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1 53 DOI : /KPI Received : Revised : Accepted : Key Words: Amyotrophic lateral sclerosis(als), ALS Functional Rating Scale-Revised(ALSFRS- R), Medical Research Council(MRC) Scale A pilot clinical study on the Traditional Korean Medicine treatment of Amyotrophic lateral sclerosis Kim Sung-chul, Na Won-min, Lim Na-ra, Lee Do-sang, Jang Eun-ha*, Song Bong-keun** * Dept. of Acupuncture & Moxibustion, Gwang-Ju Oriental Medical Hospital, Wonkwang University ** Dept. of Internal Medicine, Gwang-Ju Oriental Medical Hospital, Wonkwang University ABSTRACT Objectives : This study was to investigate the effect of Oriental medical treatment on ALS. Methods : We investigated 12 ALS patients which were admitted to Gwang-Ju O.M. hospital from Oct. 14, 2008 to Nov. 14, All patients were treated by SAAM-acupuncture, herb medication, Bee venom Pharmacopuncture therapy, Needle-embedding therapy, etc. We evaluated patients using the Amyotrophic lateral sclerosis Functional Rating Scale-Revised(ALS- FRS-R), Medical Research Council (MRC) Scale. Results : After 30 days, mean ALSFRS-R score of patients was improved from to , and mean MRC Scale of patients was improved from to But in both cases, the variation was not statistically significant. After 30 days, mean ALSFRS-R score and mean MRC Scale of patients was more improved in subjects with bulbar-onset, onset age: 51-60yrs., disease duration: 24-48mo. And the results showed partially significant difference. Conclusions : We think that the results of this case be a pilot study that proves the effect of Oriental Medical treatment on ALS. I Amyotrophic lateral sclerosis, ALS ~3 4~6 1.5 ALS ,300 ALS 3-5 symptomatic treatment supprotive Correspondence: Kim Sung-chul, Dept. of Acupuncture & Moxibustion, Gwang-Ju Oriental Medical, Hospital in WonKwang University (Tel ) kscndl@hanmail.net

2 therapy FDA ALS 12 II 1 ALS ALS El Escorial criteria World Federation of Neurology 1998 EMG biopsy ALS 12 3 ALS 1 1 limbtype HT8 SP2 LR1 SP1 KI10 LR8 LU8 LR4 SP3 LU9 HT8 LU ~20mm ~ LR cc cc ST36 SP9 LR gage 5mm g gage 0.5

3 55 CV12 CV4 CV gage 1.0 CV12 CV4 CV4 Council MRC Scale MRC scale ,5-9 8 MRC MRC 5 = 5.00; MRC 5- = 4.67; MRC 4+ = 4.33; MRC 4 = 4.00; MRC 4- = 3.67; MRC 3 = 3.00; MRC 2 = 2.00; MRC 1 = 1.00; MRC 0 = 0.00; maximum score, 40) cm, 6.0cm, 9.0cm CV23 CV17 GV1 LI11 ST36 SP6 SP SPSS PC program version ALS- FRS-R, MRC scale paired t-test, Wilcoxon signed rank test ALS Functional Rating Scale-Revised ALSFRS-R ALSFRS-R 12 gross motor function Medical Research 3 ALSFRS-R, MRC scale ANOVA III 1 Table % 6 50% Table 2

4 limb-type bulbar-type ALS El Escorial criteria ALS definite- probable ALS 12 7 ALS 2 1 ALSFRS-R MRC scale ALSFRS-R MRC scale ALSFRS-R score Max score , Table 3 MRC scale Max score , , Table 3 2 ALSFRS-R MRC scale ALSFRS-R Table 4 MRC scale p=0.039 Table 4 3 ALSFRS-R score MRC scale ALSFRS-R score bulbar-onset limb-onset Table 5 MRC scale bulbar-onset limb-onset 1.18 Table 5 4 ALSFRS-R score MRC scale ALSFRS-R score , Table 6 MRC scale p=0.049 Table 6 5 ALSFRS-R score MRC scale ALSFRS-R score 24

5 ~ Table 7 MRC scale ~ Table skin test cc 0.4cc 1 Ice pack IV ALS fasciculation ALS ALS ALS / ALS % % 10-16% 10 ALS mullul Rosen % % % 6

6 % % 12 89% 24 39,27, ALS 10% Cu/Zn superoxide dismutase synaptic transmission cell death ALS ALS ALS ALS immunoglobulin ALS ALS ALS ALS ALS ALS ALS ALS % 13%:37% Percutaneous Endoscopic Gastrostomy, PEG non-invasive ventilation, NIV PEG, NIV ALS AAL guidelines El escorial probable definite ALS %

7 59 3 ALS ALS Functional Rating Scale ALSFRS M- edical Research Council MRC scale ALSFRS ALS ALSFRS 2 ALSFRS- Revised ALSFRS-R ALSFRS-R 12 gross motor function ALS ALSFRS-R 2007 K-ALSFRS-R Medical Research Council MRC 4 MRC scale ,5- ALS ALS Yun-Tao Ma sensory gyrus Jeremy Ross ALS cortisone

8 cc Allergy Ice pack CV23 CV17 GV1 LI11 ST36 SP6 SP ALS 1 ALSFRS-R score MRCscale ALSFRS-R score Max score MRC scale Max score ALSFRS-R score MRC scale MRC grade 0 MRC grade 3 1 MRC grade 1 1 MRC grade 3 1 ALS ALS 1 ALSFRS-R score MRC scale ALS ALS 2

9 61 1 RCT ALS V ALS ALSFRS-R MRC-scale ALSFRS-R score MRC scale VI 1. Williams DB, Windebank AJ. Motor neuron disease(amyotrophic lateral sclerosis). Mayo Clin Proc 1991;66: Caroscio JT, Mulvihill MN, Sterling R, et al. Amyotrophic lateral sclerosis its natural history. Neurol Clin. 1987;5: Kim SH. Diagnosis and therapeutic strategies of amyotrophic lateral sclerosis. Hanyang medical reviews. 2006;26(1): Traynor BJ, Alexander M, Corr B, et al. An o- utcome study of riluzole in amyotrophic lateral sclerosis. A population based study in Ireland, Journal of Neurology. 2003;250: Lacomblez L, Bensimon G, Leigh PN, et al. Dose-ranging study of riluzole in amyotrophic lateral sclerosis. Amyotrophic lateral sclerosis/riluzole Study Group. Lancet. 1996;347(9013): Brooks BR, Miller RG, Swash M, Munsat TL. World Federation of Neurology Research Group on Motor Neuron Diseases. El Escorial revisited: revised criteria for the diagnosis of amyotrophic lateral sclerosis. Amyotroph Lateral Scler Other Motor Neuron Disord. 2000;1: The Amyotrophic Lateral Sclerosis Functional Rating Scale. Assessment of activities of daily

10 living in patients with amyotrophic lateral sclerosis. The ALS CNTF treatment study (ACTS) phase I-II Study Group. Arch Neurol. 1996;53: de Carvalho M, Costa J, Swash M. Clinical trials in ALS: a review of the role of clinical and neurophysiological measurements. Amyotrophic Lateral Scler Other Motor Neuron Disord. 2005;6: Cedarbaum JM, Stambler N, Malta E, Fuller C, Hilt D, Thurmond B, et al. The ALSFRS-R: a revised ALS functional rating scale that incorporates assessments of respiratory function. BDNF ALS Study Group (Phase III). J Neurol Sci. 1999;169: Mendell JR, Moxley RT, Grigs RC; et al. Randomized, double-blind six-month trial of prednisone in Duchenne s muscular dystrophy. N Engl J Med. 1989;320: Mitsumoto H, Chad DA, Pioro EP. Amyotrophic lateral sclerosis. Philadelphia: F. A. Davis Company. 1998:3-33, Lee KW. Textbookof Neurology. Seoul: EPU- BLIC Norris F, Shepherd R, Denys E, U K, Mukai E, Elias L, et al. Onset, natural history and outcome in idiopathic adult motor neuron disease. J Neurol Sci. 1993;118: Neudert C, Oliver D, Wasner M, Borasio GD. The course of the terminal phase in patients with amyotrophic lateral sclerosis. J Neurol. 2001;248: Forbes RB, Colville S, Cran GW, Swingler RJ. Unexpected decline in survival from amyotrophic lateral sclerosis/motor neuron disease. Journal of Neurology, Neurosurgery, and Psychiatry. 2004;75: del Aguila MA, Longstreth WT Jr, McGuire V, Koepsell TD, van Belle G. Prognosis in amyotrophic lateral sclerosis:a populationbased study. Neurology. 2003;60: Gubbay SS, Kahana E, Zilber N, Cooper G, Pintov S, Leibowitz Y. Amytorophic lateral sclerosis. A study of its presentation and prognosis. J Neuro.l 1985;232: Rosen AD. Amyotrophic lateral sclerosis: clinical features and prognosis. Arch Neurol (Chicago). 1978;35: Annegers JF, Appel S, Lee JR, Perkins P. Incidence and prevalence of amyotrophic lateral sclerosis in Harris County, Texas, Arch Neurol. 1991;48(6): Brooks BR. What are the implications of early diagnosis? Maintaining optimal health as long as possible. Neurology. 1999;53(Suppl):S43-S Millul A, Beghi E, Logroscino G, Micheli A, Vitelli E, Zardi A. Survival of patients with amyotrophic lateral sclerosis in a populationbased registry. Neuroepidemiology. 2005;25: Park SH, Myung HJ. A Clinical Study on Amyotrophic Lateral Sclerosis. J Korean Neurol Assoc. 1986;4(2): Jessica Mandrioli, Pietro Faglioni. Paolo Nichelli, Patrizia Sola. Amyotrophic lateral sclerosis: Prognostic indicators of survival. Amyotrophic Lateral Sclerosis. 2006;7(4): Louwerse ES, Visser CE, Bossuyt PM, Weverling GJ. Amyotrophic lateral sclerosis: mortality risk during the course of the disease and prognostic factors. The Netherlands ALS Consortium. J Neurol Sci. 1997;152: Rosen DR, Siddique T, Patterson D, Figlewicz DA, Sapp P, Hentati A, et al. Mutations in Cu/Zn superoxide dismutase gene are associated with familial amyotrophic lateral sclerosis. Nature. 1993;362: Weiss JH, Hartley DM, Koh J, Choi DW. The calcium channel blocker nifedipine attenuates slow excitatory amino acid neurotoxicity. Science. 1990;247: Drachman DB, Kunci RW. Amyotrophic later-

11 63 al sclerosis: an unconventional autoimmune disease Ann Neurol. 1989;26: Kim SH, Jung SJ, Park KS, Kim MH, Kim J, Kim HJ, Lee KW. Effects of the Immunoglobulins of Amyotrophic Lateral Sclerosis on Intracellular Calcium in PC12 Cells. J Korean Neurol Assoc. 2000;18(6): Chio A, Mora G, Leone H, et al. Early symptoms progression rate is related to ALS outcome. A prospective population-based study. Neurology. 2002;59: Turner MR, Bakker M, Sham P, Shaw CE et al. Prognostic modelling of therapeutic interventions in amyotrophic lateral sclerosis. ALS and other motor neuron disorders. 2002;3: Zoccolella S, Beghi E, Palagano G, Fraddosio A, et al. Riluzole and amyotrophic lateral sclerosis survival: a population-based study in southern Italy. European Journal of Neurology. 2007;14(3): Quality Standards Subcommittee of the American Academy of Neurology. Practice advisory on the treatment of amyotrophic lateral sclerosis with riluzole. Neurology. 1997;49: Sung JJ, Park KH, Kim SH. Clinical scales for Amyotrophic Lateral Sclerosis. J Korean Neurol Assoc. 2005;23(2): Kimura F, Fujimura C, Ishida S, Nakajima H, Furutama D, Uehara H, et al. Progression rate of ALSFRS-R at time of diagnosis predicts survival time in ALS. Neurology. 2006;66: Kim HY. Korean version of Amyotrophic Lateral Sclerosis Functional Rating Scale- Revised: A Pilot Study on the Reliability and Validity. J Korean Neurol Assoc. 2007;25(2): Aitkens S, Lord J, Bernauer E, Fowler WM Jr, Lieberman JS, Berck P. Relationship of manual muscle testing to objective strength measurements. Muscle Nerve. 1989;12(3): Medical Research Council. Aids to the Examination of the Peripheral Nervous System. London, England: HMSO. 1976: Kim DH. Illustrations Kyokam Sa-am Do-in Acupucture. Busan: Sogang. 2002: Yun-TaoMa, Mila Ma, Zang Hee Cho. Biomedical Acupuncture for Pain Management, Churchill Livingstone. 2005: Jeremy Ross, Dan Bensky. Acupuncture Point Combinations. Churchill Livingstone. 2004: Table 1. General Characteristics Variable Item N % Mean SD Gender Male Female Age 40~49y 50~59y Comorbid disease (double answer) Hypertension Diabetes Operation None

12 Table 2. Clinical profile and Characteristics Variable Item N % Mean SD 30~39y Age at symptom 40~49y ~59y Upper limb Site of symptom onset Lower limb Bulbar mo Period of disease(months) 24~48mo mo Definite El Escorial criteria Probable Possible Suspected 0 0 Table 3. Comparison of ALSFRS-R score, MRC scale between treatment and after 15,30 days Before teatment After 15days After 30days change W ALSFRS-R score MRC scale W: p value by Wilcoxon signed rank test Table 4. Change of ALSFRS-R score, MRC scale during treatment Before teatment -After 15days W After 15days -After 30days W ALSFRS-R score MRC scale * W: p value by Wilcoxon signed rank test *: p 0.05 by Wilcoxon signed rank test

13 65 Table 5. Change of ALSFRS-R score, MRC scale according to the two onset types Measurement onset type (n=12) Change p-value ALSFRS-R score bulbar-onset(n=3) limb-onset(n=9) MRC scale bulbar-onset(n=3) limb-onset(n=9) P-value was evaluated using one-way Anova test. Table 6. Change of ALSFRS-R score, MRC scale according to the age at onset Measurement onset type (n=12) Change p-value ALSFRS-R score 30~39y(n=2) 40~49y(n=6) ~59y(n=4) ~39y(n=2) MRC scale 40~49y(n=6) * 50~59y(n=4) P-value was evaluated using one-way Anova test. Table 7. Change of ALSFRS-R score, MRC scale according to the disease duration Measurement disease duration (n=12) Change p-value 24mo(n=4) ALSFRS-R score 24~48mo(n=5) mo(n=3) mo(n=4) MRC scale 24~48mo(n=5) mo(n=3) P-value was evaluated using one-way Anova test. *: p 0.05 by Wilcoxon signed rank test

Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical