The American Journal of Chinese Medicine, Vol. 43, No.

3, 407423
2015 World Scientic Publishing Company
Institute for Advanced Research in Asian Science and Medicine
DOI: 10.1142/S0192415X15500263

Am. J. Chin. Med. 2015.43:407-423. Downloaded from www.worldscientific.com

by TAIPEI VETERANS GENERAL HOSP on 05/17/15. For personal use only.

A Clinical Study of Integrating Acupuncture

and Western Medicine in Treating Patients
with Parkinsons Disease
Fang-Pey Chen,*,x,{ Ching-Mao Chang,* Jing-Huei Shiu,{ Jen-Hwey Chiu,{ Ta-Peng Wu,*
,
Jen-Lin Yang,*,{ Yen-Ying Kung,*,x,{ Fun-Jou Chen,|| Chang-Ming Cherny and Shinn-Jang Hwangz x
*Center

for Traditional Medicine

of Neurology
z
Department of Family Medicine
Taipei Veterans General Hospital, Taipei, Taiwan
yDepartment

xNational

Yang-Ming University School of Medicine, Taipei, Taiwan

Institute of Traditional Medicine, School of Medicine

National Yang-Ming University, Taipei, Taiwan

||School of Chinese Medicine, China Medical University, Taichung, Taiwan

Published 5 May 2015

Abstract: Complementary therapy with acupuncture for Parkinsons disease (PD) has been
studied for quite a long time, but the effectiveness of the treatment still remains unclear. The
aim of this study is to evaluate the integrated effects of acupuncture treatment in PD patients
who received western medicine. In the short-term acupuncture treatment study, 20 patients
received acupuncture therapy twice a week in acupoints DU 20, GB 20, LI 11, LI 10, LI 4,
GB 31, ST 32, GB 34 and GB 38 along with western medicine for 18 weeks, and 20
controlled patients received western medicine only. In the long-term acupuncture treatment,
13 patients received acupuncture treatment twice a week for 36 weeks. The outcome parameters include Unified Parkinsons disease rating scale (UPDRS), Beck Anxiety Inventory
(BAI), Beck Depression Inventory-Version 2 (BDI-II), and WHO quality of life (WHOQOL). In the short-term clinical trial, a higher percentage of patients in the acupuncture
group had score improvement in UPDRS total scores (55% vs. 15%, p 0:019), sub-score
of mind, behavior and mood (85% vs. 25%, p < 0:001), activity of daily living (65% vs.
15%, p 0:003), mobility (40% vs. 15%, p 0:155) and complication of treatment (75%
vs. 15%, p < 0:001), BDI-II score (85% vs. 35%, p 0:003), and WHOQOL score (65% vs.
15%, p 0:003) when compared to control group at the end of the 18 weeks follow up.
Correspondence to: Prof. Shinn-Jang Hwang and Associate Prof. Chang-Ming Chern, Department of Family
Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Beitou District, Taipei 112, Taiwan,
ROC. Tel: (886) 2-2875-7460, Fax: (886) 2-2873-7901, E-mail: sjhwang@vghtpe.gov.tw (S.-J. Hwang);
Tel: (886) 2-2875-7578, Fax: (886) 2-2875-7579, E-mail: cmchern@vghtpe.gov.tw (C.-M. Chern)

407

408

F.-P. CHEN et al.

After 36 weeks of long-term acupuncture treatment, the mean UPDRS total scores and subscore of mentation, behavior and mood, sub-score of complications of therapy and BDI-II
score decreased signicantly when compared to the pretreatment baseline. In conclusion,
acupuncture treatment had integrated effects in reducing symptoms and signs of mind, behavior, mood, complications of therapy and depression in PD patients who received Western
medicine.

Am. J. Chin. Med. 2015.43:407-423. Downloaded from www.worldscientific.com

by TAIPEI VETERANS GENERAL HOSP on 05/17/15. For personal use only.

Keywords: Parkinsons Disease; Acupuncture; Integrative Therapy; QOL.

Introduction
Parkinsons disease (PD) is the second most common neurodegenerative disorder, following only Alzheimers disease, and is considered as the most commonly seen serious
dyskinesia disease (de Lau et al., 2006). This disease affects about 3% of the elderly above
65 (Joh et al., 2010), and the percentage is higher for males. About 0.9% of people in
Taiwan have PD (Chen et al., 2009). In China, more than two million of people are affected
with a male: female rate of 1.7%: 1.6%, and the rate increases with age (Zhang et al., 2005;
Chen et al., 2009).
PD occurs mainly due to the degeneration of dopaminergic neurons in substantia nigra,
which leads to a decrease in dopamine and then results in the loss of the basal ganglias
activities and the onset of neurodegenerative problems (Fahn, 2003; Schober, 2004). The
clinical symptoms include resting tremor, rigidity, bradykinesia, postural instability and
signs of autonomic dysfunctions (Jankovic, 2008). Physical functions of PD patients will
decline if left untreated and lead to an inability to take care of their own daily lives. With
the progression of PD, symptoms other than motor symptoms, including cognitive function
problems such as apathy, depression, anxiety and hallucinations occur (Mercury et al.,
2007).
The most commonly used drugs to treat PD include levodopa and anticholinergic drugs.
However, its effectiveness decreases as the duration of treatment is prolonged. About 90%
of patients show good response to levodopa, but 30%, 50%, and 7080% of patients had
adverse reactions after taking levodopa for 3 years, 5 years, and 10 years, respectively.
Motor uctuations and dyskinesia are the most common side effects of using levodopa and
anticholinergic drugs in treating PD patients (Sweet and McDowell, 1975; Verhagen
Metman, 2002). More and more PD patients are actively looking for other methods of
treatment, such as complementary and alternative medicine (CAM) (Suchowersky et al.,
2006; Wang et al., 2013; Bega and Zadikoff, 2014; Li et al., 2014).
Acupuncture has shown good preliminary results for the improvement of the symptoms
of PD, but the practical clinical efcacy in patients is still unknown. In the Chinese
population, few studies of acupuncture therapy for PD treatment have used the currently
accepted Unied Parkinsons disease rating scale (UPDRS) to evaluate the treatment
responses. Hence, the purpose of this study is to evaluate the integrated effects of acupuncture treatment in PD patients who received Western medicine. We apply rigorous

INTEGRATIVE ACUPUNCTURE FOR PARKINSONS DISEASE

409

assessment tools, including the UPDRS, Hoehn & Yahr staging of PD, Beck Anxiety
Inventory (BAI), Beck Depression Inventory-Version 2 (BDI-II), and WHO quality of life
(WHOQOL), to explore the efcacy of clinical study.
Materials and Methods

Am. J. Chin. Med. 2015.43:407-423. Downloaded from www.worldscientific.com

by TAIPEI VETERANS GENERAL HOSP on 05/17/15. For personal use only.

Study Design and Subjects

The investigation was based on non-random sample and comparison clinical trials. There
were two phases in this intervention: short-term (18 weeks) and long-term acupuncture
treatment (36 weeks). The subjects were categorized into two groups according to their
intentions: Acupuncture integrated with Western medicine group and Western medicine
only group (control group). Sample size calculation of the study was based on a previous
study (Shulman et al., 2002), with the power of 0.8 (1

) and a signicant  value less
than 0.05 (two-tailed). Consecutively 40 PD patients were recruited, with 20 in each group.
Inclusion and Exclusion Criteria
Patients were selected from the Department of Neurology at Taipei Veterans General
Hospital and referred to the Center for Traditional Medicine. Inclusion criteria of patients
were aged over 55 years old who had been diagnosed with PD for over 6 months by the
criteria of the Core Assessment Program for Intracerebral Transplantation (CAPIT).
Patients with severe diseases of the heart, brain, liver, kidneys, endocrine, or hematopoietic
system, patients with psychosis or dementia and patients who did not agree to participate in
the study were excluded.
Ethics Statement
This experiment was processed in Taipei Veterans General Hospital with the approval of
IRB at the same hospital (VGHIRB 97-10-08). Written informed consents were obtained
from each patient.
Acupuncture Intervention
The acupuncture points were chosen for treating PD patients were according to Lees
Report (Lee et al., 2007) with modication by TCM doctors with over 5 years of experience at the Center for Traditional Medicine, Taipei Veterans General Hospital, Taipei,
Taiwan. The principle of operation and acupuncture points chosen were based on TCM
theory, and TCM doctors all received complete TCM training from China Medical University, Taichung, Taiwan. The revised Standards for reporting Interventions in Clinical
Trials of Acupuncture (STRICTA) guidelines were followed in our study and are listed in
Table 1.
The scalp acupuncture included the Chorea-Trembling Controlled Area, Baihui (DU
20), and Fengchi (GB 20). The body acupuncture included the Quchi (LI 11), Showsangli

410

F.-P. CHEN et al.

Table 1. The STRICTA 2010 Assessment of Acupuncture Efcacy in Patients with Parkinsons Disease
Item

Am. J. Chin. Med. 2015.43:407-423. Downloaded from www.worldscientific.com

by TAIPEI VETERANS GENERAL HOSP on 05/17/15. For personal use only.

Acupuncture
rationale

Detail
(1a) Style of acupuncture (e.g., Traditional Chinese Medicine, Japanese,
Korean, Western medical, Five Element, ear acupuncture, etc.)
(1b) Reasoning for treatment provided,
based on historical context, literature
sources, and/or consensus methods,
with references where appropriate
(1c) Extent to which treatment was varied

Details of needling

(2a) Number of needle insertions per

subject per session (mean and range
where relevant)
(2b) Names (or location if no standard
name) of points used (uni/bilateral)

(2c) Depth of insertion, based on a

specied unit of measurement, or on
a particular tissue level
(2d) Response sought (e.g., de qi or
muscle twitch response)
(2e) Needle stimulation (e.g., manual,
electrical)
(2f) Needle retention time
(2g) Needle type (diameter, length, and
manufacturer or material)

Treatment
regimen

(3a) Number of treatment sessions

(3b) Frequency and duration of treatment
sessions

Other components
of treatment

(4a) Details of other interventions administered to the acupuncture group

(e.g., moxibustion, cupping, herbs,
exercises, lifestyle advice)

Our Study
Traditional Chinese Medicine

The purpose of this study is to evaluate the integrated effects of

acupuncture treatment in PD
patients who received Western
medicine
Parkinsons Disease
19

Baihui (DU 20), Fengchi (GB 20),

Quchi (LI 11), Showsangli (LI
10), Hegu (LI 4), Fengshi (GB
31), Futu (ST 32), Yanglingquan
(GB 34), and Juegu (GB 38)
All acupuncture points were bilateral
except DU 20
530 mm

De-Qi: soreness, numbness, distention and pain

Manual
15 min
Diameter: 0.27 mm
Length: 25 or 40 mm
Manufacturer: Ching Ming Medical
Device Co., Ltd., New Taipei,
Taiwan
Material: Disposable stainless steel
needles
Short-term: 36 sections
Long-term: 72 sections
Short-term: 18 weeks, twice a week
Long-term: 36 weeks, twice a week
No other interventions in the acupuncture group except Western
medicine

INTEGRATIVE ACUPUNCTURE FOR PARKINSONS DISEASE

411

Table 1. (Continued)

Am. J. Chin. Med. 2015.43:407-423. Downloaded from www.worldscientific.com

by TAIPEI VETERANS GENERAL HOSP on 05/17/15. For personal use only.

Item

Practitioner background

Control or comparator interventions

Detail

Our Study

(4b) Setting and context of treatment,

including instructions to practitioners,
and information and explanations to
patients
(5) Description of participating acupuncturists (qualication or professional afliation, years in acupuncture
practice, other relevant experience)
(6a) Rationale for the control or comparator in the context of the research
question, with sources that justify this
choice
(6b) Precise description of the control or
comparator. If sham acupuncture or
any other type of acupuncture-like
control is used, provide details as for
Items 1 to 3 mentioned in this table.

Center for Traditional Medicine,

Taipei Veterans General Hospital,
Taipei, Taiwan
TCM doctors (experienced over
5 years) all received complete
TCM training from China Medical University, Taichung, Taiwan
Western medicine including
Levodopa

Yes

Note: STRICTA: The revised Standards for reporting Interventions in Clinical Trials of Acupuncture Guidelines.

(LI 10), and Hegu (LI 4) for the upper limbs, and Fengshi (GB 31), Futu (ST 32),
Yanglingquan (GB 34), and Juegu (GB 38) for the lower limbs. All acupuncture points
were bilateral except DU 20.
Disposable stainless steel 0:27  25 mm (diameter  length) and 0:27  40 mm needles
were used in this study (Ching Ming Medical Device Co., Ltd., New Taipei, Taiwan). The
depth of acupuncture points were about 530 mm and De-Qi sensation about soreness,
numbness, distention and pain was asked for all the acupuncture points for all patients with
manual stimulation by TCM doctors about 15 minutes per session. After the end of the
session, all the needles were removed from the subjects.
Study Protocol
Study protocol of the short-term clinical trial is listed in Fig. 1. Patients in the acupuncture
treatment group received an integrated acupuncture therapy twice a week and each section
lasted for 15 minutes besides Western medicine. This phase lasted for 18 weeks and a total
of 36 sections of acupuncture treatments were performed. Patients in the control group
received Western medicine only. All study patients were assessed before the study, in the
middle of the study (9th week), and at the end of the study (18th week). Study protocol of
long-term acupuncture treatment is listed in Fig. 2. They received an integrated acupuncture therapy twice a week and each section lasted for 15 minutes besides Western
medicine. This phase lasted for 36 weeks and a total of 72 sections of acupuncture treatments were performed. All study patients were assessed before study, in the middle of the
study (18th week), and at the end of the study (36th week).

Am. J. Chin. Med. 2015.43:407-423. Downloaded from www.worldscientific.com

by TAIPEI VETERANS GENERAL HOSP on 05/17/15. For personal use only.

412

F.-P. CHEN et al.

Figure 1. Study protocol of short-term clinical trial. Patients in the acupuncture treatment group received an
integrated acupuncture therapy twice a week and each session lasted for 15 minutes besides Western medicine.
This phase lasted for 18 weeks and a total of 36 sections of acupuncture treatments were performed. Patients in the
control group received Western medicine only.

Outcome Measurement
Four parameters were used for evaluating treatment efcacy, including UPDRS (total score
and sub-score I: mentation, behavior and mood, sub-score II: activities of daily living, subscore III: motor evaluation, sub-score IV: complication of therapy), BDI-II, BAI, and

Figure 2. Study protocol of long-term acupuncture treatment. They received an integrated acupuncture therapy
twice a week and each session lasted for 15 minutes besides Western medicine. This phase lasted for 36 weeks and
a total of 72 sections of acupuncture treatments were performed. All study patients were assessed before study, in
the middle of the study (18th week), and at the end of the study (36th week).

INTEGRATIVE ACUPUNCTURE FOR PARKINSONS DISEASE

413

WHOQOL-BREF. Cases (%) with score improvement were compared between the acupuncture treatment and Western medicine (acupuncture group) and Western medicine only
(control group) at each study time point.
Monitor Side Effects and Adverse Events

Am. J. Chin. Med. 2015.43:407-423. Downloaded from www.worldscientific.com

by TAIPEI VETERANS GENERAL HOSP on 05/17/15. For personal use only.

During the study, the side effects or serious adverse events of patients were collected. The
subjects were allowed to leave the experiment whenever they wanted, and they were
allowed to continue receiving the Western medicine therapy. The Western medicine
therapy included levodopa, dopamine agonists, and anticholinergics.
Statistical Analysis
The software SPSS (Version 17.0, Chicago, IL) was employed to analyze the results.
Fisher exact test was used to analyze score improvement response rate between acupuncture treatment group and control group. Wilcoxon signed rank test were used for
comparing the changes before and after interventions. All the tests were examined with a
two-tail test, and the p value of 0.05 was the threshold of statistical signicance.

Results
Analysis of Short-Term (18 Weeks) Clinical Trial
A total of 40 patients participated in the short-term (18 week) clinical trial. Demographic
data of the patients, such as age, sex, disease duration and Hoehn & Yahr stages, BDI-II,
BAI, and WHOQOL-BREF, are listed in Table 2, and it showed no signicant difference
between acupuncture treatment group and control group before treatment. Table 3 showed
that there were signicantly more patients in the acupuncture group who had score improvement of UPDRS total scores (55% vs. 15%, p 0:019), sub-score I of mentation,
behavior and mood (85% vs. 25%, p < 0:001); sub-score II of activities of daily living
(65% vs. 15%, p 0:003), and sub-score IV of complication of therapy (75% vs. 15%,
p < 0:001); BDI-II score (85% vs. 35%, p 0:003); and WHOQOL score (65% vs. 15%,
p 0:003) when compared to control group at the end of 18 weeks follow up. There were
more patients in the acupuncture group who had score improvement of UPDRS sub-score
of motor evaluation and BAI score when compared to control group at the end of 18
weeks follow up. However, the difference did not reach statistical signicance.
Changes of UPDRS, BDI-II, BAI and WHOQOL Scores During and After Treatment
Table 4 shows the changes of mean scores of UPDRS, BAI, BDI-II, and WHOQOL
before, at the end of 9 weeks and 18 weeks treatment in both acupuncture treatment and
control groups. Figure 3 shows the mean UPDRS sub-score I of mentation, behavior
and mood and BDI-II score in the acupuncture treatment group showed a signicant

414

F.-P. CHEN et al.

Am. J. Chin. Med. 2015.43:407-423. Downloaded from www.worldscientific.com

by TAIPEI VETERANS GENERAL HOSP on 05/17/15. For personal use only.

Table 2. Comparisons of Demographic Characteristics in the Baseline Between Subjects with

18 Weeks Acupuncture Plus Western Medicine and Western Medicine Only Group

Age (years)
Male/Female
Disease duration (years)
Hoehn & Yahr stages
UPDRS total score
Sub-score I
Sub-score II
Sub-score III
Sub-score IV
BDI-II
BAI
WHOQOL Global
Physical
Psychological
Social
Environment

Acupuncture and Western

Medicine (n 20)

Western Medicine
Only (n 20)

p value

72.1  8.5
15/5
3.9  3.6
1.3  0.6
22.1  13.0
3.3  1.7
8.2  4.5
6.5  6.2
4.1  3.7
13.6  9.2
10.3  9.1
12.2  2.6
12.7  2.5
13.9  2.4
14.1  2.5
16.0  2.0

75.4  12.2
15/5
4.0  3.3
1.6  1.1
21.2  17.4
3.8  2.6
8.8  7.7
8.7  8.9
4.5  3.5
13.0  9.9
11.0  5.8
11.3  2.8
11.7  2.8
13.3  2.7
13.5  2.6
15.7  2.5

0.184
0.708
0.902
0.449
0.862
0.474
0.765
0.380
0.728
0.884
0.881
0.302
0.268
0.487
0.497
0.667

Notes: Data are expressed as mean  standard deviation. UPDRS: Unied Parkinsons disease rating
score, sub-score I: mentation, behavior and mood, sub-score II: activities of daily life, sub-score III:
motor examination, sub-score IV: complications of therapy, BDI-II: Beck Depression Inventory,
version 2, BAI: Beck Anxiety Inventory, WHOQOL: World Health Organization quality of life.

Table 3. Comparison of Treatment Outcomes Between 18 Weeks Acupuncture Plus Western

Medicine and Western Medicine Only Group

Parameters
UPDRS
Sub-score
Sub-score
Sub-score
Sub-score
BDI-II
BAI
WHOQOL

total
I
II
III
IV

Acupuncture and Western

Medicine (n 20)

Western Medicine
Only (n 20)

Cases (%) with Score

Improvement

Cases (%) with Score

Improvement

p value

11(55)
17(85)
13(65)
8(40)
25(75)
17(85)
9(45)
13(65)

3(15)
5(25)
3(15)
3(15)
3(15)
7(35)
6(30)
3(15)

0.019*
0.000*
0.003*
0.155
0.000*
0.003*
0.514
0.003*

Notes: UPDRS: Unied Parkinsons disease rating score, sub-score I: mentation, behavior and
mood, sub-score II: activities of daily life, sub-score III: motor examination, sub-score IV: complications of therapy, BDI-II: Beck Depression Inventory, version 2, BAI: Beck Anxiety Inventory,
WHOQOL: World Health Organization quality of life. *: p < 0:05.

INTEGRATIVE ACUPUNCTURE FOR PARKINSONS DISEASE

415

Table 4. Changes of Parameters at 9 Weeks and 18 Weeks Treatment Between 18 Weeks Acupuncture Plus
Western Medicine and Western Medicine Only Group

Am. J. Chin. Med. 2015.43:407-423. Downloaded from www.worldscientific.com

by TAIPEI VETERANS GENERAL HOSP on 05/17/15. For personal use only.

Acupuncture and Western Medicine (n 20)

UPDRS
total score
Sub-score I
Sub-score II
Sub-score III
Sub-score IV
BDI-II
BAI
WHOQOL
Global
Physical
Psychological
Social
Environment

Western Medicine Only (n 20)

Baseline

9 Weeks

18 Weeks

Baseline

9 Weeks

18 Weeks

22.1  13.0

20.2  10.0

19.6  10.7

21.2  17.4

25.9  20.0*

25.9  20.1*

3.3
8.2
6.5
4.1
13.6
10.3
12.2









1.7
4.5
6.2
3.7
9.2
9.1
2.6

3.1
7.3
6.8
3.2
10.2
10.3
11.8









1.9*
4.2
4.1
3.7
7.1*
6.9
2.2

2.6
7.0
7.8
2.3
10.0
9.5
11.5









2.1*
3.7
5.2
2.1*
8.7*
7.6
2.3

3.8
8.8
8.7
4.5
13.0
11.0
11.3









2.6
7.7
8.9
3.5
9.9
5.8
2.8

3.2
8.6
9.6
4.5
11.3
10.2
11.4









2.1
7.1
10.2
3.3
7.4
5.8
2.7

3.1
8.7
9.6
4.6
11.2
10.2
11.4









2.2
7.1
10.2
3.2
7.5
5.9
2.7

12.7
13.9
14.1
16.0






2.5
2.4
2.5
2.0

13.1
14.1
14.5
15.6






2.4
2.4
2.4
2.2

13.2
14.1
14.5
15.3






2.4
2.4
2.4
2.1

11.7
13.3
13.5
15.7






2.8
2.7
2.6
2.5

11.5
12.9
13.5
15.7






2.7
2.3
2.5
2.2

11.5
12.9
13.5
15.7






2.7
2.3
2.5
2.2

Notes: Data are expressed as mean  standard deviation. UPDRS: Unied Parkinsons disease rating score, subscore I: mentation, behavior and mood, sub-score II: activities of daily life, sub-score III: motor examination, subscore IV: complications of therapy, BDI-II: Beck Depression Inventory, version 2, BAI: Beck Anxiety Inventory,
WHOQOL: World Health Organization quality of life. *: compare with baseline, p < 0:05.

Figure 3. Changes of parameters at baseline, 9 weeks and 18 weeks treatment in the acupuncture plus Western
medicine group. *p < 0:05, when compared to baseline.

Am. J. Chin. Med. 2015.43:407-423. Downloaded from www.worldscientific.com

by TAIPEI VETERANS GENERAL HOSP on 05/17/15. For personal use only.

416

F.-P. CHEN et al.

Figure 4. Changes of parameters at baseline, 9 weeks and 18 weeks treatment in the Western medicine group only.
*p < 0:05, when compared to baseline.

improvement at the end of 9 weeks of acupuncture treatment when compared to pretreatment values (p < 0:05). Mean UPDRS sub-score I of mentation, behavior and mood;
sub-score IV of complication of therapy, and BDI-II score in the acupuncture treatment
group showed a signicant improvement at the end of 18 weeks acupuncture treatment
when compared to the pretreatment values (p < 0:05). Figure 4 shows the mean total
UPDRS score, sub-score II of activities of daily living, sub-score III of motor evaluation,
BAI, and WHOQOL score in the acupuncture treatment group and all parameters in the
control group did not show signicant improvement at the end of 9 weeks and 18 weeks
study time points when compared to pretreatment values. On the contrary, mean total
UPDRS score in the control group signicantly worsened at the end of 9 weeks and 18
weeks study time points when compared to pretreatment values (p < 0:05).
Results of Long-Term (36 weeks) Acupuncture Treatment
Among the 20 subjects in the short-term acupuncture treatment, 13 of them received longterm (36 weeks) acupuncture treatment. Their mean age was 72:7  9:8 years old and the
ratio of male to female was 9 (69.2%) to 4 (30.8%). The mean duration of PD was
3:4  3:0 years. Their mean Hoehn & Yahr stage was 1:3  0:6.

INTEGRATIVE ACUPUNCTURE FOR PARKINSONS DISEASE

417

Table 5. Changes of Parameters at 18 Weeks and 36 Weeks Treatment in 13 Patients with PD Who
Received Long-Term Acupuncture and Western Medicine Treatment
Acupuncture Treatment and Western Medicine

Am. J. Chin. Med. 2015.43:407-423. Downloaded from www.worldscientific.com

by TAIPEI VETERANS GENERAL HOSP on 05/17/15. For personal use only.

Baseline
UPDRS total score
Sub-score I
Sub-score II
Sub-score III
Sub-score IV
BDI-II
BAI
WHOQOL Global
Physical
Psychological
Social
Environment

26.1
4.0
8.9
7.7
5.5
15.8
12.3
11.9
12.2
13.2
13.5
15.7














14.2
1.7
4.6
7.3
3.6
10.4
10.8
2.9
2.4
2.8
3.0
2.5

18 Weeks
18.2
2.6
6.3
7.2
2.2
10.9
10.3
11.3
13.0
13.9
14.1
14.8














11.6
2.2
4.7
5.3
2.2
10.3
9.5
2.2
2.5
3.2
2.7
2.6

36 Weeks

p value 1

p value 2

p value 3














0.046
0.014
0.098
1.000
0.025*
0.044
0.720
0.457
0.206
0.405
0.546
0.341

0.006*
0.002*
0.065
0.328
0.012
0.018
0.202
0.476
0.677
0.778
0.953
0.384

0.069
0.010*
0.373
0.195
0.681
0.126
0.373
0.084
0.591
0.953
0.796
0.878

15.1
1.1
6.0
6.1
1.9
7.6
8.9
12.4
12.6
13.6
13.8
15.1

11.8
1.8
5.3
4.8
2.3
8.1
15.6
1.7
2.6
2.6
1.8
2.0

Notes: Data are expressed as mean  standard deviation. UPDRS: Unied Parkinsons disease rating score, subscore I: mentation, behavior and mood, sub-score II: activities of daily life, sub-score III: motor examination, subscore IV: complications of therapy, BDI-II: Beck Depression Inventory, version 2, BAI: Beck Anxiety Inventory,
WHOQOL: World Health Organization quality of life. *: p value 1: 18 weeks vs. baseline, p value 2: 36 weeks vs.
baseline, p value 3: 36 weeks vs. 18 weeks.

Table 5 shows the changes of mean scores of UPDRS, BAI, BDI-II, and WHOQOL
before, at the end of 18 weeks and 36 weeks acupuncture treatment. Mean UPDRS total
score, sub-score I of mentation, behavior and mood, sub-score IV of complication of
therapy and BDI-II score showed a signicant improvement at the end of 18 weeks
acupuncture treatment when compared to pretreatment values (p < 0:05). Mean UPDRS
total score, sub-score I of mentation, behavior and mood and sub-score IV of complication
of therapy and BDI-II score showed a signicant improvement at the end of 36 weeks
acupuncture treatment when compared to pretreatment values (p < 0:05). Mean UPDRS
sub-score II of activities of daily living, sub-score III of motor evaluation, BAI and
WHOQOL score did not show signicant improvement at the end of 18 weeks and 36
weeks acupuncture treatment when compared to pretreatment values.
Side Effects and Adverse Events
There were no side effects or serious adverse events in both the acupuncture treatment
group and control group during the study period.
Discussion
The most classic therapy of Western medicine for PD is levodopa, but its efcacy declines
and its adverse effect increases as the disease progress. More and more PD patients, up to
40% to 60% in Europe and Singapore, are actively looking for other methods of treatment,

Am. J. Chin. Med. 2015.43:407-423. Downloaded from www.worldscientific.com

by TAIPEI VETERANS GENERAL HOSP on 05/17/15. For personal use only.

418

F.-P. CHEN et al.

such as traditional Chinese medicine (TCM) (Li et al., 2014), acupuncture (Cristian et al.,
2005), Tai Chi (Li et al., 2007; Hackney and Earhart, 2008), health food supplement (Tan
et al., 2006) and CAM (Suchowersky et al., 2006). In South Korea, 76% of the PD patients
used CAM, including homeopathy, hypnosis, herbal medicine, other drugs from health
drug store, diet changes, zone therapy, acupuncture, magnetic eld treatment, iris diagnostics and hair/mineral analysis, and nearly 60% of them have shown improvement in
motor symptoms (57.6%), physical fatigue (19.6%), pain (4.3%), and constipation (5.4%)
(Kim et al., 2009). In Sweden, up to 34% of PD patients utilize CAM, and acupuncture
treatment accounted for the highest proportion (Lokk and Nilsson, 2010).
TCM clinicians regard PD as tremor paralysis or a trembling disease in the book of
Yellow Emperors Internal Classic since 2000 years ago, which results from lesions in
three human organs, the kidney, spleen, and liver (Zhang and Liu, 2006). Lesions in the
kidneys lead to inertia. Deciency of the qi in the spleen leads to muscle dystrophy. Liver
wind leads to tremors. Based on the diagnosis and treatment, the symptoms can be divided
into liver and kidney deciencies, Qiblood deciency, wind phlegm, meridian blockage,
and spleen phlegm (Li et al., 2006; Zhang et al., 2006). TCM clinicians usually use
Tianma-Gouteng-Yin to calm down the wind, Rencan-Yangrong-Tang, Huanglian-JieduTang or Xiefu-Zhuyu-Tang for treatment (Li, 1995; Zhuang and Wang, 2000; Chen et al.,
2003; Chung et al., 2006).
Integrated medicine serves as some adjuncts, which when combined with the conventional treatment, includes these dimensions about minds and spirits into diagnosis and
treatment while elevating the efcacy, reducing the side-effect and raising the quality of life
of the patient (Astin, 1998; Rees and Weil, 2001). Acupuncture, one of the integrated
treatments, has been used for more than 2000 years in the Chinese population. Acupuncture has been reported as an adjunctive treatment for chemotherapy-induced nausea/
vomiting (Garcia et al., 2013). However, mechanisms of acupuncture treatment are complex. In Western countries, the utilization of acupuncture to treat chronic pain problems
continues to increase. Other disorders of the nervous system and other disorders of the
central nervous system were reported in Taiwan as the top 20 diseases treated with acupuncture treatment (Chen et al., 2006).
Several reports have indicated that the mechanism of using acupuncture in treating PD
is closely related to the neurological system. The messages can be integrated and pass
through nerve pathways to the central nervous system when acupuncture points are
stimulated, and consequently, the surrounding tissue is effected (Langevin et al., 2001).
Some other possible mechanisms of acupuncture treatment found in animal studies have
pointed out that acupuncture has a neuroprotective effect, and increases the variety of
neuroprotective required substances such as brain-derived neurotrophic factor (BDNF),
glial cell line-derived neurotrophic factor (GDNF), etc. In addition, acupuncture treatment
can also reduce cell death and slow down the process of cellular oxidative stress in the
substantia nigra dopaminergic neurons (Joh et al., 2010). Other animal studies have also
shown that acupuncture treatment can repair the trkB dopamine neurons and cyclophilin A
and also repair the gene expression of Art (Park et al., 2003; Jeon et al., 2008; Kim et al.,
2011). An experiment on rats using electroacupuncture showed that the neuroprotective

Am. J. Chin. Med. 2015.43:407-423. Downloaded from www.worldscientific.com

by TAIPEI VETERANS GENERAL HOSP on 05/17/15. For personal use only.

INTEGRATIVE ACUPUNCTURE FOR PARKINSONS DISEASE

419

effects and damage repair functions increase the dopamine levels in the striatum and
promote the expression of the dopamine transporter (Lee et al., 2007).
Complementary therapy with acupuncture for Parkinsons disease has been studied for
quite a long time, but the precise acupuncture points and effective treatment sessions still
remain unclear. Scalp acupuncture points and body acupuncture points are often combined
in treating PD patients. Scalp acupuncture points for PD includes the Baihui, occiputvertex, Fronto-parietal bands, sports zone and chorea-trembling zone acupoints (Lee et al.,
2013). Body acupuncture points include Fengfu (GV 16), Hegu (LI 4), Yanglingquan (GB
34) and Taichong (LV 3), etc. (Liu and Sadove, 1974; Wang et al., 2002; Lam et al., 2008;
Yeo et al., 2012, 2014). Since acupuncture might offer two-way adjustment of the human
body, it can improve blood ow in the brain, and anti-free radical activity (Ren et al.,
2012). Acupuncture can improve physical activity function, decrease tremor frequency and
slow down the progression of the disease, leading to reduced dosage of medication and the
enhanced physical function of PD patients (Kim et al., 2014). Moreover, there are few side
effects of acupuncture treatment and can be used for the long-term (Rajendran et al., 2001;
Shulman et al., 2002). One report showed that after 5 to 8 weeks of treatment with
acupuncture, PD patients had improved hand writing ability, and had less tremors, difculty walking and other symptoms (Shulman et al., 2002).
Although our study is not a randomized, blinded clinical trial, we compared the clinical
parameters before and after acupuncture treatment to avoid the bias between study subjects.
We also followed the STRICTA Guideline of Acupuncture Clinical Trial, and our results
warrant attention.
Sham control in acupuncture clinical studies usually use the methods of non-acupoints,
minimal acupuncture, supercial insertion or no de-qi. However, the inter-practitioner
variability, the patients knowledge and experience of acupuncture and the visual impact of
needling may be the potential factors when performed in the acupuncture studies (Tsukayama et al., 2006). Because the two criteria of the sham control are to mimic those
aspects of the real treatment and not mimic those aspects of treatment that have benecial
effects (Hammerschlag and Zwickey, 2006), we do not use the sham control to compare
with our acupuncture group.
PD is a chronic degenerative disease. Except for suffering from the symptoms, patients
are also greatly impacted emotionally. Decrease of dopamine in the limbic system plays a
role in emotional stress and depression (Remy et al., 2005). Clinically, anxiety and depression were commonly found in PD patients. Previous research has found that the
probability of depression ranged from 7% to 76% in PD patients (Veazey et al., 2005). Many
studies have found that the quality of life of PD patients decreases due to anxiety, depression
or other emotional problems (Kasten et al., 2012). Few studies have applied rigorous clinical
parameters to evaluate the efcacy of acupuncture in treating PD patients. This study used a
comprehensive symptom scoring system and questionnaires to compare the differences
before and after acupuncture treatment. UPDRS is currently the most commonly used
assessment tool. Since PD has been shown to be related to anxiety and depression, we also
used psychological evaluating tools including the Beck Anxiety and Depression Inventory.
To assess the health-related quality of life, WHOQOL-BREF was used.

Am. J. Chin. Med. 2015.43:407-423. Downloaded from www.worldscientific.com

by TAIPEI VETERANS GENERAL HOSP on 05/17/15. For personal use only.

420

F.-P. CHEN et al.

Our results showed that a signicantly higher percentage of patients in the 18 weeks
acupuncture treatment group had score improvement in UPDRS total scores, sub-score of
mentation, behavior and mood, activity of daily living and complication of treatment, when
compared to control group at the end of follow up. After 36 weeks long-term acupuncture
treatment, the mean UPDRS total scores and sub-score of mentation, behavior and mood,
sub-score of complications of therapy improved signicantly when compared to the pretreatment values. Our results were consistent with Changs Report that needling the
Shenting, Baihui, Sishencong points improved overall UPDRS scores, and Zhuang &
Wangs Report that acupuncture treatment could improve clinical symptoms, slow down
degeneration and reduce drugs side effects (Zhuang and Wang, 2000; Chang et al., 2008).
These ndings indicate that acupuncture could improve the clinical symptoms of PD.
Our results also showed that 18 weeks acupuncture treatment signicantly reduced
depression score and increased quality of life score when compared to those of the control
group. Decreased physical symptoms, reduced treatment adverse effects and motivating
patients to perform daily activities might account for the differences. In addition to the
effects of acupuncture treatment, frequent contact with medical care staff during the study
period might offer the patients more psychological support, while patients with Western
medicine only visited the physician every one or three months. Scholars regard acupuncture as a hopeful approach for the treatment of Parkinsons disease patients (Eng et al.,
2006).
The average disease course of PD in this study was approximately 4 years. However,
experiments on mice have generally been carried out at the early stage of their PD. If the
acupuncture therapy in human trials can be studied as soon as the patients are diagnosed,
the effects of the improvement and the delay of disease progression might be achieved.
Conclusions
Acupuncture treatment can reduce overall UPDRS scores, depression and improve the
quality of life in PD patients. Further clinical trials with larger sample size or longer length
of treatment time deserve further evaluation.
Acknowledgments
This study was supported by a grant from the Ministry of Science and Technology, Taiwan
[NSC97-2627-B-008-003]. This study was also supported by National Yang-Ming University
under the Aim for Top University Plan of the Ministry of Education, Taiwan, R.O.C.
References
Astin, J.A. Why patients use alternative medicine: Results of a national study. Jama 279: 15481553,
1998.
Bega, D. and C. Zadikoff. Complementary & alternative management of Parkinsons disease: An
evidence-based review of eastern inuenced practices. J. Mov. Disord. 7: 5766, 2014.

Am. J. Chin. Med. 2015.43:407-423. Downloaded from www.worldscientific.com

by TAIPEI VETERANS GENERAL HOSP on 05/17/15. For personal use only.

INTEGRATIVE ACUPUNCTURE FOR PARKINSONS DISEASE

421

Chang, X.H., L.Z. Zhang and Y.J. Li. Observation on therapeutic effect of acupuncture combined
with medicine on Parkinson disease. Chinese Acupuncture & Moxibustion 28: 645647, 2008.
Chen, C.C., T.F. Chen, Y.C. Hwang, Y.R. Wen, Y.H. Chiu, C.Y. Wu, R.C. Chen, J.J. Tai, T.H. Chen
and H.H. Liou. Different prevalence rates of Parkinsons disease in urban and rural areas: A
population-based study in Taiwan. Neuroepidemiology 33: 350357, 2009.
Chen, F.P., Y.Y. Kung, T.J. Chen and S.J. Hwang. Demographics and patterns of acupuncture use in
the Chinese population: The Taiwan experience. J. Altern. Complement. Med. 12: 379387,
2006.
Chen, J., J. Guo, J. Sun, W. Jiang and B. Wu. TCM treatment of Parkinsons syndrome A report of
40 cases. J. Tradit. Chin. Med. 23: 168169, 2003.
Chung, V., L. Liu, Z. Bian, Z. Zhao, W. Leuk Fong, W.F. Kum, J. Gao and M. Li. Efcacy and safety
of herbal medicines for idiopathic Parkinsons disease: A systematic review. Mov. Disord. 21:
17091715, 2006.
Cristian, A., M. Katz, E. Cutrone and R.H. Walker. Evaluation of acupuncture in the treatment of
Parkinsons disease: A double-blind pilot study. Mov. Disord. 20: 11851188, 2005.
de Lau, L.M. and M.M. Breteler. Epidemiology of Parkinsons disease. Lancet Neurol. 5: 525535,
2006.
Eng, M.L., K.E. Lyons, M.S. Greene and R. Pahwa. Open-label trial regarding the use of acupuncture
and yin tui na in Parkinsons disease outpatients: A pilot study on efcacy, tolerability, and
quality of life. J. Altern. Complement. Med. 12: 395399, 2006.
Fahn, S. Description of Parkinsons disease as a clinical syndrome. Ann N Y Acad Sci. 991: 114,
2003.
Garcia, M.K., J. McQuade, R. Haddad, S. Patel, R. Lee, P. Yang, J.L. Palmer and L. Cohen.
Systematic review of acupuncture in cancer care: A synthesis of the evidence. J. Clin. Oncol.
31: 952960, 2013.
Hackney, M.E. and G.M. Earhart. Tai Chi improves balance and mobility in people with Parkinson
disease. Gait Posture 28: 456460, 2008.
Hammerschlag, R. and H. Zwickey. Evidence-based complementary and alternative medicine: Back
to basics. J. Altern. Complement. Med. 12: 349350, 2006.
Jankovic, J. Parkinsons disease: Clinical features and diagnosis. J. Neurol. Neurosurg. Psychiatry
79: 368376, 2008.
Jeon, S., Y.J. Kim, S.T. Kim, W. Moon, Y. Chae, M. Kang, M.Y. Chung, H. Lee, M.S. Hong, J.H.
Chung, T.H. Joh and H.J. Park. Proteomic analysis of the neuroprotective mechanisms of
acupuncture treatment in a Parkinsons disease mouse model. Proteomics 8: 48224832, 2008.
Joh, T.H., H.J. Park, S.N. Kim and H. Lee. Recent development of acupuncture on Parkinsons
disease. Neurol. Res. 32(Suppl 1): 59, 2010.
Kasten, M., L. Kertelge, V. Tadic, N. Bruggemann, A. Schmidt, J. van der Vegt, H. Siebner, C.
Buhmann, R. Lencer, K.R. Kumar, K. Lohmann, J. Hagenah and C. Klein. Depression and
quality of life in monogenic compared to idiopathic, early-onset Parkinsons disease. Mov.
Disord. 27: 754759, 2012.
Kim, S.N., A.R. Doo, J.Y. Park, H.J. Choo, I. Shim, J.J. Park, Y. Chae, B. Lee, H. Lee and H.J. Park.
Combined treatment with acupuncture reduces effective dose and alleviates adverse effect of Ldopa by normalizing Parkinsons disease-induced neurochemical imbalance. Brain Res. 1544:
3344, 2014.
Kim, S.N., S.T. Kim, A.R. Doo, J.Y. Park, W. Moon, Y. Chae, C.S. Yin, H. Lee and H.J. Park.
Phosphatidylinositol 3-kinase/Akt signaling pathway mediates acupuncture-induced dopaminergic neuron protection and motor function improvement in a mouse model of Parkinsons
disease. Int. J. Neurosci. 121: 562569, 2011.

Am. J. Chin. Med. 2015.43:407-423. Downloaded from www.worldscientific.com

by TAIPEI VETERANS GENERAL HOSP on 05/17/15. For personal use only.

422

F.-P. CHEN et al.

Kim, S.R., T.Y. Lee, M.S. Kim, M.C. Lee and S.J. Chung. Use of complementary and alternative
medicine by Korean patients with Parkinsons disease. Clin. Neurol. Neurosurg. 111: 156
160, 2009.
Lam, Y.C., W.F. Kum, S.S. Durairajan, J.H. Lu, S.C. Man, M. Xu, X.F. Zhang, X.Z. Huang and M.
Li. Efcacy and safety of acupuncture for idiopathic Parkinsons disease: A systematic review.
J. Altern. Complement. Med. 14: 663671, 2008.
Langevin, H.M., D.L. Churchill and M.J. Cipolla. Mechanical signaling through connective tissue: A
mechanism for the therapeutic effect of acupuncture. FASEB J. 15: 22752282, 2001.
Lee, H., H.J. Park, J. Park, M.J. Kim, M. Hong, J. Yang and S. Choi. Acupuncture application for
neurological disorders. Neurol. Res. 29(Suppl 1): S49S54, 2007.
Lee, H.S., H.L. Park, S.J. Lee, B.C. Shin, J.Y. Choi and M.S. Lee. Scalp acupuncture for Parkinsons
disease: A systematic review of randomized controlled trials. Chin. J. Integr. Med. 19:
297306, 2013.
Li, F., P. Harmer, K.J. Fisher, J. Xu, K. Fitzgerald and N. Vongjaturapat. Tai Chi-based exercise for
older adults with Parkinsons disease: A pilot-program evaluation. J. Aging Phys. Act. 15:
139151, 2007.
Li, G. Clinical analysis of Parkinsons disease treated by integration of traditional Chinese and
Western medicine. J. Tradit. Chin. Med. 15: 163169, 1995.
Li, M., M.H. Yang, Y. Liu, X.D. Luo, J.Z. Chen and H.J. Shi. Analysis of clinical evaluation of
response to treatment of Parkinsons disease with integrated Chinese and Western medicine
therapy. Chin. J. Integr. Med. 21: 1721, 2014.
Li, Q., D. Zhao and E. Bezard. Traditional Chinese medicine for Parkinsons disease: A review of
Chinese literature. Behav. Pharmacol. 17: 403410, 2006.
Liu, T.H. and M.S. Sadove. Scalp needle therapy-acupuncture treatment for central nervous system
disorders. Am. J. Chin. Med. (Gard City NY) 2: 261269, 1974.
Lokk, J. and M. Nilsson. Frequency, type and factors associated with the use of complementary and
alternative medicine in patients with Parkinsons disease at a neurological outpatient clinic.
Parkinsonism Relat. Disord. 16: 540544, 2010.
Mercury, M.G., W. Tschan, R. Kehoe and A. Kuechler. The presence of depression and anxiety in
Parkinsons disease. Dis. Mon. 53: 296301, 2007.
Park, H.J., S. Lim, W.S. Joo, C.S. Yin, H.S. Lee, H.J. Lee, J.C. Seo, K. Leem, Y.S. Son, Y.J. Kim,
C.J. Kim, Y.S. Kim and J.H. Chung. Acupuncture prevents 6-hydroxydopamine-induced
neuronal death in the nigrostriatal dopaminergic system in the rat Parkinsons disease model.
Exp. Neurol. 180: 9398, 2003.
Rajendran, P.R., R.E. Thompson and S.G. Reich. The use of alternative therapies by patients with
Parkinsons disease. Neurology 57: 790794, 2001.
Rees, L. and A. Weil. Integrated medicine. BMJ 322: 119120, 2001.
Remy, P., M. Doder, A. Lees, N. Turjanski and D. Brooks. Depression in Parkinsons disease: Loss
of dopamine and noradrenaline innervation in the limbic system. Brain 128: 13141322, 2005.
Ren, B.B., Z. Yu and B. Xu. Overview of the two-way regulatory effect of acupuncture on gastrointestinal motility. Chinese Acupuncture & Moxibustion 32: 765768, 2012.
Schober, A. Classic toxin-induced animal models of Parkinsons disease: 6-OHDA and MPTP. Cell
Tissue Res. 318: 215224, 2004.
Shulman, L.M., X. Wen, W.J. Weiner, D. Bateman, A. Minagar, R. Duncan and J. Konefal. Acupuncture therapy for the symptoms of Parkinsons disease. Mov. Disord. 17: 799802, 2002.
Suchowersky, O., G. Gronseth, J. Perlmutter, S. Reich, T. Zesiewicz and W.J. Weiner. Practice
Parameter: Neuroprotective strategies and alternative therapies for Parkinson disease (an evidence-based review): Report of the Quality Standards Subcommittee of the American
Academy of Neurology. Neurology 66: 976982, 2006.

Am. J. Chin. Med. 2015.43:407-423. Downloaded from www.worldscientific.com

by TAIPEI VETERANS GENERAL HOSP on 05/17/15. For personal use only.

INTEGRATIVE ACUPUNCTURE FOR PARKINSONS DISEASE

423

Sweet, R.D. and F.H. McDowell. Five years treatment of Parkinsons disease with levodopa.
Therapeutic results and survival of 100 patients. Ann. Intern. Med. 83: 456463, 1975.
Tan, L.C., P.N. Lau, R.D. Jamora and E.S. Chan. Use of complementary therapies in patients with
Parkinsons disease in Singapore. Mov. Disord. 21: 8689, 2006.
Tsukayama, H., H. Yamashita, T. Kimura and K. Otsuki. Factors that inuence the applicability of
sham needle in acupuncture trials: Two randomized, single-blind, crossover trials with acupuncture-experienced subjects. Clin. J. Pain 22: 346349, 2006.
Veazey, C., S.O. Aki, K.F. Cook, E.C. Lai and M.E. Kunik. Prevalence and treatment of depression
in Parkinsons disease. J. Neuropsychiatry Clin. Neurosci. 17: 310323, 2005.
Verhagen Metman, L. Recognition and treatment of response uctuations in Parkinsons disease:
Review article. Amino Acids 23: 141145, 2002.
Wang, L., C. He, Y. Liu and L. Zhu. Effect of acupuncture on the auditory evoked brain stem
potential in Parkinsons disease. J. Tradit. Chin. Med. 22: 1517, 2002.
Wang, Y., C.L. Xie, W.W. Wang, L. Lu, D.L. Fu, X.T. Wang and G.Q. Zheng. Epidemiology of
complementary and alternative medicine use in patients with Parkinsons disease. J. Clin.
Neurosci. 20: 10621067, 2013.
Yeo, S., I.H. Choe, M. van den Noort, P. Bosch, G.H. Jahng, B. Rosen, S.H. Kim and S. Lim.
Acupuncture on GB34 activates the precentral gyrus and prefrontal cortex in Parkinsons
disease. BMC Complement. Altern. Med. 14: 336, 2014.
Yeo, S., S. Lim, I.H. Choe, Y.G. Choi, K.C. Chung, G.H. Jahng and S.H. Kim. Acupuncture
stimulation on GB34 activates neural responses associated with Parkinsons disease. CNS
Neurosci. Ther. 18: 781790, 2012.
Zhang, L. and S.M. Liu. Recent developments of traditional Chinese medicine in treatment of
Parkinson disease. Chin. J. Clin. Rehabil. 10: 152154, 2006.
Zhang, Z.X., G.C. Roman, Z. Hong, C.B. Wu, Q.M. Qu, J.B. Huang, B. Zhou, Z.P. Geng, J.X. Wu,
H.B. Wen, H. Zhao and G.E. Zahner. Parkinsons disease in China: Prevalence in Beijing,
Xian, and Shanghai. Lancet 365: 595597, 2005.
Zhang, Z.X., Z.H. Dong and G.C. Roman. Early descriptions of Parkinsons disease in ancient China.
Arch. Neurol. 63: 782784, 2006.
Zhuang, X. and L. Wang. Acupuncture treatment of Parkinsons disease A report of 29 cases.
J. Tradit. Chin. Med. 20: 265267, 2000.