Volume 3, Number 1 | Spring 2008

Clinical Report 1 (Japan)
Development of Acupuncture Therapy for Aspiration
Pneumonia and Traditional Medicine Outpatient Clinic ofTohoku Univeristy Hospital
Takashi Seki, MD, PhD
Center for Asian Traditional Medicine
Tohoku University Graduate School of Medicine

be noticed (inapparent aspiration), allowing saliva
or intraoral bacteria to enter the lungs.
Evaluationofthedeglutitional

measurement of the deglutition reflex latency
For the assessment of the deglutitional function
videofluorographic studies areThe Super-aging Society Japan and Aspiration
Pneumonitis
Based on an announcement made bey the cabinet
the ratio of elderly in Japan (the portion of the
population older than 65 years) has increased
steadily every year since investigations have been
started (in 1968) and in 2007 the ratio exceeded 21%,
resulting in a super-aging society, and by October
2008 this ratio has reached 22.1%. By the year 2055
the ratio will reach 40.5%, so that is has been
estimated, that one in every 2.5 people will be anelderly. (2008, Current situation of the elderly
population and the state of implementation ofcountermeasures for the aging society.)
Pneumonitis is the fourth frequent cause of deathin Japan. More than 90% of the deceased are elderly
over the age of 65. A characteristic form ofpneumonitis

inelderly

peopleisaspiration

pneumonitis. The deglutition and cough reflex are
defense mechanisms protecting the lungs fromaspiration. A major cause of pneumonitis in theelderly are diminished deglutition and coughfunction:

employed, but theirperformance is restricted to facilities capable ofperforming them and definitely are not easy. For
this study we used the latency time of theswallowing

reflex:LTSRdeveloped

atDepartment of Geriatrics of the Tohoku University
as a measuring method for the deglutitional
function and as an assessment technique. Thismethodhas

theadvantage

that

it

suggests a correlation with aspiration pneumonitis.
Multipurpose 8f tubes and syringes (1 ml, 10 ml)
are attached to a three-way stopcock, the tip of thetube inserted to a depth of about 12 cm and left
dwelling the pharynx of the examinee, then 1 ml ofdistilled water in injected (Figure 1) and the LTSR
defined as the period from the begin of the injectionof the distilled water to the begin of the pharyngeal
elevation. It is common knowledge that there is arisk of aspiration, when this LTSR exceeds 5
seconds.
Figure 1: Kit for the measurement of the deglutitionreflex latency

cerebral basal ganglia (Nakagawa T, et al. Arch
Intern Med 1997; 157:321-324). Vascular disorders
in the basal ganglia lower the amount of dopamine
produced in the nigrostriatal body. In this way theamount of substance P (SP) released from thesyringes

sensory branch of the vagal nerve to the pharyngealand tracheal mucosa decreases. Since the SPsyringes

represents an important trigger stimulus for theamount of SP also decreases those reflexes (Yamaya

three-way
stopcockM, et al. JAGS. 2001; 49:85-90). In cases with adiminished deglutition reflex the aspiration may not

10allowsmeasurement everywhere and available evidence

reflexes due to cerebrovascular disorders of thedeglutition or cough reflex, a reduction in thetheThe Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

insert to nose

Volume 3, Number 1 | Spring 2008

Necessity of acupuncture treatmentMaterials and methods

During the treatment of patients with dysphagia

The study included 41 patients with sequelae oforal application of the required drugs may not

cerebrovascular disorders (average age ± standard

possible precisely because there are difficulties indeviation 76±2 years), all of whom presented with aswallowing. For this reason new treatment forms

history of deglutition disorders. The primary lesion

are required that improve the deglutition reflexof the cerebrovascular disorder was located in most

without relying on oral drug application.

patients in the basal ganglia and the adjoining deep

Development of an acupuncture treatment for
improving the deglutition reflex
Aspiration is considered to be due to a lack ofproper control of deglutition and inhalation and in
traditional Chinese medicine one of the causes is
attributed, based on the visceral manifestation
theory, to the weakened functions "harmonizing
array" of the stomach and "qi absorption" of thekidneys.

white matter. Patients with infarct sites in the brain
stem were excluded.
The LTSR was defined as the time from the beginof injecting 1 ml of distilled water through atransnasal catheter into the pharynx until the beginof the swallowing movement. The measurement wasperformed 5 times and the measurement value
defined as the mean value excluding maximal andminimal values.

Further, since patients with cerebrovascular

The Ashi Sanri and Taikei were needled. Seirin

disorders may not be able to use their extremities at

disposable stainless steel needles (diameter, 0.16will, an approach using acupuncture therapy canmm; length 40 mm) were inserted at the acupoints

easily be conceived. Moreover, as a treatment formon the left and right to a depth of 1 cm. The needles

using stimulation of safe sites it is effective in thewere neither manipulated manually nor used forclinical setting. Under these circumstances we choseelectrical stimulation. After retaining the needles

to use the sea point of the brighter yang stomach

for 15 minutes the needles were removed. Breathing

meridian and the source point of the lesser yin

based tonification or sedation was not used either.

kidney meridian as stimulation sites.

The LTSR was performed immediately before theBelow the results of two trials are described.

needling and 30 minutes after removing theneedles.

Research 1:
Deglutition reflex and acupuncture treatment forpatients with cerebrovascular disorders
Seki T, Kurusu M, Tanji H, Arai H, Sasaki H,Acupuncture and swallowing reflex in poststroke
patients. J Am Geriatr Soc. 51(5) 726-727, 2003.

Saliva and blood samples were also obtained
immediately before the needling and 30 minutes
after removing the needles. The sampled saliva andblood was stored as -80ºC and subsequently theirsubstance P content measured. For this purpose weused a radioimmune assay and followed theinstructions of the manufacturer for quantitative

Background and purpose
Therapies requiring the oral application of drugs

measurements.

TheamountofsubstanceP

are limited in patients who have problems eating.

immediately before the needling and after theThus,

needle stimulation were compared.

nonpharmacologic

methods

promotingrecovery of the swallowing function have to be

In seven of the examinees the LTSR wasdeveloped. In this study we examined the effects ofmeasured daily from the day after the needle

needle stimulation at Ashi Sanri (ST36) and Taikei

stimulation for one week.

(KI3) on decreased swallowing reflexes.

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

11

Volume 3, Number 1 | Spring 2008

are related to spontaneous swallowing (Zald DH, etResults
Figure 2 shows that the LTSR significantly

al. Ann Neurol 1999) and since acupuncture isimproved after a single needle stimulation (averageknown to regulate the subcortical grey matter, itvalue before needle stimulation: 10.2 ± 1.4 seconds,

may be inferred that acupuncture treatment causes

average value after needle stimulation: 4.5 ± 0.6local activation of the brain.

seconds). After adjusting for age, sex and activities
of daily living and primary disease (cerebral infarct,cerebral hemorrhage) a logistic regression analysis
was performed and showed that the longer theLTSR was before the needle stimulation, the better
were the therapeutic effects (P=.002).
Moreover, the effects of needle stimulation on theLTSR continued for 7 days. The average LTSR
before and after needling as well as 1, 2, 3, 4 and 7
days later were 12.8±4.5, 3.2±0.7, 6.2±2.5, 6.7±2.8,
5.6±2.1, 3.6±1.4 and 2.2±0.2 seconds respectively.

Research 2:
Deglutition reflex and acupuncture treatment forpatients with cerebrovascular disorders:
videofluorographic studies
Seki T, Iwasaki K, Arai H, Sasaki H, Hayashi H,
Yamada S, Toba K.
Acupuncture for Dysphagia in poststroke patients: avideofluoroscopic study. J Am Geriatr Soc.
53(6):1083-4. 2005.
Background and purpose

The concentration of substance P in plasma

We reported that needle stimulation of Ashi

(average of 25.9±3.0 vs 26.6±3.0 pg/mL) and saliva

Sanri and Taikei improved the swallowing reflex.

(average of 15.2±2.9 vs 17.7±3.4 pg/mL) showed noHere we used videofluorography to investigate

significant variation before and after the needle

whether needle stimulation improved swallowing

stimulation.

disorders or the swallowing in patients with

Health disturbances like local infections etc. werenot observed.
Figure 2 (below)

Discussion
A network of cholinergic, histaminergic anddopaminergic nerves is involved in the control of theswallowing reflex (Jia YX, et al. Geriatr Gerontol
Int 2001). The activities of several sites in the brain

12

cerebrovascular disorders.
Materials and methods
The study included 32 patients living a healthcare center for the elderly in Sendai city (average
age ± standard deviation; 84±4 years; 20 women, 12men) in whom cerebrovascular disorders had been
diagnosed using MRI. A written informed consent
was obtained from these patients. The examinees
were randomly divided into two groups. The
patients in the needle stimulation group (average
age ± standard deviation; 77±9 years; 10 women, 8men) received acupuncture treatments 3 times aweek over a period of 4 weeks. The needle
stimulation was the same as the one used inresearch 1. The control group included 14 persons(average age ± standard deviation; 79±5 years; 10women, 4 men) and received only the ordinary carewithout needle stimulation.
The videofluorography was performed in theneedle stimulation group before and after the firstneedle stimulation and in the fourth week before
and after the last treatment. In the control group it

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 3, Number 1 | Spring 2008was performed before observation begin andfollowing completion of the observation after fourweeks. For a single videofluorographic examination
the patients were asked to swallow 5 ml of waterover a period of 5 minutes, 5 ml of liquid diet andsolid food (cookies corresponding to 5 ml) inarbitrary order. The water and food was mixed withbarium (Enemastar Enema Powder, FUSHIMI
Pharmaceutical, Marugame, Japan). For theimaging during the videofluorography the patientswere asked to assume either a sitting position or lie
on their side. For the imaging a DVD/HDD recorder(RD-XS30, Toshiba, Tokyo, Japan) was used,connecting it to an imaging device (Prestige, GE
Medical Systems, Tokyo, Japan). Thirty frames per
second were taken and the measurements
performed using an image processing software(Premier 6.0, Adobe Systems, Tokyo, Japan) by aradiological technician, who was not informed about
the group to which the examinee belonged. If afterswallowing water or food boli were still observed in
the epiglottal groove or the piriform recess, this wasdefined as pharyngeal retention. If water or foodboli reached the trachea below the height of the
vocal cord folds, this was defined as aspiration. The
patients were observed from the moment theswallowing instruction was issued to the examinees
until the water and food boli had reached theesophagus.
Body temperature of the examinees wasmeasured daily at 2 o'clock in the afternoon. The
number of days when the body temperature
exceeded 37.8°C during the 4-week period wererecorded.

stimulation group 1.1±0.3 sec (p< .05), liquid diet
5.0±4.8 sec (p< .05) and for solid food 11.8±9.3
seconds. In the control group the times were forwater 2.1±0.9, liquid diet 5.4±5.4 and for solid food10.1±6.9 seconds. In the needle stimulation groupthe swallowing time for water and liquid diet wascompared to the pretest value after four weeks
significantly shortened.
Figure 3 shows the percentage of pharyngeal
retention and aspiration in the two groups ofexaminees. The degree of pharyngeal retention had
significantly decreased in the needle stimulationgroup, but in the control group no significant change
was observed. Aspiration before test begin was in
the needle stimulation group 40% for water, 8% forliquid diet and 25% for solid food, but after fourweeks aspiration was no longer observed for any of
the food forms.
In the control group no significant change in theratio of aspiration was observed between the pretest
condition and the condition after 4 weeks. The
number of days body temperature exceeded 37.8°C
was in the needle stimulation group 4 out of 356 days,
whereas it was in the control group 28 out of 394,
showing that it was significantly higher in the control
group than in the needle stimulation group (P <.01).
Figure 3 (below)

Results
In the needle stimulation group the time required
the swallowing before test begin until the swallowedmaterial reaches the esophagus was for water on theaverage (±SD) 1.7±1.0, for liquid diet 8.7±13.2 and forsolid food 10.4±7.0 seconds. In the control group therespective times were for water 1.9±0.6, liquid diet
4.5±3.7 and for solid food 9.7±7.6 seconds.
Four weeks later these values were in the needle

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

13Volume 3, Number 1 | Spring 2008

Discussion
Needle stimulation of Ashi Sanri and Taikei
improves the incidence of pharyngeal retention andaspiration

inpatients

withcerebrovasculardisorders repeatedly suffering from aspiration.
Conclusions
These results indicated the possibility thatneedle stimulation of Ashi Sanri and Taikei canimprove the swallowing reflex, reduces the amountof pharyngeal retention and aspiration and thus
may prevent aspiration pneumonitis.
These studies are characterized by1) the needle stimulation consisted only of direct
insertion, retention for 15 minutes and removal ofthe needles, not using any manual manipulation orelectrical stimulation of the inserted needles at all;2) this can conceivably be designated a clinical trialof acupuncture therapy of the examinees not basedon pattern identification, but from the perspective of
the western medical diagnosis; here (1) indicates,that even acupuncture therapy using only simple
retention of the needles alone can have marked
clinical effects, while (2) indicates that clinical trials
including examinees selected based on western
medical diagnosis may show the effectiveness of theacupuncture therapy.

14This study showed great potential for
acupuncture treatment, but the medical educationin Japan almost does not include teaching about
acupuncture at all, so that even simple acupuncture
treatments present for the physicians in the clinicalsetting a great hurdle and obstruct the spread of
this treatment modality. For this reason weperformed trials using stimulation with low
frequency currents with surface electrodes attachedto Ashi Sanri and Taikei after completion of theabove described two trials. The results showed, thata similar degree of improvement of the LTSR wasobserved. This indicates that both needle insertionand low frequency currents induce identical changes
in the human body. If improvements of theswallowing function can be obtained without
inserting needles, this treatment modality is
considered to become popular in the clinical setting.
On the other hand, comparing the degree ofimprovement of the swallowing reflex between thestudies 1 and 2 and this latter study showed thatthe insertion of filiform needles produces a greater
degree of improvement as compared to low
frequency currents. The results of these studies arescheduled to be published in the Journal of The
American Geriatrics Society. (Akamatsu C, Seki T.
et al. Improvement of swallowing reflex after
electrical stimulation to lower leg acupoints inpatients after stroke. JAGS. in press.)

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 3, Number 1 | Spring 2008

DepartmentofKampo

MedicineofTohoku

in patients with glaucoma and similar results.
In the acupuncture and Kampo outpatient

University
The Department of Kampo Medicine of Tohoku

service the therapeutic effects are evaluated before

University does not use only Kampo medicine, but

and after each acupuncture treatment session,embraces an integrated approach to traditional

using the results as therapy feedback, whereby amedicine

usingsystem that might be called 'Evidence Basedacupuncture treatment, Suina and traditional

Clinical Acupuncture' is being built. Building a

dietary guidance. In the past the departments ofsystem that will allow to put acupuncture treatment

geriatrics and respiratory diseases used Kampo

and Kampo medicine to use in clinic represents one

medicine and acupuncture in their outpatientof our goals.

service,originating

butinfrom2003

theChinaalso

TohokuUniversity

established a lecture for advanced Kampo medical

Medical education

practice within its faculty of medicine and also a

The education is not directed only towards

department of Kampo (internal) medicine within its

physicians, but also acupuncturists and medical

university hospital. Here a department using

students and thus the department represents one of

mainlyKampo

the few medical faculties that performs clinicaloutpatient service and an acupuncture and Kampo

practice in acupuncture and has therefore earned aoutpatient section using a combination of Kampo

very high reputation amoung the students. Fifth

preparations and acupuncture treatment wereyear students of the medical faculty are divided into

established. Since April 2008 a Kampo outpatient

small groups of 5-6 students and are taught once

section was also set up within the obstetrics andevery two weeks, including instructions in practical

gynecologic department.

examination, brewing Kampo medical decoctions

Kampo

preparations

initsand practicing insertion of acupuncture needles.
DemandforKampo

outpatientservices

andFrom among the sixth grades 6-7 applicants canpartake in practical training courses of 1-2 months.

outpatient backgroundThe number of patients is steadily growing. TheHere they will receive lectures about the theoreticalbroad age range of the patients ranges from 0 to 90

foundations, participate in outpatient practice andyears. The acupuncture and Kampo outpatient service

participate in practical training in the pharmacy oris booked for one year ahead and cares mainly forpharmaceutical botany.

patients with intractable diseases. For this reason theUsing the advantages of a general hospital, amost frequent target illnesses are mysasthenia gravis,

system of cooperative care and research with each

Parkinsonism,

department is being established.

ALS andsimilar

neuromusculardiseases, glaucoma, cancer, GVHD etc.
Research into Kampo medicine and acupuncture
treatmentThis department has published about the effects
of Yokkansan for the treatment of mental disorders
associated with dementia, acupuncture treatment(needling of Taikei and Ashi Sanri) for cerebral
stroke associated with dysphagia, the effects ofacupuncture treatment on lowering ocular tension

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

15