|Year : 2019 | Volume
| Issue : 2 | Page : 95-98
Treatment Effects of Acupuncture and Calligraphy Training on Cognitive Abilities in Senile Demented Patients
Henry S. R Kao1, Miqu Wang2, Shuguang Yu3, Shihong Yuan4, Miranda M. Y Fung5, Lin Zhu6, Stewart P. W Lam7, Tin Tin Kao8, Xiaoyang Kao9
1 Department of Psychology, University of Hong Kong, HKSAR; Calligraphy Therapy Research Laboratory, Shenzhen Institute of Neuroscience, Shenzhen, China
2 Institute of Psychology and Genetics of Chinese Medicine, Chengdu, China
3 School of Acupuncture and Tuina, Chengdu University of Traditional Chinese Medicine, Chengdu, China
4 Department of Medicine, Shanxi Medical College for Continuing Education; Beijing Tong Ren Tang Chinese Medicine Clinic, Beijing Tong Ren Tang Taiyuan Chinese Medicine Hospital, Beijing, China
5 Department of Chinese Medicine, China Academy of Chinese Medical Sciences, Beijing, China
6 Division of Research Advocacy, 21st Century Education Research Institute, Beijing, China
7 Department of Psychology, University of Hong Kong, HKSAR, China
8 Department of Psychology and Geography, University of Hong Kong, HKSAR, China
9 Department of Electrical Engineering, University of Illinois at Urbana–Champaign, Champaign, Illinois, USA
|Date of Web Publication||19-Jun-2019|
Prof. Henry S. R Kao
University of Hong Kong, Hong Kong
Source of Support: None, Conflict of Interest: None
Purpose: This study compared the relative effectiveness of Chinese calligraphy handwriting (CCH) and acupuncture in the treatment of patients with senile dementia. Materials and Methods: A randomized controlled trial (RCT) with 17 mild-to-moderate dementia patients with an average age of 77.29 years were randomly assigned with 9 to the calligraphy handwriting group and 8 to the acupuncture treatment group for a month of consecutive treatment. The participants' cognitive abilities, as well as symptoms of senile dementia, were measured by the Chinese version of the Mini-mental State Examination (CMMSE) and the Chinese Medicine Quantitative Diagnostic Survey for Senile Dementia Symptoms, respectively, before and after the treatment. Results: The calligraphy group showed a significant increase in calculation and memory as well as a decline in the symptoms of senile dementia. Patients in the acupuncture group experienced a significant growth in total CMMSE scores and the subscales in orientation to time and place, behavioral operations, as well as reduced clinical symptoms. However, no significant changes were found in their memory and calculation abilities. Conclusion: Both CCH and acupuncture treatments were found significantly effective for, respectively, enhancing the patients' cognitive abilities and reducing their clinical symptoms. Further, calligraphy handwriting also improved the level of their attention and concentration, physical relaxation, and emotional stability.
Keywords: Acupuncture, calligraphy handwriting, cognitive abilities, senile dementia
|How to cite this article:|
Kao HS, Wang M, Yu S, Yuan S, Fung MM, Zhu L, Lam SP, Kao TT, Kao X. Treatment Effects of Acupuncture and Calligraphy Training on Cognitive Abilities in Senile Demented Patients. Chin Med Cult 2019;2:95-8
|How to cite this URL:|
Kao HS, Wang M, Yu S, Yuan S, Fung MM, Zhu L, Lam SP, Kao TT, Kao X. Treatment Effects of Acupuncture and Calligraphy Training on Cognitive Abilities in Senile Demented Patients. Chin Med Cult [serial online] 2019 [cited 2019 Aug 24];2:95-8. Available from: http://www.cmaconweb.org/text.asp?2019/2/2/95/260705
| Introduction|| |
Senile dementia is the mental deterioration is associated with old age. Two major types of senile dementia are identified: one is generalized “atrophy,” resulting in long-term decline due to damage or disease (such as, Alzheimer's disease) and others due to vascular problems which are the result of a unique global brain injury (mainly, strokes). Based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition text revision, senile dementia includes a disruption in cognition, attention, memory, and problem-solving. In the later stages, patients might be disoriented in place, time, or even toward their relatives, and, in view of the fact that the effects of pharmacological treatment for dementia are usually short-lived and not guaranteed for all users. It may impose significant, financial burden on patients and their families. Hence, it will be a promising step ahead to use new specifically alternative target approaches for likely prevention or slowing down the decline of cognitive abilities.
Research in recent years has gradually established calligraphy therapy as an indigenous and complementary treatment. Chinese calligraphy has been studied within the principles of psychology, cognitive science, and cognitive neuroscience. It is capable of improving aspects of people's behavioral and psychosomatic conditions of essential hypertension, diabetes, and cancer patients  by enhancing their attention and concentration as well as facilitating their physical relaxation and emotional stabilization. Of particular note is also its effective improvement of the Alzheimer patients' cognitive abilities such as spatial ability, visual attention, calculation, and picture memory.,,,, Furthermore, its effect in postponing the cognitive deterioration of the normal aging has also been reported recently. A latest investigation on cortical excitation associated with the writing of universal character forms has reported an electroencephalography state during this practice. This is a state very close to being asleep, but occurring during a dynamic act of brush handwriting. These findings have advanced the role of this visuomotor task to a cognitive neuroscience level of analysis.
Similar to the Chinese calligraphic handwriting, acupuncture is also a traditional Chinese cultural heritage. Acupuncture as an effective system of nonpharmacological treatment has been studied rigorously in both academic and clinical settings around the world. It is a form of traditional Chinese medicine that essentially corrects healthy problems by the use of sterilized needles inserted into meridian points of the human body. From a physical standpoint, acupuncture has been found to produce treatment effect on migraine prophylaxis headaches being as good as that of preventive medicine. A further success was also noted in acupuncture treatment of insomnia , as well as in reducing heart rate variability. Recent empirical evidence has shown acupuncture produces positive outcomes in cognitive impairment.,,,, Above all, the positive absence of side effects was reported as a common outcome of the clinical application of acupuncture.
Above all, the present study was intended for a randomized controlled trial to compare calligraphy and acupuncture as two independent but effective systems of treatment for patients with senile dementia in similar areas of clinical and cognitive abilities.
| Materials and Methods|| |
Seventeen mild-to-moderate dementia patients from a hospital in Chengdu, the capital of Sichuan Province participated on a voluntary basis. There were 8 males and 9 females with an average age of 77.29 years. Patients were eligible for this study, who ranged in age from 62 to 93, had educational level of primary school or above, and all their Chinese Version of Mini-Mental State Examination (CMMSE) scores were above 20. Presenting with behavioral and/or psychiatric disturbances was psychometrically assessed using CMMSE and Chinese Medicine Quantitative Diagnostic Survey for Senile Dementia Symptoms (self-made) as methods of reference diagnosis and differential diagnosis, before and after the treatment. Recruited patients were divided into two groups randomly: calligraphy group and acupuncture group. The calligraphy group comprised 9 patients (males = 2, females = 7) and acupuncture group included 8 patients (males = 7, females = 1). All the participants were right-handed, nonexperienced in Chinese calligraphy handwriting (CCH) or acupuncture. None of them had serious heart, liver, and kidney dysfunctions, or postdepression or poststroke with behavioral problems. Informed consent was obtained from all the participants.
All participants in the calligraphy group had a calligraphic training together in a quiet, tidy, and bright big room led by a professional calligraphy teacher. They traced firstly and then copied the characters mainly in Yan Zhen-Qing style, the regular script with occasional (Seal script or Cursive script). The frequency of calligraphy writing was 45 min twice daily, one in the morning and the other in the afternoon, for 1 month. Seven days in the course of treatment, and then there were 3 days for the rest in between the courses. Normally, they wrote 100–200 characters each day. The calligraphic brushes were of the same size, a 6 cm × 6 cm pane was printed on the calligraphic rice paper.
three acupoints were selected for acupuncture treatment, namely, Sishencong (Ex-HN01), Shenmen (HT07), and Taixi (KI03). The treatment was carried out by a registered Chinese medicine practitioner with considerable clinical experience in the acupuncture. Based on the National standard of China “Location of Acupoints” (GB12346-90), Sishencong (Ex-HN01) was joined puncture in the direction of Baihui (DU20) with horizontal puncturing for 0.5 inch. Perpendicular needling of Shenmen (HT07) was 0.5 inch. Moreover, Taixi (KI03) was perpendicular needling in 0.8 inch. All the steps were completed with twirling reinforcing method with the low-amplitude vibration. The duration of the treatment was 1 month with acupuncture conducted once each day and 7 days in the course of treatment. Furthermore, there were 3 days for rest in between the courses.
The total scores of CMMSE served as the assessment index of cognitive abilities and the scores of the subscales, which included orientation to time and place (10 marks), calculation (5 marks), and behavioral operations (9 marks, comprising paper folding, problem-solving, language, writing, and picture abilities), were combined with JR Sampson's Picture Free-Recall Test  for measuring memory ability (12 items). The CMMSE was a widely adopted test designed for the evaluation of cognitive deficits in persons with dementia. The test was administered by trained research assistants, measured once before and once after the treatment in both groups. The decreased scores indicated more severe cognitive deficiencies.,
Senile dementia symptoms
In the Chinese Medicine Quantitative Diagnostic Survey for Senile Dementia Symptoms, the common symptoms of senile dementia were classified into 34 types of symptoms such as amnesia and lumbago. Each symptom was scored 0, 2, 4, and 6 for none, light, moderate, and severe states, respectively. Each symptom reported by subjects was initially given a score of 8. The patients apiece were tested in the pretreatment and the posttreatment stages, respectively. The cumulating scores for pretreatment and posttreatment were compared to evaluate the global treatment effects. Higher total scores represented more serious symptoms of senile dementia in the diagnosis.
The data on treatment effectiveness were tested by the Statistical Package for the Social Sciences (SPSS) version 19.0 (IBM Corporation, 1 Orchard Rd, Armonk, NY 10504, USA). Paired samples t- test was used to compare the differences between the pretreatment and posttreatment in calligraphy and acupuncture groups, respectively. P < 0.05 was accepted as the basic statistical level of significance.
| Results|| |
The patients in calligraphy group showed a significant increase in calculation scores (pretreatment = 1.89, posttreatment = 3.00, P < 0.05) and average score of memory (pretreatment = 12.57, posttreatment = 15.84, P < 0.05). Significant changes were also found in the calligraphy group in the Chinese Medicine Quantitative Diagnostic Survey for Senile Dementia Symptoms (pretreatment = 30.253, posttreatment = 12.67, P < 0.05). However, no significant improvement was observed in total CMMSE scores and its two subscales (orientation to time and place and behavioral operations).
Patients in acupuncture group experienced a significant growth in total CMMSE scores (pretreatment = 13.63, posttreatment = 18.13, P < 0.05) and subscales in orientation to time and place (pretreatment = 3.13, posttreatment = 4.05, P < 0.01) as well as the scores of behavioral operations (pretreatment = 5.63, posttreatment = 7.13, P < 0.05). Senile Dementia Symptoms were also significantly decreased after acupuncture treatment (pretreatment = 12.25, posttreatment = 8.25, P < 0.05). However, there were no significant changes in memory and calculation subscales of the CMMSE.
| Discussion|| |
The results of our study show that both calligraphy handwriting and acupuncture treatment have good treatment effects on improving cognitive abilities and lessening the symptoms of senior dementia. As practices of complementary and alternative medicines, each treatment has resulted in some positive effects for persons suffering senior dementia.
The findings of this present study have offered preliminary evidence to the effectiveness of practicing Chinese calligraphic handwriting (CCH) in treating senior dementia patients' cognitive functions, such as calculation. Memory ability in the posttreatment test also enhanced significantly, as well as improvements in clinical symptoms. It is further indicated that the act of calligraphic writing enhanced the patients' attention and concentration, physical relaxation, and emotional stabilization. This effectiveness is in line with our previous studies on normal elderly people or Alzheimer's disease patients.,,,, These results have broadened its effects in treating the cognitive and mental states of senile dementia by moving into a more advanced state of cognitive decline. Theoretical explanation of the effect of calligraphy treatment is largely attributed to a systematic behavioral feedback control mechanism underlying the act and process of handwriting and calligraphy practice. Furthermore, a recent study reported that both the closed Chinese characters and the closed English letters could advance the practitioners' general visual-spatial aptitude in terms of their enhanced cognitive capability to detect two-and three-dimensional cues. Therefore, future research should identify other special Chinese character or English letters forms to benefit and improve different symptoms that are associated with senile dementia. Moreover, then patients in different stages of senile dementia stages will know specific kinds of characters or letters that could benefit them most on top of the general characters used in the present study.
Consistent with recent studies,,,,, we also found the acupuncture treatment had positive effects on several cognitive functions, such as time and spatial orientation and behavioral operation, but resulted in insignificant improvement in memory ability. This is interpreted as showing that the lack of any linguistic content in the treatment process, but physical insertion of the needling act would seem to account for this outcome. This is, on the contrary, true to the act of brush writing of linguistic-based character formation which is filled with semantically enriched perceptual and cognitive contents in the case of calligraphy production. These findings are highly encouraging, with special reference to those of the practice of acupuncture as important branch of traditional Chinese medicine. In the prevalence of psychobehavioral application of acupuncture, significant improvements have been confirmed in such diseases as depression, anxiety disorder,, mental stress, as well as motor and cognitive abilities., These positive findings of acupuncture treatment have added a new chapter of its application.
In general, the overall total CMMSE score did not produce a significant increase in posttreatment measurement in the case of calligraphy writing, which falls short of supporting our previous research on the Alzheimer's Disease patients, where a significant improvement was found in our earlier studies reviewed., Here again, this outcome might also be attributable to calligraphy treatment being involved in a mild level of a minds-pacifying process, and thus its effect may not be as immediately apparent in the case of our very elderly participants. In addition, the small number of the participants might have lessened the likely impact of calligraphy treatment on the patients in the present study.
| Conclusion|| |
Both the CCH and acupuncture treatments were found significantly effective for, respectively, enhancing the patient's cognitive abilities and reducing their clinical symptoms. Further, calligraphy handwriting also improved their attention and concentration, physical relaxation, and emotional stability.
The implications of these positive findings are especially noteworthy in respect to the disappointing news about the lack of effective treatment validity of some of the commonly used Alzheimer's disease drugs. Biogen and Eisai expressed, however, commitment after their discontinuation of the ENGAGE and EMERGE clinical trials programmes.
The Biogen officials reported and confirmed the complexity of treating Alzheimer's disease and the need to further advance knowledge in neuroscience. Alzheimer's disease is the most common form of dementia, the collective term for a range of degenerative neurological conditions that affect memory, thinking, behaviour and emotion. There is no cure for dementia and has been no new treatment for the symptoms of dementia since 2002.
Our comprehensive research on Acupuncture and Calligraphy is the first of such cognitive-neural treatment being applied as an integrated system of treatments that goes beyond the conventional biomedical model of intervention, and contributes to improved neural activation, cognitive facilitation and emotion regulation. We believe this unique system of acupuncture and calligraphy which may open up new areas of behavioral and neuroscience enhancement of the debilitating conditions of the Alzheimer' disease.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Guo NF, Kao HS, Liu X. Calligraphy, hypertension and the type-A personality. Ann Behav Med 2002;23:159.
Kao HS, Ding BK, Cheng SW. Brush handwriting treatment of emotional problems in patients with Type II diabetes. Int J Behav Med 2000;7:50.
Yang XL, Li HH, Hong MH, Kao HS. The effects of Chinese calligraphy handwriting and relaxation training in Chinese nasopharyngeal carcinoma patients: A randomized controlled trial. Int J Nurs Stud 2010;47:550-9.
Kao HS. Chinese calligraphy handwriting for health and rehabilitation of the elderly. In: Second World Congress of the International Society of Physical and Rehabilitation Medicine. Prague, Czech Republic; 2003. p. 63.
Kao HS, Gao D, Wang M. Brush handwriting treatment of cognitive deficiencies in Alzheimer's disease patients. Neurobiol Aging 2000;21:14.
Kao HS, Gao D, Wang M, Cheung HY, Chiu J. Chinese calligraphic handwriting: treatment of cognitive deficiencies of Alzheimer's disease patients. Alzheimers Rep 2000;3:281-7.
Kwok TC, Bai X, Kao HS, Li JC, Ho FK. Cognitive effects of calligraphy therapy for older people: A randomized controlled trial in Hong Kong. Clin Interv Aging 2011;6:269-73.
Kao HS. Calligraphy therapy: A complementary approach to psychotherapy. Asia Pac J Couns Psychother 2010;1:55-66.
Leung GT, Fung AW, Tam CW, Lui VW, Chiu HF, Chan WM, et al.
Examining the association between late-life leisure activity participation and global cognitive decline in community-dwelling elderly Chinese in Hong Kong. Int J Geriatr Psychiatry 2011;26:39-47.
Xu M, Kao HS, Zhang M, Lam SP, Wang W. Cognitive-neural effects of brush writing of Chinese characters: Cortical excitation of theta rhythm. Evid Based Complement Alternat Med 2013;2013:975190.
Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR, et al
. Acupuncture for migraine prophylaxis. Cochrane Database Syst Rev. 2009;(1):CD001218. doi: 10.1002/14651858.CD001218.pub2.
Hughes CM, McCullough CA, Bradbury I, Boyde C, Hume D, Yuan J, et al.
Acupuncture and reflexology for insomnia: A feasibility study. Acupunct Med 2009;27:163-8.
Sun JL, Sung MS, Huang MY, Cheng GC, Lin CC. Effectiveness of acupressure for residents of long-term care facilities with insomnia: A randomized controlled trial. Int J Nurs Stud 2010;47:798-805.
Li Z, Wang C, Mak AF, Chow DH. Effects of acupuncture on heart rate variability in normal subjects under fatigue and non-fatigue state. Eur J Appl Physiol 2005;94:633-40.
Yang MH. The effectiveness of acupuncture/acupressure in treating dementia. Sigma Theta Tau International's 24th
International Nursing Research Congress. Sigma Theta Tau International; 2013.
Lee MS, Shin BC, Ernst E. Acupuncture for Alzheimer's disease: A systematic review. Int J Clin Pract 2009;63:874-9.
Li G, Zhang X, Cheng H, Shang X, Xie H, Zhang X, et al.
Acupuncture improves cognitive deficits and increases neuron density of the hippocampus in middle-aged SAMP8 mice. Acupunct Med 2012;30:339-45.
Liu CZ, Yu JC, Zhang XZ, Fu WW, Wang T, Han JX, et al.
Acupuncture prevents cognitive deficits and oxidative stress in cerebral multi-infarction rats. Neurosci Lett 2006;393:45-50.
Yu J, Liu C, Zhang X, Han J. Acupuncture improved cognitive impairment caused by multi-infarct dementia in rats. Physiol Behav 2005;86:434-41.
Gragnon DL. A review of reality orientation (RO), validation therapy (VT), and reminiscence therapy (RT) with the Alzheimer's client. Phys Occup Ther Geriatr 1996;14:61-77.
Sampson JR. Free recall of verbal and non-verbal stimuli. Q J Exp Psychol 1970;22:215-21.
State Administration (CN). People's Republic of Standard Point Positioning. Beijing: China Standard Press; 1990. p. 8.
Tombaugh TN, McIntyre NJ. The Mini-mental state examination: A comprehensive review. J Am Geriatr Soc 1992;40:922-35.
Kao HS, Gao DG, Wang MQ. Brush Handwriting Treatment of Cognitive Deficiencies in the Alzheimer's Disease Patients. Washington D.C, U.S.A: World Alzheimer's Congress; 2000.
Kao HS. Chinese calligraphic handwriting: A science for health and behavioural therapy. Int J Psychol 2006;41:282-6.
Kao HS, Lui WS, Guan M, Cao, H. Cognitive effects of English brush handwriting: The case of visual – Spatial aptitude. Asia Pac J Couns Psychother 2012;3:190-201.
MacPherson H, Thorpe L, Thomas K, Geddes D. Acupuncture for depression:First steps toward a clinical evaluation. J Altern Complement Med 2004;10:1083-91.
Spence DW, Kayumov L, Chen A, Lowe A, Jain U, Katzman MA, et al.
Acupuncture increases nocturnal melatonin secretion and reduces insomnia and anxiety: A preliminary report. J Neuropsychiatry Clin Neurosci 2004;16:19-28.
Pilkington K, Kirkwood G, Rampes H, Cummings M, Richardson J. Acupuncture for anxiety and anxiety disorders – a systematic literature review. Acupunct Med 2007;25:1-0.
Middlekauff HR, Yu JL, Hui K. Acupuncture effects on reflex responses to mental stress in humans. Am J Physiol Regul Integr Comp Physiol 2001;280:R1462-8.
Kao HS, Wang M, Yu S, Yuan S, Mao W, Zhang W, et al
. Acupuncture enhancement in clinical symptoms and cognitive-motor abilities of the Alzheimer's disease patients. Neurobiol Aging 2000;21:S7.
Kao HS, Wang MQ, Chan SK, Gao DG, Miao W. Acupuncture Enhancement in Clinical Symptoms and Cognitive-Motor Abilities of the Alzheimer's Disease Patients. Washington D.C., U.S.A: World Alzheimer's Congress; 2000.
Alzheimer's Disease International (ADI) News. Biogen and Eisai remain committed after discontinuation of ENGAGE and EMERGE programmes. ADI News. 2019. Available from: https://www.alz.co.uk/news
. [Last accessed on 2019 Mar 31].