Behandlung

Amyotrophic Lateral Sclerosis :

Extracranial Acupuncture as a Possible Adjuvant therapy
Dr.med. Dae-Joon Yoo, Institut fuer chinesische Medizin, Reventlowstr.45, D-22605 Hamburg, Germany. Phone +49 40 8805030, Fax +49 40 8810120, e-mail: DR.YOO@t-online.de

ABSTRACT ALS is considered to be a devastating disease with no effective treatment available. A series of extracranial stimulation with acupuncture needles on ALS-patients of different disease progression showed positive and long lasting therapeutic effects especially in seven cases. whose case reports are described. in detail. In twenty out of totally 45 patients showed some fluctuating motoric improvement.. In addition I point out that during extracranial stimulation there was evidence of a direct and simultaneously visible response to acupuncture as involuntary movement on the body. The above positive therapeutic experience could also be applied to the treatment of other diseases of the central nervous system as one of adjuvant therapeutic measure Keywords Amyotrophic Lateral Sclerosis , ALS, Lou Gehrig´s Disease, Scalp Acupuncture, Extracranical Acupuncture, Simultaneous Acupuncture effect. Amyotrophic Lateral Sclerosis (ALS), also known as Motor Neuron Disease (MND), has recently been described comprehensively by Pamela J. Shaw(1). Her precise resumes the generally accepted current view of ALS: "The disease causes progressive injury and cell death of lower motor neuron groups in the spinal cord and brain stem and usually also of upper motor neurons in the motor cortex. Those affected typically develop a combination of upper and lower motor neuron signs, with progressive muscle weakness and wasting usually accompanied by pathologically brisk reflexes, eventually involving the limb and bulbar muscles. Clinical variants of the disease may affect purely the lower motor neurons (progressive muscular atrophy) or the upper motor neurons (primary lateral sclerosis). Death usually results from respiratory failure due to weakness of the respiratory muscles. The precise causes of the nerve degeneration process remain unknown." Pamela J. Shaw also writes: "Currently, there is no treatment that substantially slows disease progression." Classical points on the scalp have been used before for the treatment of different diseases, including some neurological diseases; but "scalp acupuncture" or "extracranial acupuncture", as I prefer to call it, is a particular method of Traditional Chinese Medicine for the treatment of neurological diseases, which has been developed in China by neurologist Dr. Jiao Shunfa(2) around 1971. In China it is practised by a few specialists only, mostly in neurological university clinics or in some of special centers. In scalp acupuncture the needling points are not determined according to the traditional meridian lines of Chinese Medicine: A great part of stimulation areas of this therapy is determined in accordance with the localization of the cerebral cortical function on the projected areas of the scalp. So scalp acupuncture is based on he knowledge of functional anatomy of the brain as well as the knowledge of TCM. Since the seventies there is abundant literature(3) reporting on the successful use of this method of treatment. Margaret A. Naeser published two reviews(4) on the treatment of neurological diseases with body and scalp acupuncture. There is, however, no report on the treatment of ALS with scalp acupuncture. Margaret A. Naeser explicitly excludes ALS from her reviews. Since 1990 the author has been treating different diseases of the nervous system such as morbus Parkinson, MS, the sequelae of apoplexia, facial paresis, migraine, trigeminus neuralgia applying the extracranial acupuncture method of Jiao Shunfa with satisfactory results. Encouraged by these results I have adopted this method for treating ALS of different types with significant succes In the period of June 98 to June 99 I have treated totally 45 ALS patients: 24 patients in Hamburg 21 patients in Munich. The patients in Hamburg were treated by myself . In Munich the treatment was done by myself and a collegue, who was trained for this specific treatment and worked under my supervision. Among the 45 patients 19 were females from 37 to 72 years of age and 26 male patients between 33 and 67 years. The average time between assured ALS diagnosis and the beginning of my treatment was between 1 month and 6 and a half years. Twenty out of 45 patients responded to my treatment, however the results were not stable and not lasting more than a week of time. Only seven among 45 patients showed remaining improvements of more than 4 weeks to one year. Therefore in my present report I concentrated on seven cases whose case reports are presented in detail (see II case reports). I METHOD and MATERIAL The various scalp acupuncture meridians, which are described by Jiao Shunfa, have been internationally defined as scalp acupuncture meridians (Geneva 1989). ( s. page 4+5) For the treatment of ALS-patients the following meridians or combinations of meridians are used, which I chose according to the predominant symptoms of the patients: It is not my intention to classify ALS as classically known but I have treated my patients according to their symptoms.In addition to this I did not separate the patients according to the location of motor neuron damage in this work. The meridians of choice were always chosen contra lateral to the limbs or structures of the body involved. In cases of motor aphasia or other forms of aphasia the meridians of both sides of the scalp were used. The points which were located on the central line of the body were of course only needled there. Other body-points were chosen according to the classical Chinese pulse findings which were investigated before the beginning of the treatment. 1) Extracranial meridians or areas used for different symptom groups of ALS patients. A.. Meridians used for patients with speech, swallowing and tongue movement problems : The bulbar type of ALS (Primary and secondary not separated) a) Anterior temporal lines (MS 10), which are bilateral lines connecting GB 4 (Han Yan) and GB 6 (Xuan Li). Fig. 1c b) 2/5 of the lower part of the anterior oblique line of the vertex temple (MS 6). The anterior oblique line which is connecting Dumai 21 with gallbladder 6. Fig. 1b c) The lower 2/5 of the posterior oblique line of vertex temple (MS 7) which connects Dumai 20 (Baihui) with gallbladder 7 (Qubin). Fig. 1b d) An extra point of Renmai between Rm 23 and Rm 24 which is located under the chin, a midpoint between chin and Rm 23. e) Other points used: Du 15 (Fengfu) and Du 16 (Yamen). Fig 1e B. Meridians used for patients with predominant symptoms of the lower extremities. a) Upper 1/5 of the anterior and posterior oblique lines of the vertex temple. Fig 1b b) Bilateral parallel lines 1 cm beside the anterior posterior mid line which connect UB 10 and UB 11. Fig 1c C. Meridians used for patients with symptoms of the upper extremities: a) The middle 2/5 of the anterior and posterior oblique line of the vertex temple. (MS 6 and MS 7) Fig 1b b) Lateral Line 2 of Vertex which connect GB 17 and GB 18. D. Treatment method D for patients with spastic symptoms: a)The so-called Chorea tremor-controlled area which is the parallel line 1,5 cm in front of the anterior oblique lines of the vertex temple. Fig 1b 2).Acupuncture needles, method of insertion and stimulation A)Acupuncture needles Acupuncture needles of the company Seirin, Japan, were mainly used. The dimensions of the needles were 0,25mm caliber and 4 cm in length for sensitive patients and for those with a very thin scalp skin. For those with a normal scalp skin 0,30 mm caliber and 5 cm in length were used. B)Insertion of needles The acupuncture needles were inserted at first almost vertically through the surface layer of the scalp skin quickly 1 or 2 mm deep, then obliquely almost parallel to the surface of the scalp through a layer between the subcutis and aponeurosis 3-4 cm in length quickly inserted. Desinfection of the meridians or intended insertion points with 70% alcohol . C) Stimulation: After insertion the needles were stimulated by twisting them with thumb and index about 100 to 200 times in a minute (corresponding to 200 Hz) by holding them at the insertion handle for one to three minutes for each needle on the head. Between the stimulation the needles were retained in the head for between 5 to 10 minutes. After three times of stimulation the needles were removed quickly and the insertion points were pressed down with sterile pads for preventing possible bleeding 4) Other therapeutic method used : A) With Body acupuncture Traditional body acupuncture was used in addition to extracranial acupuncture to prepare the patient, to reduce rigidity, to make fluent movements possible. Acupuncture points were chosen according to pulse diagnosis. In the following part of my report I will omit the description of body acupuncture in detail, since it plays a subordinate role in ALS-treatment. I have been treating previously to my present work ALS patients with only body acupuncture .There was no notable reaction among those patients. B) With Moxibustion For the moxibustion of some body points and in places of rigidity due to immobility of joints and muscles Sennenkyu moxa cones from Japan were used. The places in question were warmed twice before or during a treatment, for each patient 8 - 16 moxa cones were necessary. The purpose of needles on the scalp is to improve directly the mobility of certain limbs or parts of limbs and muscles, in cases of dysarthria to improve the tongue movement or other speech performing organs or muscles, whereas body acupuncture was done for the purpose of improving the general health of the patient. In cases of local treatment of edematous, rigid or painful regions of the body, this was done in order to minimize inhibition of extracranial acupuncture. 4) Treatment and Follow up A)Interval and duration of treatment Atreatment lasts about 30 minutes. During this time 3 stimulation of about 3 - 5 minutes are executed, with resting time of 7 - 10 minutes in between stimulation periods.Normally 2 - 3 treatments are done per week.But as some patients live too far away from Hamburg for this rhythm of treatment,I tried intensive treatments of 5 days per week for 1 or 2 weeks. b)Post therapeutic check and Follow up The physical findings were checked and documented before the first treatment . In cases where many parts of the body were involved the video is taken so that it can be used as documentation assistance. Before the beginning of the next treatment each parts of the body involved were checked for the extent of movement. No point system is used , instead the extent of movements or improvements were expressed in degree or in words. After releasing from the treatment the results were checked by calls. The results were checked at least for 4 weeks or more. II CASE REPORTS Case 1 A female patient, age 73, from Hamburg, actress. Onset of the disease in 1991: unusual beginning with aphasia, later dysarthria, breathing problems, paralysis. Finally complete loss of speech and tetraplegia in July 1995. Diagnosed as ALS in 1993 in a university neurological center. In the beginning of the TCM-treatment the patient did not show any active movement of the limbs, she was artificially respirated and fed artificially through a stomach tube and had a supra pubic catheter. She was unable to communicate.The patient was treated with traditional Chinese body acupuncture and scalp acupuncture using the meridians and points which were chosen from Jiao (see method). Since the patient had paralysis of the lower and upper limbs, the extracranial meridians and points of method B + C were used. For her speech problems the meridians and points were chosen according to method A. Against spasm meridians and points of method D were used. There was no reaction to the first seven treatments, which were done three times a week. On the 10th of May 98 (the 8th treatment) during the stimulation of shoulder and arm (method C) a movement of the right hand middle and index finger and small finger was observed, which was documented on video by the patient's husband. June 9th 98 the dorsal flexion of the left hand was possible without any sign of spasm. The index finger also moved in the antero dorsal direction and vice versa. It was a smooth and coordinated movement without spasm. Sept. 17th, 98 the left thumb showed adduction movement several times during acupuncture stimulation. During the course of a one- month- treatment (in the above interval) no special alteration in the movement occurred, however, the before mentioned movements were repeatedly caused by stimulation. October 15th, 98 rotations of the right forearm occurred, which was held vertically, the elbow resting on the bed, without any exertion of force in order to eliminate any influence on the movement. It was caused simultaneously with the needle stimulation for the corresponding arm (middle 2/5 of MS 6). During the stimulation of meridians according to method A during the preceding 2 months swallowing of saliva seemed to be improving, especially during the treatment. November 27th, 98 for the first time a rotation of the right forearm was observed - not only in the dorso-ventral direction - but also in ventro dorsal direction. Dec. 15th, 98 until this time the movements described above were repeatable, also the movement of different fingers individually or together were frequently observed. The adduction and abduction of the left thumb could be seen although to different degrees. But now the dorsal extension and ventral flexion of the four fingers in the basal joints could be observed during stimulation. On this day the dorsal flexion of the right hand was clearly seen before the forearm rotated about 90° in dorso ventral direction. Jan. 20th, 99. the rotation of the right forearm could be observed frequently under treatment as described above. But the degree of rotation increased to more than 100°. Feb. 25th, 99. for the first time the patient turned her left hand dorsoventral and ventrodorsal. She could close her hand though not completely. Abduction and adduction of the left thumb was observed and in addition the three middle fingers (index finger, middle finger and ring finger) showed ventral and dorsal flexion movement. May 5th, 99 during the preceding two months no significant change had occurred, except that the above described movements were intermittently present during the treatment to different degrees. - On this day the patient partially closed her right hand to make a fist. In addition to this she made a rotating movement with her right forearm which she held loosely stretched on her bed cover. This movement could be induced twice during needle stimulation. Since then occasional spontaneous movements of fingers of the right and left hand had been reported by the physiotherapist and attending nurses, independently off acupuncture. Case 2 Female patient, 58 years of age. Onset of symptoms in May 1996 with difficulties in swallowing and breathing. The left arm and left leg got weaker, so that she could not walk properly. In the course of the summer of 1996 she lost her speech gradually. In December 1996 per cutaneous endoscopic gastrostomy became necessary due to swallowing problems. The diagnosis of ALS of the bulbar type was established by the University Neurological Clinic of Hamburg (September 96).. March 19th, 1998. In the beginning of my treatment, the patient was in the following status: Tetraplegia for three to four months. The fingers of her right hand were contracted into a fist. Her paralyzed left arm did not show any tonus at all. The patient could not hold her head up, it had to be supported. She could only communicate by nodding or shaking her head for "yes" and "no". May 1st, 1998. Her right big toe showed some strength under needle stimulation. During the stimulation she could bend her left big toe and had more strength in it as well. This occurred during her 12th treatment. May 2nd, 1998. The left thumb could be moved on request and under treatment . Her middle ring and small finger could be extended slightly, but not the index finger. The big toe of her right foot could be moved voluntarily, as could all toes of the left foot. May 7th, 1998. More stabilization of the established and above named movements and increase of strength in these movements. May 10th, 1998. The patient's right hand and foot showed no further improvement, however all the toes of the left foot but with the exception of the 5th toe could be flexed distinctly. The left thumb showed increase of strength in abduction and adduction. June 2nd, 1998. She could move her third, fourth and fifth toe voluntarily under treatment, in addition to the above mentioned bending of the big toe of her left foot, which had been repeatedly observed in the preceding weeks. July 7th, 1998. After seven days of a treatment-free interval due to hospitalization because of breathing problems the patient could not move her right big toe, second and third toe any more. The strength of her left hand was reduced. July 24th, 1998. On request and under treatment each toe could be bent and stretched separately and together. Aug 3rd, 1998. Unfortunately the patient died due to a sudden attack of respiratory problems. Case 3 A male patient, age 67, a horn blower. In May 1996 the patient suddenly could not hold the tune. He could not move the tongue very well and had swallowing problems. Gradually his speech became inarticulate. During the following months he suffered from pain and tension of the neck and shoulder muscles. His arms became gradually powerless and he suffered from cold hands. Legs and feet were relatively free of symptoms except ischialgia-like pain in the upper legs. The diagnosis of ALS was assured by the Diakonie Hospital in Rothenburg, Wümme, 1997. In the beginning of my treatment, Jan. 17, 1999, the patient had been unable to drive his car for four months due to the weakness of his arms. Feb. 2nd, 1999. After seven treatments the tongue movement was improved, the speech was still inarticulate, but he had less difficulty in swallowing. Both arms had gained strength, so that the patient could drive from his home to my office which is about 60 km. Feb. 22nd, 1999. Encouraged by this success the patient was treated twice instead of three times a week. However the patient complained of increased tension in his neck and facial muscles. The strength in his arms had remained stable so that he could continue driving his car by himself. Feb. 25th, 1999. The strength in his arms had remained normal, but the tension in his neck still existed. His legs did not show any specific difficulties, but saliva production seemed increased. There was no improvement in speech and tongue movement. March 5th, 1999. No significant changes occurred. March 12, 1999. In the right face side and upper lip the patient felt more sensation. He reported that his tongue movement had improved and his speech had become more distinct and his voice stronger. The tension in the neck had decreased and the strength of his arms had improved. June 1st, 1999: At the time of writing, the strength in both arms had remained so that he continued driving his car. There was no significant further improvement of speech. Case 4 A female patient, 60 years of age. Onset of ALS symptoms in 1998 with weakness in arms, hands and legs. The diagnosis of ALS was assured in the same year. In the beginning of the acupuncture treatment the lifting up of the left foot till 120° in extension position was possible. The right foot could be lifted up till 90°. Both knees and hips showed no restriction in movement, nor did her shoulders and elbows. The fingers of her right hand could be stretched till about 170° and of her left hand till 120°. The left hand fingers were in a flexed position and could not be stretched. Whereas her right hand, wrist and fingers could be moved almost normally though strength was reduced. The wrist joint (left) was in a bent position of 135°. April 26th, 1999. After the 14th treatment both thumbs could be moved during stimulation. Abduction and adduction could be observed during stimulation. April 27th, 1999. On the 16th day of treatment both big toes and both thumbs moved up on needle stimulation during the treatment. April 28th, 1999. The second toe could move independently. The patient was now able to close and open her left hand. She could move her thumb in abduction and adduction, and her wrist could be flexed and extended in an almost normal way. Now she could grasp objects with her left hand and she could use her hands to put on her stockings, which had been impossible so far. April 30th, 1999. With these results the patient was released from treatment. May 27th, 1999 (4 weeks after the last treatment). On the telephone the patient assured: The left hand movement was still stable, the strength had increased under physiotherapy. Also the thumb movement (left) remained stable. June 15th, 1999. This last result was confirmed on the telephone. Case 5 A female patient, 43 years of age. Diagnosis of ALS at the age of 41 in the USA (Sept.97) about 6 months after giving birth to a child. She was treated at home in Ecuador by an Ecuadorian acupuncturist with body acupuncture with no significant improvement. In the beginning of my treatment April 6th, 1999 the patient had passed most of her time in a wheelchair. Her speech was inarticulate. She had problems with swallowing. Occasionally she complained of difficulty in breathing. She suffered from spasm in various parts of the body and "electrical currents" went through her body especially during the night. She woke up at night with pain especially in her legs. Lifting her arms was impossible. Her left hand was in a flexed position of about 90°. Her right hand was extendible to about 150°. Her left elbow could be flexed up to 30° and stretched till 115°. Her right elbow could be flexed to 20° and stretched to 180°. Lifting up her feet was impossible, as well as moving her toes. Her right knee could be stretched to 170° and was flexible till 150°. Her left knee could be stretched to 180o and was flexible to 90°. Spreading the legs to the side was about 5°. April 9th, 1999. After three treatments the toes of both feet could be moved. April 12th, 1999. After five treatments - she could spread her legs to the side for about 15°. She could lift up her arms up to 180°. April 15th, 1999 . After the eighth treatment the patient reported that she could turn round in her bed, which had not been possible for a long time. The movement of her legs had become much better. She could spread her legs for about 45° to the side. Spasm and pain in the legs were less. Her speech improved a lot, so that her daughter, who had not met her mother for one year, affirmed that she could now understand her much better. This was the last day of her treatment, since the patient had to return home to Ecuador. Case 6 Male patient, age 55. In July 98 onset of the illness with speech problems. Paresthesia of upper and lower lips, speech problems. ALS was diagnosed in August 98 ( University Hospital Berlin). After that the patient noticed a gradual loss of muscles in both arms and a weakness in his legs when riding his bicycle. Swallowing became difficult, especially when drinking. He also had to cough frequently with mucus production, but without breathing problems. His sense of taste and vision were not affected. His tongue movement was limited so that he could not move it deliberately in his mouth. Beginning of the treatment with acupuncture in February 1999. March 9th, 1999. The speech had improved, the tongue movement was easier. Fibrillations of the tongue muscle decreased. The weak muscle condition in his arms and legs had not changed, the paresthesia of the upper lip had become better. April 1st, 1999. The tongue movement was stable, while the paresthesia of the upper lip was gone, the lower lip was unchanged. April 13th, 1999. According to the patient's comment his tongue felt thicker, but the motility had remained unchanged. April 29th, 1999. The speech had become clear, except that he could not pronounce properly the German sounds of sch - z - ü. June 15th, 1999. The speech remained clear . Case 7 A female patient, age 68. Onset of the ALS-symptoms with pain in her left arm and weakness in October 1998. At the end of 98 her speech was inarticulate and slurred. Jan. 1999. The weakness of her right arm began. At the same time onset of weakness in the knees of both legs, walking and standing became difficult. Additionally breathing problems occurred especially in a lying position. Also swallowing became a problem. ALS was diagnosed at the University of Erlangen in March 99. After starting medical treatment with "Rilutek", the patient came for acupuncture treatment. In the beginning of the treatment the patient's speech was so inarticulate that she could hardly be understood. She did not show any sign of breathing difficulty at rest, even though she claimed that she could not lie down due to breathing problems. Her arm movements were not significantly restricted, but the strength in both arms - left more than right - had decreased. The elbow and wrist flexion and extension was not restricted nor was the rotation of the forearms. It was no problem for her to close and open the fist of her right hand. Her left hand though could not make a fist or open completely. The four fingers of her left hand were in a flexed position at the 3.proximal and distal joints. The movement of both legs was not impaired passively, but she could not stand alone for a longer time. The movement in the foot joints was actively possible. She could bend her feet freely in dorsal direction. The toes of both feet could be bent and stretched. Beginning of the treatment: June 7th, 1999 during the first treatment she moved thumb and fingers of the left hand. The patient felt more strength in her left hand. After this treatment the patient could open and close her right hand almost completely. Only the last joints of her fingers could not be extended June 11th, 1999. The left hand could be further opened and closed. The strength in her left arm and left leg had increased, so that the movement of her limbs appeared more controlled. June 30th, 1999. The strength of her knees had decreased, so that she had fallen. She complained of pain in both knees, even though her hand remained improved. The speech had not become clearer after minor improvements in the beginning. III. SUMMARY OF RESULTS : Case 1 Movement of both hands could be produced during acupuncture stimulation, although the patient had been tetraplegic since 1995. This result was repeatable during the course of the one-year-treatment. The extent of the movement was - during this period of time - increasing with some variation. At the time of this report the result had remained unchanged. The movement included: thumb abduction and adduction, flexion and extension of the other fingers, hand movement, rotation of the right forearm. No improvement took place concerning speech or movement of legs or feet. Swallowing was frequently observed. Recently occasional spontaneous movements of hand and fingers had been reported by physiotherapist and attending nurses. Date of Diagnosis: 1993; Time between Diagnosis and Treatment :4.5 years; Duration of Treatment: 1 year; Follow Up: 1 year. Case 2 Communication was possible through nodding (yes) shaking (no) of her head, so that the result of my treatment could be confirmed or rejected. During the course of the five-month-treatment movement of toes and fingers on both sides could be improved significantly. There was, however, no reaction concerning her speech. There was a minor improvement of breathing during the course of the treatment. Date of Diagnosis: Sept. 96; Time between Diagnosis and Treatment: 1 year 6 months, Duration of Treatment: 4 months, Follow Up: 4 weeks. Case 3 Shortly after the beginning of the treatment the patient regained strength in both arms and hands, so that he could drive his car again. The strength in his arms did not decrease within seven months. The speech could not be improved during the 7-month-period of treatment. Date of Diagnosis: 1997, Time between Diagnosis and Treatment 1 year,Duration of Treatment: 6 months, Follow Up: 1 year. Case 4 The simultaneous movement of the left thumb and left and right big toes could be demonstrated during acupuncture stimulation. The patient gained strength and improved the wrist-thumb-other finger movement, so that she could use her hands for getting dressed and grasping objects. This improvement was augmented through her own exercise and with the help of her physiotherapist. These achievements seem to be stable. Date of Diagnosis: 1998, Time between Diagnosis and Treatment: 1 year, Duration of Treatment: 1.5 months, Follow Up: 8 weeks. Case 5 During the short period of nine treatments speech had improved significantly. The extent of arm and leg movement had also improved. The patient could turn from one side to the other in her bed. Spasms and pain decreased. Date of Diagnosis: Sept. 97, Time between Diagnosis and Treatment: 1yr 6 months Duration of Treatment: 10 days, Follow Up: 6 weeks. Case 6 The speech had clearly improved. Paresthesia of lips had partly improved. Date of Diagnosis: August 98, Time between Diagnosis and Treatment: 6 months, Duration of Treatment : 9 months, Follow Up: 6 weeks. Case 7 The simultaneous movement of thumb and other fingers could be demonstrated during acupuncture stimulation. The strength of the left arm and leg had increased. The left hand could be opened and closed more easily. Date of Diagnosis: May 99, Time between Diagnosis and Treatment: 3 months, Duration of Treatment: 19 days,Follow Up: 4 weeks. IV DISCUSSION 1. Direct positive effect of acupuncture Until now acupuncture has been used to relieve from pain or other symptoms, however the effectiveness of the treatment could never be demonstrated simultaneously during treatment. The acupuncturist had to rely on the patient's subjective evaluation. As I described in cases 1, 4 and 7 it could be demonstrated and documented that extracranial acupuncture stimulation can cause an involuntary movement on different selected parts of the extremities by needling specific corresponding parts on the scalp area. In these cases patients were unable to cooperate actively during stimulation. With no exception all the patients I have treated, reported that they felt warmth in the treated parts. Even though the sensory disturbances do not belong to the main symptoms of ALS, ,it is worth of mentioning because this indicates improvement of circulation which in turn prepares the body parts for movement. Some patients felt a paresthesia-like tickle in those parts of the body, for which the stimulation was given. With two patients I observed significant improvement of speech. The movement during the extracranial stimulation were no spasms or reflex movements. This direct and simultaneous effect of acupuncture needling according to my knowledge has never been described before. Not only the above mentioned motion, but also the increase of the body temperature and effect on paraesthesia could be regarded as a direct and immediate reaction to acupuncture stimulation for specific parts of the body. Therefore there seem to exist a functional connection between the extracranial area or point and the functional centers of the cerebral cortex.as postulated in the work of Jiao Shunfa.(2). It is my assumption that the extracortical acupuncture stimulation seem to improve circulatory function and to send nerve impulses to the intended parts of the body, causing movements of the body targeted for the treatment. 2)Cell death in ALS and inducement of movement by extracranial acupuncture - a contradiction? These directly provoked movements were achieved in patients with amyotrophic lateral sclerosis. According to the existing theory motor neurons in ALS-patients are destroyed, so that no nerve impulse can be transmitted: "The disease causes progressive injury and cell death of lower motor neuron groups in the spinal cord and brain stem and usually also of upper motor neurons in the motor cortex (Pamela J. Shaw, 1)." This raises a number of questions: How can the above described motion be possible, if motor neurons have died? Does this method activate remaining intact or slightly injured neurons? Another question is if the extracranial stimulation was not propagated through the supposedly dead nerve cells , what would be the pathway of nerve impulses, which caused the movement of the body. Is there another pathway of nerve impulse transmission such as the acupuncture meridians? would this support the meridian theory of TCM ? Excessive accumulation of glutamate has been made responsible for non-functioning of nerve cells in ALS. Does extracranial acupuncture influence in some way the level of glutamate metabolism?. The mechanism by which extracranial acupuncture induces movements in paralyzed limbs remains unknown. For these and many other questions to be answered there must be done a great amount of research including image giving proof. According to the results of my work it could be said that the extracortical acupuncture stimulation seems to stop the progression of ALS symptoms at least for a certain period of time. In some patients it seems that the process of paresis was partly reversed so that the patient could move some parts of the body which were previously paralyzed . But this improvement did not occur in all intended parts of the body as a result of scalp acupuncture. The positive and often long lasting therapeutic effect of extracranial stimulation is encouraging and can be recommended as one of the physical rehabilitation treatments on ALS-patients together with other medical and physical treatments. This positive effect on the central nervous system of ALS patients could be also applied to the treatment of other diseases of the central nervous system such as multiple sclerosis, Parkinson's disease, Alzheimer disease and the sequelae of apoplectic insults. Research in China was funded by Deutsche Gesellschaft fuer Muskelkranke (German Association for Muscle Diseases), Hamburg. REFERENCES: (1) Pamela J Shaw: Motor Neurone Disease. BMJ 1999;318:1118-1121( 24 April ). (2) SCALP-NEEDLING THERAPY. Edited and translated by P.S.Yau. Medicine and Health Publishing Co., Hong Kong 1975. (3) See e.g.: Lu Shoukang: Scalp acupuncture therapy and its clinical application. 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