-vegetative-state when he can execute instructions or answer. The other functional score was computed according to the sum of four clinical feature scoring and two objective scoring, and the score was 0–12. The standard of the total curative effect was scored through the following points: improvement of 0 to 2 was nullity, improvement greater than or equal to 3 was better, and improvement greater than or equal to 8 was remarkable.

Clinical curative effect

After 3 days of the above treatment, the patient can open his eyes on his own. After 12 days, he was in tears when he was being acupunctured but was unable to cry. Afterward, we stopped administering the Angong Niuhuang Wan, but the other methods of the treatment program were still employed. After 3 weeks, he regained consciousness and was able to perform simple tasks, such as handshaking and using his right fingers to represent numbers (Fig.2). However, he was unable to cry under pain stimulation and speak. His left limbs exhibited parallel translation near the bed and muscle power was grade two. During these conditions, we stopped administering Xingnaojing injection and performed physical therapy. After 1 week, the patient was able to make sounds and exhibited continuous speech, which gradually became clear. The motor function of the left limbs and muscle power recovered gradually, until it became normal. The curative efficacy evaluation of TCM syndrome showed remarkable effect, and the clinical symptoms and signs improved significantly. For Western medicine efficacy evaluation, the patient was out of the vegetative state. The score of the PVS rating scale was 8, as shown Table 1.

After the course of treatment, the patient was conscious, was able to follow instructions well, and was able to communicate effectively with others, but the words were not clear. He spoke slowly, had normal crying reaction from pain stimulation, and was able to walk slowly, but the gait was unstable because of left hemiplegia. His muscle strength on the left limb was grade four, although fine motor of the left arm was poor. At this conditions, we stopped subjecting him to TCM inhalation therapy and continued the Xingnao Kaiqiao acupuncture, physical therapy, operating therapy, and speech therapy to improve his motor and speech functions. In the 8th week, we rechecked his cranial CT, which showed no abnormality. EEG results was roughly normal, and the somatic evoked potentials showed N20 normal latency. The efficacy evaluation of TCM syndrome was near recovery, and the clinical symptoms and signs were all resolved. For Western medicine, the patient was out of the vegetative state (III), and the score of PVS was 12, as shown in Table 2. The patient was nearly a normal child (Fig.3).

After a period of time, we received information that the patient exhibits normal intelligence, speech, and motor functions, and he can attend kindergarten. With regard to his limb function, we suggested to enhance his fine motor skills with activities, such as picking up soybeans, and to recite Chinese poems and songs to develop his intelligence and speech functions. We also recommended that the child be frequently monitored to prevent another fall.

Discussion

Persistent vegetative state (PVS) is a disorder of consciousness in which patients with severe brain damage are in a state of partial arousal rather than true awareness. After 4 weeks in a vegetative state (VS), the patient is classified as in a persistent vegetative state. According to TCM, PVS is mostly caused by brain injury, emotional disorders, improper diet, congenital factors, debility of bone marrows, and heat toxins. These factors cause dysfunctional organs, phlegm turbidity, disturbed mind, disordered Qi and blood, and stasis of the brain, which then lead to the patient being in an unconscious state for a long time. This disorder belongs to the “Shenhun” category.

The main treatment methods of Western medicine for PVS are neurotrophic drug treatment, surgery, hyperbaric oxygen therapy, and stem cell transplantation. Doctor Yihua Shi [¹¹] and his partners researched about the injection on PVS patients of consciousness-promoting drugs through the carotid artery. They considered that injection of the drugs through the carotid artery is effective for PVS patients. Doctor Pande Zhang did a research about the effect of human umbilical cord blood stem cell transplantation on PVS. In this method, 4 times stem cell transplants were performed during the period, lumbar puncture was performed three times, and venous injection was administered one time, and each of them was performed once a week. Routine treatment was then performed before and during the transplantation. After treatment, all four patients regained consciousness, two awoke after being subjected to transplantation two times, one awoke after four times, and the last one awoke after a month and transplantation for four times.

Some doctors use hyperbaric oxygen treatment on PVS. Doctor Qiusha Wang [¹²] investigated the “curative effect observation of using hyperbaric oxygen treatment on 52 cases of PVS patients.” The control and treatment groups were treated with drug therapy. The treatment group was treated with hyperbaric oxygen treatment on the basis of the above treatment methods. After the treatment, statistical analysis showed that the difference between the two groups was significant (P<0.01), and the treatment group was better than the control group.

Several cases using TCM and acupuncture on PVS are successful. Doctor Weibo Wu [¹³] used Jin’s three-needle technique to treat 18 cases with PVS. The main acupoints were Niesanzhen, Zusanzhen, and Zuzhizhen. After the treatment, efficiency was improved (22.22%). Doctor Xiaoyan Wang and her partners did the research of observing the effect of using Xingnao Kaiqiao acupuncture on PVS. The result was that the curative effect of the treatment group was better than that of the control group (P<0.01), and they concluded that the method on PVS patients should be performed earlier and longer. Doctor Qiuxian Huang adopted Xingnao Kaiqiao acupuncture based on hyperbaric oxygen treatment to treat PVS. The total effectivity rate was 96.30%. Doctor Yuanbiao Shun used Xingnao Kaiqiao acupuncture and neuromuscular facilitation technique on PVS for the treatment group, and the efficiency was 95.2%. The control group was only treated with the neuromuscular facilitation technique, and the efficiency was 70%.The difference between the two groups was considerable. Doctor Haoran Chu adopted the Jing acupoints and heavy-moxibustion Governor Vessel to treat six cases of PVS, and the total efficiency was 83.3%. Jingtai Sun used Huiyang Jiuzhen acupuncture to awaken one PVS patient.

Treatment for patients with PVS includes TCM (Chinese medicinal herbs or Chinese patented medicine), acupuncture (Shi’s acupuncture or traditional Xingnao Kaiqiao). TCM treatment of PVS must be differentiated. Our patient conformed to the Chinese diagnostic criteria of PVS [¹⁴]. He belonged to the “Shenhun” category of TCM (turbid phlegm and blood stasis, obturation of brain). Therefore, we used Chinese patented medicine Xingnaojing combined with Angong Niuhuang Wan [³] to reduce sputum and induce resuscitation. The TCM inspiratory therapeutics [⁶,⁷] are our novel method for treating PVS patients. We allowed the patient to inhale Chinese medicine with aromatics through the nasal cavity to achieve the purpose of inducing resuscitation. Modern medicine considers that one part of the olfactory nerve fiber is related to the smell center (temporal lobe uncal gyrus, which is in front of the hippocampus and amygdala), and the other part is related to the subcallosal gyrus. Nearly all these nerve centers are associated with waking up. Therefore, Chinese medicine of resuscitation with aromatics, which stimulates the central nervous system, is effective for coma patients.

The Xingnao Kaiqiao acupuncture was invented by Professor Xuemin Shi, who is a famous professor of acupuncture at Tianjin University of Traditional Chinese Medicine. Many clinical workers applied his acupuncture method to various mental diseases on the basis of his research and reported satisfactory clinical curative effects. Meanwhile, the “Shenhun” of our patient was caused by trauma. We performed Shi’s Xingnao Kaiqiao acupuncture on this patient and obtained a satisfactory effect. With regard to the mechanism of Shi’s Xingnao Kaiqiao method in treating mental disease, we considered the following aspects. First, it can improve cerebral blood supply and can thus achieve the aim of protecting brain tissue [¹⁴,¹⁵]. Second, it can improve electrical activity, which is an indicator of the state of the cerebral cortex function. When the function of the nerve cells is slightly changed, the electrical activity in the brain becomes evident. By dynamically observing the EEG, Doctor Zhongren Li et al. [¹⁶] found that acupuncture can increase a wave index and amplitude of EEG and reduce abnormal b, q, and d waves. Third, it can enhance the excitability of nerve cells and activate the function of reticular formation of the brain stem, thereby stimulating the inhibition of brain cells, improving compensatory circulation, and promoting the recovery and regeneration of nerve cells. Several studies showed that acupuncture can directly expand the blood vessels of brain, significantly increase the supply of oxygen and blood flow in the ischemia area of the brain, improve the excitability of nerve cells, activate the brain stem reticular system, make the brain cell that is in a state of supression revived, also increase the intracranial pressure lowering effect of drugs [¹⁷], improve cerebral blood flow and oxyhemoglobin saturation [¹⁸], improve cerebral circulation, and promote recovery of cerebral function. Lastly, it can enhance the activity of superoxide dismutase and may directly inhibit the generation of free radicals to protect the brain nerve cells [¹⁹]. Numerous clinical and experimental studies indicated that acupuncture is extremely important in treating disorders in consciousness.

Our patient is a young child. Thus, from the perspective of Western medicine, his brain development is not yet mature. Meanwhile, in traditional Chinese medicine, his innate and acquired essences are still undeveloped. Therefore, we obtained desirable effect from this patient through TCM treatment.

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