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Journal of Acupuncture and Meridian Studies

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J Acupunct Meridian Stud 2013;6(1):56e59

- CL IN ICAL CASE REPORT -

Acupuncture for Management of BalanceImpairment in a Patient with BipolarDisorder

Kun Hyung Kim 1, Jae Kyu Kim 2,*, Gi Young Yang 2, Byung Ryul Lee 2,Seung Hee Noh 1

1Department of Acupuncture & Moxibustion Medicine, Korean Medicine Hospital, Pusan National University,Yangsan, Republic of Korea2Division of Clinical Medicine, School of Korean Medicine, Pusan National University, Yangsan,Republic of Korea

Available online 26 December 2012

Received: Jul 20, 2012Revised: Dec 8, 2012Accepted: Dec 11, 2012

KEYWORDSbalance impairment;bipolar disorders;symptom management;Taegeuk acupuncture;traditional Korean

* CKE

CopypISSNhttp:

medicine

orresponding author. Division of Corea.-mail: kjk@pnu.edu.

right ª 2013, International Pharm2005-2901 eISSN 2093-8152//dx.doi.org/10.1016/j.jams.201

AbstractA case is reported of unexplained unilateral thigh muscle atrophy and frequent fallingwith poor response to conventional conservative treatments in a patient with bipolardisorder who self-selected acupuncture treatment as a last resort. The patient experi-enced gradual improvements in lower extremity weakness and fewer falls during the8-month treatment. No adverse event or aggravation of the bipolar disorder wasobserved. These outcomes suggest that acupuncture may be a feasible adjunct forreducing falling and restoring postural balances in patients with bipolar disorder.

1. Introduction

Bipolar disorder is a debilitating and chronic mood disorderthat substantially affects the personal and socioeconomicaspects of a patient’s life [1]. The condition itself often

linical Medicine, School of Korean

acopuncture Institute

2.12.001

resists treatment, and a frequent need for a combination ofmedications that are associated with significant sideeffects, such as medication-related neuromuscular sideeffects in patients with bipolar disorder, calls for non-pharmacological management of comorbid conditions [2,3].

Medicine, Pusan National University, Yangsan 626-870, Republic of

Acupuncture for bipolar disorder 57

Data from the 1979e2006 National Hospital DischargeSurvey in the USA showed higher proportional morbidityratios of musculoskeletal (1.2e1.9) and nervous system(1.4e3.8) disorders in patients with bipolar disorders thanthose without bipolar disorder, implying significant associ-ation between the presence of neuromuscular conditionsand bipolar disorder [4]. Mood disorder and lack of coop-eration in patients often yield suboptimal clinical reasoningfor nonpsychotic symptoms and challenge the effectivemanagement of patients. Here, we present a case withbipolar disorder showing unilateral thigh muscle atrophy,with subjective symptoms (weakness of lower extremityand reduced thigh circumference), who recovered by 66sessions of acupuncture delivered for 8 months.

Table 1 Patient-reported symptoms and quality of life at8 months from the baseline.

Scores

Patient global assessment Much improvedSF-36 (0e100)a

Physical function 29.7Role physical 22.6Bodily pain 62.1General health 41.0Vitality 49.0Social function 35.0Role emotional 20.9Mental health 44.4

Beck depression inventory (0e63)b 11a Short-form medical outcome health survey. Higher scores

reflect better outcomes.b Higher scores reflect worse outcomes.

2. Case report

A 43-year-old female, who had been diagnosed with bipolardisorder in 2006, visited a traditional Korean medicine(TKM) hospital due to a sudden onset of subjective weak-ness in the right lower leg as a primary symptom andsignificantly visible right thigh muscle atrophy, which hadstarted 11 months earlier. She had been admitted once ina closed-ward hospital for a month in 2008 and havecontinued psychiatric outpatient follow-up with daily oraladministration of 350 mg of antipsychotics (Seroquel XR)and 1000 mg of sodium valproate (Depakine Chrono) asmaintenance therapies without any change in regimen ordose. She had no past or family history related to rheumaticor autoimmune diseases, and her creatinine kinase levelwas within the normal range, implying little associationbetween subjective muscular weakness and medication-related iatrogenic neuromuscular disorder [5]. At the firstreferral of an orthopedic surgeon at a tertiary universityhospital, magnetic resonance imaging of the lumbar regionshowed a mild degree of disk herniation at the level of thefourth to fifth lumbar spine, which seems unlikely to causevisible asymmetric thigh muscle atrophy. Right foot dropand decreased dorsiflexion power were observed by herorthopedic physician. Electromyography and nerveconduction studies showed slightly delayed sensory nerveaction potentials of right superficial peroneal and bilateralsural nerves, normal H-reflexes at the S1 level, and intactcompounded muscle action potentials of both lowerextremities. Taking into account the symptoms and radio-graphic findings, the patient’s condition was tentativelyclassified as lumbar radiculopathy. Orthotic devices wereused by a rehabilitation doctor, with which the patientpoorly complied due to subjective discomfort when wearingthe device. Given the frequent falling events and increasedgait disturbance, the patient and her caregiver (husband)decided to receive acupuncture at the center as a lastresort.

One of the authors (K.J.K.), a senior TKM doctor with 35years of clinical experience, provided all 66 acupuncturetreatments, which were delivered two or three times/week. Concurrent symptoms, including poor sleep qualityand anorexia, were also treated. As an individualizedapproach, Taegeuk acupuncture, which is based on tradi-tional Korean medicine theory and Sasang constitutionalmedicine in Korea, was conducted [6]. Taegeuk

acupuncture has been used for the management of variouspsychological disorders, such as anxiety, cognitivedysfunction and other psychosomatic symptoms [6].Acupuncture was performed for 20e25 minutes, with de-qisensation through the use of 0.25 � 40 mm2 sterile, single-use stainless needles inserted to a depth of 1e2 cm. Pointsused were HT3, KI3, SP3, LI4, LI11, and ST36 unilaterally.These points were selected according to the constitutionaldiagnosis of the patient (i.e., So-yang constitution), andaimed to enhance the qi and blood circulation thus restoreyin-yang balance [7]. Needles were manually stimulatedand left in situ for about 20 minutes. While needles weremanipulated, the patient was instructed to breathe deeply.Warm infrared irradiation was gently applied on thepatient’s abdomen. In addition, herbal decoctions andextracts were used to manage her general condition. Awarm, sympathetic, and comfortable atmosphere had beenkept during the whole treatment and patient consultationprocess. The patient maintained the routine care and thesame dose of oral medication for her bipolar disorderthrough the whole observation period.

After the initial treatment, the patient reported that shefelt comfortable and relaxed after the session. She re-ported improvement in gait disturbances 1 month after thestart of the treatment. After 5 months, she felt less diffi-culty in walking on flat ground, but walking on the stairswas still challenging. After 8 months, she and her caregiverreported no difficulties in walking on flat ground and thefelt comfortable walking on the stairs. The thigh circum-ference was measured immediately below the line of thethickest area of the buttocks when the legs were spread10 cm apart in the standing position [8], showing 45.5 cm atthe right side and 49.5 cm at the opposite side. She re-ported a perceived improvement of lower leg discomfortsand feelings of imbalance. Beck depression inventoryscores showed a relatively mild depressive status (Table 1).The patient and her caregiver were interviewed by oneauthor (K.K.H.) at the clinic room, revealing thatacupuncture treatment was comfortable and a gradualimprovement of physical symptoms (i.e., gait disturbanceand feeling of weakness in lower leg) was a major motive of

58 K.H. Kim et al.

receiving a regular, long-term acupuncture treatment.Acupuncture treatment was recognized as an effectiveadjunctive treatment of concurrent physical symptoms, notas a completely alternative intervention for managingbipolar disorders by the caregiver. Although neither thepatient nor her caregiver believed that acupuncture wouldcure her psychiatric condition and they did not report anynoticeable improvement of bipolar disorder, they werewilling to continue acupuncture treatment for residualsymptoms and the general management of the conditions.

After the third acupuncture treatment, itchless skinflare on the whole body was observed, which resolvedspontaneously. Other than that, no adverse events orsubjective discomfort during or after the acupuncturetreatment was reported by the patient or caregiver, or wasobserved by the practitioner. No physical or psychiatricsymptom flare-up was observed during the wholeacupuncture treatment period.

3. Discussion

In this case, subjective physical symptom improvement andrestoration of balance after an adjunctive series ofcombined TKM with conventional psychiatric managementwere observed. The patient tolerated long-term regularacupuncture treatments with herbal medicine for herphysical symptom management, whereas rehabilitationorthotic devices were poorly complied with and showedlittle benefit. Adjunctive TKM did not hinder the routinecare by psychiatric physicians, suggesting the feasiblecombination of both traditional and conventional medicinefor concomitant physical symptom management in patientswith bipolar disorder. However, nonspecific effects fromseveral origins, including the empathic patient-practitionerrelationship, high expectations of the patient, combineduse of acupuncture and herbal medicine as well as deepbreathing, and possible natural remission may have playeda role in observed symptom improvements in this case.Outcomes were not assessed at baseline, and only subjec-tive measurements not serial over time were available atthe post-treatment evaluation, which should be pointedout as a weakness of this report. Although general quality oflife was measured after the treatment, no outcome asso-ciated with bipolar disorder such as occurrence of episodesof bipolar disorder, cognitive dysfunction, or anxiety wereassessed [9,10]. As a result, whether acupuncture treat-ments that aimed to exert systemic restoration of yin-yangbalance also showed positive effects on outcomes relatedto bipolar disorder remains uncertain. Future well-controlled clinical studies may explore the true role ofacupuncture for bipolar disorder patients who do notcomply with given management options or seek reliablecomplementary treatments after experiencing no responseto conventional management.

In the patient and caregiver interview, self-perceivedand caregiver-observed significant gait disturbance andseveral events of falling concurrent with unilateral lower-limb weakness were reported before the initiation ofacupuncture treatment, which seemed to be poorly corre-lated with mild lumbar radiculopathy. The neurologicalcomplication of lithium and other antipsychotic drugs has

been reported in patients with bipolar disorder, althoughthere was no evidence of neurotoxicity due to medicationsin this case [11]. Postural control deficits showing greatersway magnitude and reduced complexity were found in 16bipolar disorder patients, suggesting possible deficits insensorimotor integration and a reduced range of timescales for postural corrections, which may involvea dysfunction of the key-brain structure, including cere-bellum, brainstem, and basal ganglia for postural balance[12]. In Parkinsonian model rats with lesions on the medialforebrain bundle, high-frequency electroacupuncturestimulation improved motor impairment, which may berelated to increased GABAergic inhibition in the outputstructure of the basal ganglia [13]. Modulation of brainstemnuclei, which are important to endogenous monoaminergicand opioidergic systems, was observed after the stimula-tion of the ST36 acupuncture point by functional magneticresonance imaging [14]. Considering these experimentalfindings, the reported benefit of acupuncture might beassociated with the neuromodulating effects in key brainstructures although little clinical information is available onthe effects of acupuncture on postural imbalance in bipolardisorder patients. Future controlled trials and experimentalstudies are needed to test this hypothesis.

In conclusion, long-term use of acupuncture showedsymptomatic improvement in unilateral lower leg weaknessand frequent falling in a patient with bipolar disorder. Wesuggest that acupuncture as a feasible and acceptableadjunct for managing subjective neuromuscular symptomsfor patients with bipolar disorder warrants furtherresearch.

Conflict of interest statement

The authors declare that they have no conflict of interest.

Acknowledgments

Support: This study was supported by a clinical researchgrant from Pusan National University Hospital in 2013.

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