Progressive bulbar palsy (PBP) is a motor neuron disorder (MND) characterized by the premature degeneration of neurons [1]. In 2016, MND had a global prevalence of 4.5 and affected 0.78 per 1,000 people [2]. PBP begins insidiously and progresses to involve the cerebral cortex, brain stem, spinal cord, and pyramidal tracts leading to muscular weakness, paralysis and eventually atrophied [1,3]. The etiology is unclear; however, factors such as oxidative stress, glutamatergic toxicity, genetic factors, and damage to target proteins and organelles contribute to neuronal injury [1]. PBP primarily affects glossopharyngeal, vagus, and hypoglossal nerves, causing symptoms such as fasciculations, tongue and facial muscle weakness, dysarthria, dysphagia, dysphonia, and mastication difficulty [4-6]. The life expectancy of the patients is low as they die within 2–4 years because of aspiration pneumonia and malnutrition [5]. Therefore, detailed neuroimaging of the brain, complete blood count, electromyography, and nerve conduction tests are necessary for timely management. Symptoms are managed by conventional medications. Multidisciplinary care, including yoga, exercise, massage, hydrotherapy, diet, and nutritional supplements, aids in improving quality of life [7,8].

Acupuncture is an ancient Chinese medicine, involving needle insertion which activates the afferent peripheral nerves that release several neuropeptides and neurotransmitters such as glutamate, acetylcholine, gamma- aminobutyric acid, and serotonin causing neurological and physiological changes. It also plays a key role in neuromodulation and protection by regulating brain-derived neurotrophic factor, which helps in neuron maintenance and regeneration [9]. This case report emphasizes the use of traditional Chinese medicine (TCM)-based acupuncture in PBP rehabilitation, highlighting its potential in managing neuromuscular degenerative diseases.

A 60-year-old undernourished female, who was weak, emaciated, and desperate came with complaints of difficulty swallowing even liquids, breathlessness even with mild exertion, slurred speech, nasal regurgitation, lower limb weakness, gradual weight loss, disturbed sleep, and generalized fatigue for the past 3 years. She was taking pyridostigmine, Nervtrix, and riluzole initially for the first 2 years, followed by self-withdrawal of all medications due to poor prognosis. She was referred from the Department of Yoga to the Department of Acupuncture and Energy Medicine to address the extensive exhaustiveness during yoga rehabilitation, which decelerated her early prognosis. Thereby, the patient was abruptly restrained from yogic practices and subjected to TCM based acupuncture thereafter. The timeline of the study is provided in Fig. 1. The clinical findings before, after the acupuncture intervention, and on follow-up are provided in Table 1.

Figure 1. Timeline of the study.

Table 1 . Clinical findings before and after the acupuncture intervention and on follow-up of the patient.

Cranial nerve	Test performed	Day 31	Day 59	Day 150
Oculomotor	Ice pack test for left eye ptosis (height of the palpebral fissure)
	Before	6 mm	6 mm	7 mm
	After	7 mm	9 mm	9 mm
	Prognosis	-	+ve	+ve
	Lagopthalmus (incomplete closure of the left eye)	2.0 mm	1.5 mm	1.5 mm
Facial nerve	Nasolabial fold (left)	Obliterated	Obliterated	Obliterated
	Deviation of the mouth	Toward the right side	Mild decrease in the mouth angle	Mild decrease in the mouth angle
	Frontalis muscle assessment (left eye)
	No. of wrinkles in the forehead	1	1	1
Facial and trigeminal nerves	Corneal reflex	Present	Present	Present
Facial, trigeminal, glossopharyngeal, vagus, and hypoglossal nerves	Swallowing reflex (with straight neck)	Difficulty swallowing semisolids Takes 30 s to empty the mouth	Could swallow semisolid foods with minimum difficulty Takes 15 s to empty the mouth	Could swallow semisolid foods Takes 10 s to empty the mouth
Glossopharyngeal and vagus nerves	Gag reflex	1st reflex-after 4 s	1st reflex-after 4 s	1st reflex-immediately
Vagus nerve	Laryngeal crepitus	+ve	+ve	+ve
Muscle tone (Modified Ashworth Scale)	Upper limb (bilateral flexor hypertonia)	2	1+	1+
	Lower limb (bilateral extensor hypertonia)	2	1+	1
Emotional lability		Pensiveness with no expressions	Could relatively express emotions	Emotional instability

-, not available; +ve, positive..

Magnetic resonance imaging of the brain revealed nonspecific white matter hyperintensity in the frontal region. Mild sensorineural hearing loss in bilateral ears and tympanometry showed bilateral A tympanogram. Video laryngoscopy revealed minimal pooling of secretions in the larynx. Muscle-specific kinase antibody and acetylcholine receptor (AChR) were negative. The results of the barium swallow were normal.

According to TCM, irregular dietary habits, protein-deficient diet, and emotional imbalance such as pensiveness affected the spleen, and her grief depleted her lung qi. The right-hand pulse of the patient at the deeper aspect of the proximal and middle positions was empty, denoting reduced qi flow to the spleen and lung. Therefore, she was diagnosed with spleen and lung qi deficiency.

Initially, for a month, the patient was prescribed only yoga as intervention to reduce the symptoms of odynophagia, dyspnea, depression, etc. Yoga protocols were abruptly stopped because of the sudden worsening of symptoms with undue fatigue and low energy levels. The yoga protocol given to the patient before the acupuncture intervention (days 1–30) and in the follow-up (days 60–77) included mild practice of Pawanmuktasana series I; eye exercises; hand stretch, hand in and out, deep breathing; Ujjayi, Brahmari, and Sheetkari pranayamas; Shambhavi Mudra; quick relaxation technique; and AUM chanting. The details of the yoga protocol are provided in Table 2. On day 31, TCM-based acupuncture intervention was started after assessing the patient’s pulse. Needling at SP-3, BL-20, BL-21, GB-20, LI-4 bilaterally and DU-20 in a chair for 20 minutes daily was performed without any electrical or manual stimulation by a registered medical practitioner, pursuing a postgraduate degree in acupuncture and energy medicine with 4 years of clinical experience, using ACS acupressure health care system, 0.25 × 25-mm size sterile copper handle with silicone-coated filiform needles, manufactured in India. The same acupuncture points were used for 28 continuous days. The details of the acupuncture points are provided in Table 3.

Table 2 . Details of the yoga practice before the acupuncture intervention and during follow-up.

Yoga practice	Number of repetitions (round)	Duration of the practice (minute)
Pawanmuktasana series I (loosening exercises–neck, shoulder, elbow, and hand)	5	5
Eye exercise	5	5
Deep breathing (both nostrils)	5	1
Hand stretch breathing	5	1
Hand in and out breathing	5	1
Ujjayi pranayama	5	1
Brahmari pranayama	5	1
Sheetkari pranayama	20	2
Shambhavi Mudra	3	2
Quick relaxation technique	1	3
AUM chanting	10	1
Shavasana (relaxation)	-	2
Total	-	25

-, not available..

Table 3 . Details of the acupuncture points.

Acupuncture point	Location	Depth/direction of needling	Rationale
SP-3 (Taibai)	On the inner aspect of the foot, at the posteroinferior to the head of the first metatarsal bone	0.5 t-sun, straight	Yuan source point of the spleen, strengthens the spleen, improves digestion and assimilation, boosts the production of qi, blood, and vitality, and supports the nervous system
UB-20 (Pishu)	On the back, 1.5 t-sun lateral to the tip of the spinous process of the 11th thoracic vertebra	0.5 t-sun, slanting toward the midline	Back shu point of the spleen, and tonifies the spleen
UB-21(Weishu)	On the back, 1.5 t-sun lateral to the tip of the spinous process of the 12th thoracic vertebra	0.5 t-sun, slanting toward midline	Back shu point for the stomach
GB-20 (Fengchi)	At the apex of the posterior triangle of the neck, in the hollow directly below and between the external occipital protuberance and mastoid process; it lies between the insertion of the trapezius and the sternocleidomastoid muscles	0.5 t-sun, slanting toward the opposite eye	Clears wind Point for the stiff neck Improves cerebral circulation It has a strong influence on the head and neck area
LI-4 (Hegu)	On the dorsum of the hand, the midpoint between the first and second metacarpal bones	0.5 t-sun, straight	Distal point for the face, front of the neck and eyes, nose, ears, and mouth Promotes and regulates the lung qi Calms the mind
DU-20 (Baihui)	On the scalp in the midline 5 t-sun above the midpoint of the anterior hairline	0.5 t-sun, slanting posteriorly	It governs all the channels, calms the mind, and gives mental clarity

From day 7 (day 38) of acupuncture intervention onward, the patient felt invigorated and showed improvement in symptoms. On day 28 (day 59) of acupuncture intervention, the patient was able to swallow semisolid foods with minimum difficulty, and she reported reduction in swallowing difficulty to a greater extent, improvement in quantity of food intake, hunger sensation, articulation, phonation of speech, and overall improved agility. On examination of pulse (day 28 of intervention), the patient expressed restitution in the spleen and lung qi. Following 28 days (day 60 onward) after the active acupuncture intervention, the patient was able to practice the yoga protocol for the next 17 days (days 60–77) without exhaustion and with enthusiasm. Insidious fall in energy levels from day 77 onward led to nil intervention for 3 days, insisting total physical rest at home (days 78–80). Because of null improvement in physical energy reported by the patient, acupuncture to the aforementioned points was continued along with minimal yoga practices (days 81–150). Thereafter, the patient reported sustenance of a uniform pattern of energy levels regardless of regular activities.

Based on TCM pulse diagnosis, the combined pattern of spleen and lung qi deficiency was the main cause of the disease in this case, that clinically manifested into poor appetite, tiredness, limb weakness, breathlessness, cough, weak voice. Qi cannot be transported to the muscles if the spleen is weak, thereby causing fatigue, chewing difficulty, muscle weakness, and even muscle atrophy in severe cases. The spleen transforms the ingested food and drink to extract food qi, and transports to nourish all the tissues. The state of the spleen is one of the most important factors in determining physical energy. Poor diet weakens the spleen, which eventually affects the lungs. Lungs regulate all physiological activities, tone and strength of the voice by regulating qi and respiration. Thus, both the spleen and lungs determine the crucial stages of qi production [10]. The selected acupuncture points such as SP-3, UB-20, and UB-21 effectively improved the motor function by strengthening the spleen qi, promotes lungs qi. UB-21 improves digestion and assimilation, boosts qi production, supports the nervous system along with SP-3. GB-20 improves cerebral circulation, LI-4 promotes the lung qi. DU-20 governs all the channels and calms the mind.

This study result shows, bioelectrical network of acupuncture facilitates neuromuscular functions by replenishing and channelizing the energy through the meridian network. The acupoints are linked in a network of meridians, the Jing Luo system, which correlates tissues and organs, regulates physiological activities through qi and blood circulation. The higher excitability and the functional activities of the meridians are bacause of calcium, sodium, and potassium ion flow [11]. Biochemically, acetylcholinesterase is an integral structural component of the neuromuscular junction (NMJ) and it’s ubiquitous in skeletal muscles, central and peripheral nervous systems, and other tissues containing cholinergic neurons. In addition, NMJ regeneration is expressed through the aggregation of AChR in the motor endplate region. A few studies have revealed that acupuncture increases AChR expression in the NMJ [12].

In 2014, Liu et al. explained that the cytosolic DNA sensor, cyclic guanosine monophosphate-adenosine monophosphate synthase (cGAS), is activated when cellular homeostasis is disrupted, causing the synthesis of cyclic guanosine monophosphate and transmitting a signal to the stimulator of interferon genes (STING) in the endoplasmic reticulum [13]. This cGAS-STING signaling pathway promotes neuronal inflammation, accelerates neurodegeneration, cytotoxicity of Natural Killer cells, resulting in the activation of microglia cells and synthesis proinflammatory cytokines promoting neuronal damage. Electro–acupuncture limits inflammatory responses by downregulating the cGAS-STING signaling pathway, motor neuron death, and NMJ degeneration, attenuating muscle atrophy, and improving motor function in amyotrophic lateral sclerosis mice [13]. Previous studies shown that electro–acupuncture promotes the survival of injured neurons and accelerates NMJ formation even after transection of the neural stem. These findings support the notion that acupuncture can improve the reconstruction of degenerated NMJ [14]. Fragoso and Ferreira [15] showed manual acupuncture provides sufficient neuromuscular stimuli to promote immediate changes in the motor unit without repercussions in the maximal force output.

Acupuncture with or without stimulation activates the peripheral nerves through sensory stimuli, sending signals to the central nervous system. This enhances neuromuscular functions by modulating certain neurotransmitters and immune responses through various cellular mechanisms in the body. The TCM-based acupuncture intervention has proven its authority in the rehabilitative management of PBP by adequately improving neuromuscular function and motor performance in MNDs. Although yoga rehabilitation has initially alleviated the symptoms in the presented case, it failed to maintain the energy levels of the patient. Thus, acupuncture is the standalone measure in replenishing the energy levels and is pivotal in managing neurodegenerative diseases.

Conceptualization: KVV. Methodology: KVV, AJ. Project administration: KVV. Supervision: KVV. Writing – original draft: MMR. Writing – review & editing: KVV, MMR.

The authors have no conflicts of interest to declare.

None.

The patient has given consent to use the data for clinical and research purposes.