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Effect of Press Needles on Swallowing Reflex in
Older Adults with Cerebrovascular Disease: A
Randomized...
Article in Journal of the American Geriatrics Society · December 2014
DOI: 10.1111/jgs.13164.

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Akiko Kikuchi

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2438

LETTERS TO THE EDITOR

and risk of lobar hemorrhage to be identified but is anindication of an association between occurrence of SCLH
and different apoA-1 plasma levels. Data regarding apoA-1
as a risk factor for SCLH could be more adequately
acquired using a prospective study design. Second, statistical power was poor because of the small sample size.
If these findings are confirmed in further studies withlarger samples and different designs, apoA-1 plasma level
could become a promising diagnostic and predictive marker of CAA, as well as a potential target for prevention
strategies in CAA-related hemorrhage.
Massimiliano Godani, MD
Neurology Unit, Sant’Andrea Hospital, La Spezia, Italy
Roberta Baldi, MD
Elisa Raggio, MD
Epidemiology Unit, Sant’Andrea Hospital, La Spezia, Italy
Elisabetta Traverso, MD
Elisa Giorli, MD
Massimo Del Sette, MD
Neurology Unit, Sant’Andrea Hospital, La Spezia, Italy

ACKNOWLEDGMENTS
We thank Prof. Vincenzo Fontana (Biostatistics & Clinical
Trials Unit, San Martino Hospital and Statistical Method
in Biomedical Research, Genoa University, Italy) for his
advice in conducting statistical analyses.
Conflict of Interest: The editor in chief has reviewed
the conflict of interest checklist provided by the authors
and has determined that the authors have no financial orany other kind of personal conflicts with this paper.
Author Contributions: Massimiliano Godani: study
concept and design, wrote the manuscript. Roberta Baldi:
analysis and interpretation of data, wrote the manuscript.
Elisa Raggio: analysis and interpretation of data. Elisabetta Traverso: acquisition of data.
Elisa Giorli: acquisition of data. Massimo Del Sette:supervised the manuscript.
Sponsor’s Role: None.

REFERENCES
1. Frank PG, Marcel YL. Apolipoprotein A-1: Structure-function relationships.
J Lipid Res 2000;41:853–872.
2. Obici L, Franceschini G, Calabresi L et al. Structure, function and amyloidogenic propensity of apolipoprotein A-1. Amyloid 2006;13:191–205.
3. Lefterov I, Fitz NF, Cronican AA et al. Apolipoprotein A-1 deficiency
increases cerebral amyloid angiopathy and cognitive deficits in APP/PS1DeltaE9 mice. J Biol Chem 2010;285:36945–36957.
4. Lewis TL, Cao D, Lu H et al. Overexpression of human apolipoprotein A-1
preserves cognitive function and attenuates neuroinflammation and cerebral
amyloid angiopathy in a mouse model of Alzheimer disease. J Biol Chem2010;285:36958–36968.
5. Handattu SP, Garber DW, Monroe CE et al. Oral apolipoprotein
A-1 mimetic peptide improves cognitive function and reduces amyloid
burden in a mouse model of Alzheimer’s disease. Neurobiol Dis 2009;34:
525–534.
6. Charidimou A, Gang Q, Werring D. Sporadic cerebral amyloid angiopathy
revisited: Recent insights into pathophysiology and clinical spectrum. J Neurol Neurosurg Psychiatry 2012;83:124–137.
7. Viswanathan A, Greenberg SM. Cerebral amyloid angiopathy in the elderly.
Ann Neurol 2011;70:871–880.

DECEMBER 2014–VOL. 62, NO. 12JAGS

8. Yamada M. Predicting cerebral amyloid angiopathy-related intracerebral
hemorrhages and other cerebrovascular disorders in Alzheimer’s disease.
Front Neurol 2012;3:8.

EFFECT OF PRESS NEEDLES ON SWALLOWINGREFLEX IN OLDER ADULTS WITH
CEREBROVASCULAR DISEASE: A RANDOMIZEDDOUBLE-BLIND CONTROLLED TRIAL
To the Editor: The global population is aging.1 Pneumonia
is a leading cause of death in elderly adults, especiallythose with dysphasia and microaspiration.2 Because aspiration pneumonia is related to impairment of the swallowingand cough reflex,3 the development of preventive strategies
is needed to improve such protective reflexes to reduce theincidence of pneumonia in older people. In Japan, pneumonia is the third leading cause of death.4 It was previously reported that acupuzncture at two points on the legs
(ST36 and KI3) improved the swallowing reflex after
stroke5 and reduced pharyngeal retention and aspiration.6
To investigate the effectiveness of acupuncture withpress needles in improving the swallowing reflex in elderly
adults with cerebrovascular disease, a three-arm randomized double-blind controlled multicenter trial was conducted by incorporating sham patches and sham points.
Individuals aged 65 and older who had had a stroke andhad dysphasia were recruited consecutively from two hospitals and two nursing homes in Sendai, Japan. The purpose and design of the study were explained to eachindividual, and informed consent was obtained. TheTohoku University ethics committee approved the study
protocol.
Twenty-nine individuals (10 men, 19 women; meanage  SD 82.2  7.1) were recruited and assigned randomly to three groups: group 1, press needles (Pyonex;Seirin Corporation, Shizuoka, Japan) on the ST36 andKI3; group 2, sham patches on the acupuncture points;
and group 3, press needles on sham points. The needles
were 0.2 mm in diameter and 0.6 mm long. The design ofthe sham patch was identical to that of the press needle
except most of the needle had been cut off, so that only
the head of the needle remained in the resin. Patches wereapplied and changed every day for 4 weeks. Latent time ofswallowing reflex (LTSR), plasma substance P (SP), BarthelIndex, Mini-Mental State Examination, and days of fever
were measured at baseline and 4 weeks later.
Table 1 shows the outcomes of this study. The primary outcome was change in LTSR. A statistically significant shortening of LTSR was evident in Group 1(6.9  2.3 vs 2.5  0.3 seconds, P = .005), whereas no
statistically significant difference was observed in the othertwo groups. There was a significant difference between thethree groups in change in LTSR (P = .009). Change inLTSR in Group 1 was significantly different from that inGroup 2 (P = .008) but not Group 3 (P > .99). There wasa significant difference in LTSR at day 28 between Groups
1 and 2 (P = .001), but no significant difference between
Groups 1 and 3 (P = .51). Plasma SP did not change significantly during the study in any group, and no differences in secondary outcomes were observed in any group

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DECEMBER 2014–VOL. 62, NO. 12

LETTERS TO THE EDITOR

2439

Table 1. Primary and Secondary OutcomesGroup 1 vs Group 2Outcome

Group 1, n = 10Group 2, n = 10

PrimaryLTSR, seconds, mean (SE)Baseline
6.9 (2.3)
4.0 (1.1)
Day 282.5 (0.3)
8.5 (2.8)
P-value.005c.20c
Plasma substance P, pg/mL, mean (SE)Baseline
709.4 (297.9)
809.5 (117.7)
Day 28643.0 (245.2)
801.6 (104.2).91d
P-value.37c
Secondary outcomes
Barthel Index, mean (SE)Baseline
15.5 (10.2)
17.5 (7.6)
Day 2815.0 (10.4)
18.0 (7.7).32cP-value.66c
Mini-Mental State Examination Score, mean (SE)Baseline
8.2 (2.8)
5.9 (2.7)
Day 288.3 (2.9)
6.1 (2.9).41c
P-value.86dDays of fever, mean (SE)Baseline
5.0 (3.1)
3.7 (1.5)
Day 287.0 (3.0)
5.6 (2.4).06c
P-value.29c2
Body mass index, kg/m mean  SD
Baseline
19.2  1.4
15.8  3.3
Day 2816.6  2.6
18.1  3.1.10d
P-value.17d

Group 3, n = 9

14.9 (6.2)
8.4 (3.4).26cGroup 1 vs Group 3

P-Valuea

.008b

>.99b

483.4 (129.1)
550.4 (121.2).77d

8.3 (7.1)
8.9 (7.7).32c
3.7 (2.2)
3.7 (2.3)>.99c
1.6 (0.7)
1.2 (0.7).26c
20.2  1.3
20.3  1.3.67c

SE = standard error.
aIntergroup comparisons of change in latent time of swallowing reflex (LTSR).
b
Kruskal–Wallis test.
cWilcoxon signed rank test.
dPaired-t test.

between baseline and Day 28. Peripheral blood tests were
performed to assess inflammatory and nutritional status.
No statistically significant differences were observed inwhite blood cell count, C-reactive protein, total protein,albumin, or total cholesterol between baseline and Day 28.
There were no significant differences in any parameters.
Neither press needle nor sham needle treatment caused
any side effects.
Attachment of press needles at the two leg acupuncture points improved the swallowing reflex of elderly
adults with cerebrovascular disease. Lack of a significant
difference between acupuncture points and sham points
indicates that the attachment of the fine needle itself has
some effect on the swallowing reflex. Even if the press needles are placed at positions that deviate from the acupoints(e.g., sham points in this study), LTSR may improve,
which is clinically convenient. This type of acupuncture
may become a new adjuvant method for the prevention
and treatment of pneumonia in elderly adults.
The limitations of the present study were the small
sample size and short follow-up time. In addition, onlyGroup 3 included participants with extremely poor LTSR
at baseline, which could have been why there was no difference between Groups 1 and 3 in LTSR at Day 28. Further studies are required to investigate the effect of thepress needle on swallowing function.

Akiko Kikuchi, MD, PhD
Department of Traditional Asian Medicine, Graduate
School of Medicine, Tohoku University, Miyagi, JapanTakashi Seki, MD, PhD
Division of Geriatric Behavioral Neurology, Departmentof Traditional Asian Medicine, Graduate School ofMedicine, Tohoku University, Miyagi, JapanShin Takayama, MD, PhD
Koh Iwasaki, MD, PhD
Department of Traditional Asian Medicine, Graduate
School of Medicine, Tohoku University, Miyagi, Japan
Satoshi Ishizuka, MD, PhD
Sendai Tomizawa Hospital, Miyagi, Japan
Nobuo Yaegashi, MD, PhD
Department of Traditional Asian Medicine, Graduate
School of Medicine, Tohoku University, Miyagi, JapanACKNOWLEDGMENTS
This clinical study was registered in UMIN Clinical TrialsRegistry. ID: UMIN000002133.

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LETTERS TO THE EDITOR

The authors wish to thank Dr. Yoichi Kosaka, Hikarigaoka Spellman Hospital, Sendai, Japan, who recruited
some of participants.
Conflict of Interest: We declare that we have no conflicts of interest. This work was supported by Grant-in-Aid
for Scientific Research from Japan Society for the Promotion of Science (Grant No. 22790608).
Author Contributions: Kikuchi A. was the study chair
and wrote the first draft of the paper. Seki T. contributedto study design and interpretation. Takayama S., Iwasaki
K., and Yaegashi N. commented on the report. Ishizuka S.
contributed to recruitment of participants. All authors contributed to review and approved the final draft of thispaper. The corresponding author had full access to all thedata in the study and had final responsibility for the decision to submit for publication.
Sponsor’s Role: The study sponsor had no role in thestudy design; in the collection, analysis, or interpretationof data; in the writing of the report; or in the decision tosubmit the paper for publication.

REFERENCES
1. World Health Organization. Health Topics: Ageing [on-line]. Available at
http://www.who.int/topics/ageing/en/ Accessed February 20, 2014.
2. Yamaya M, Yanai M, Ohrui T et al. Interventions to prevent pneumonia
among older adults. J Am Geriatr Soc 2001;49:85–90.
3. Nakajoh K, Nakagawa T, Sekizawa K et al. Relation between incidence ofpneumonia and protective reflexes in post-stroke patients with oral or tube
feeding. J Intern Med 2000;247:39–42.
4. Ministry of Health, Labour and Welfare. Annual Health, Labour and Welfare Report 2011–2012 [on-line]. Available at http://www.mhlw.go.jp/english/wp/wp-hw6/index.html Accessed February 20, 2014.
5. Seki T, Kurusu M, Tanji H et al. Acupuncture and swallowing reflex inpoststroke patients. J Am Geriatr Soc 2003;51:726–727.
6. Seki T, Iwasaki K, Arai H et al. Acupuncture for dysphagia in poststroke
patients: A video fluoroscopic study. J Am Geriatr Soc 2005;53:1083–1084.

AGING AND WITHIN- AND BETWEEN-DAY
VARIABILITY ASSESSED USING 7-DAY/24-HOUR
AMBULATORY BLOOD PRESSURE MONITORING
To the Editor: Blood pressure (BP) being highly variable,ambulatory BP monitoring (ABPM) more thoroughly
depicts underlying BP fluctuations and predicts cardiovascular risk better than conventional measurements.1–4
ABPM also assesses the extent of BP decrease (dip) during sleep. “Nondipping” (ND), defined as a day:nightratio (DNR) of less than 10%, is reportedly associatedwith target organ damage and cardiovascular events,independently of overall mean BP.1,2 Day-to-day variability in circadian BP characteristics is often observed in 7day ABPM records. Changes with age in the extent ofday-to-day variability in 24-hour SBP mean and DNR
were examined.
A greater morning BP surge on Mondays was foundin Uraus, a rural northern Japanese town,5 but not inTosa, a southern Japanese city. Geographic differences inchanges with age in circadian features of BP were explored
between these two cities and Tokyo.
A total of 644 community-dwelling subjects living inTokyo, Uraus (Hokkaido), or Tosa (Kochi Prefecture) wereView publication stats

DECEMBER 2014–VOL. 62, NO. 12

JAGS

initially recruited. Of the 644, 609 (368 women, 241 men,aged 23–79) who provided ABPM records spanning atleast 6 days were included in this study. As reported earlier,5–8 BP was measured oscillometrically at 30-minute(7:00 a.m. to 10:00 p.m.) or 60-minute (10:00 p.m. to
7:00 a.m.) intervals, using monitors (TM-2431, A&D Co.,Tokyo, Japan) validated for accuracy.9 Daily (24-hour)
averages and DNR values were computed.
Hypertension (HT) was defined as a 24-hour mean BP
greater than 130/80 mmHg. ND was defined as a DNR ofsystolic BP (SBP) of less than 10%. Mean 24-hour BP andDNR were used to subdivide the 609 subjects into fourgroups (Classification 1: Group 1 = consistent normotension (NT), Group 2 = NT on day 1 but HT on ≥1 of thefollowing 6 days (masked HT), Group 3 = HT on day 1but NT on ≥1 of the following 6 days (masked NT),Group 4 = consistent HT; Classification 2: Group 1 = consistent dipping (DP), Group 2 = DP on Day 1 but ND on≥1 of the following 6 days (masked ND), Group 3 = ND
on day 1 but DP on ≥1 of the following 6 days (maskedDP), Group 4 = consistent ND).
The incidence of consistent and inconsistent classification was compared using the Kruskal-Wallis test (significance at the .05 probability level) for subjects in three agegroups (23–49, n = 113; 50–64, n = 257; 65–79,n = 239), for all subjects, for men and womem separately,
and for subjects in each of the three cities (Table 1).
Inconsistent classifications from day to day increasedwith age (P < .001), masked NT being more frequent thanmasked HT (Table 1, left). Results were significant forwomen (P < .001) but not for men (P = .22) and for citizens of Uraus (P < .001) and Tosa (P = .005) but notTokyo (P = .72). Inconsistent DNR classifications also
increased with age, overall and for men and women separately (all P < .001), being significant in Uraus (P = .01)
but not in Tosa (P = .09) or Tokyo (P = .54) (Table 1,right).
Depressive mood affects BP and BP variability,7,8 withindividuals with depression having a more-prominent circaseptan component in SBP, associated with subjective sleep
disturbances. Aging was found to affect the extent of dayto-day BP variability, more so in women than in men, perhaps because day-to-day variability is already high inyounger men. An age effect was not found in Tokyo,
where the incidence of consistent HT was already high inthe younger age group.
An age effect in DNR classification was significant
for men and women but only in Uraus (Hokkaido prefecture) in northern Japan, where winters are cold. Resultsin Tosa are similar but not significant, perhaps because
the clement weather of southern Japan favors a higher
incidence of consistent dippers in all age groups. A
busy and noisy lifestyle in Tokyo may account for thelargest percentage of inconsistent day-to-day classification(80.2%).
DNR classification is almost invariably more inconsistent than BP-mean classification. Habituation to the monitor may account for the numerically higher incidence ofmasked normotension than masked HT, observed primarily in elderly adults (P = .02).
In conclusion, aging affects day-to-day BP variability
in 24-hour BP mean and in DNR. Several consensus