Locked-in syndrome (LIS) is a neurological condition characterized by the near-total loss of voluntary muscle movements, in which only the eyelid muscles are spared and cognitive function remains intact. This condition most commonly results from a lesion in the ventral pons [1]. Despite profound physical limitations, patients with LIS are conscious and can communicate by blinking [2]. LIS can be classified into three subtypes based on the degree of the remaining mobility: classic LIS where eye movements are preserved; incomplete LIS where residual voluntary movements are beyond the eyes and eyelids, for example, fingers; and total LIS where all voluntary movements, including eye movements, are absent, though consciousness is maintained [3].

Diagnosing LIS requires clinical assessment, neuroimaging, and use of tools such as electroencephalography [4]. Communication is crucial in the rehabilitation of patients with LIS, and a comprehensive care team is essential. This team typically includes a nurse, nursing assistant, physiotherapist, occupational therapist, speech therapist, and physician working together to enhance the patient’s recovery [3]. Early, multidisciplinary, and comprehensive interventions, including psychological support and coping strategies, are highly recommended [4]. Although the medical literature on acupuncture for LIS is limited, post-stroke acupuncture has become a standard practice in many general hospitals in Taiwan [5].

Herein, we present an LIS case managed through a multidisciplinary rehabilitation program that included traditional acupuncture, repetitive transcranial magnetic stimulations (rTMS), physiotherapy, occupational therapy, speech and swallowing therapy, and social worker consultations. This case highlights the potential contribution of acupuncture within a multidisciplinary treatment framework for severe neurological conditions such as LIS.

1. Case presentation

A 56-year-old male patient, without known medical history, was diagnosed with a pontine infarction and right posterior inferior cerebellar artery (PICA) territory infarct, presenting with a National Institutes of Health Stroke Scale (NIHSS) score of 23. He received tissue plasminogen activator therapy and underwent a tracheostomy in the intensive care unit. By week 3 post-stroke, he survived respiratory failure and was transferred to the general ward. At that time, he exhibited signs of LIS, as he could communicate by blinking to answer yes or no while being quadriplegic. A brain magnetic resonance imaging on day 3 post-stroke revealed a recent infarction involving the pons (with focal hemorrhage) and the right inferior cerebellum (PICA territory; Figs. 1, 2). These brain imaging findings are consistent with those in a similar LIS case reported by Hocker and Wijdicks [6].

Figure 1. Magnetic resonance image on day 3 post-stroke revealed a pontine infarction.

Figure 2. Magnetic resonance image on day 3 post-stroke revealed a pontine infarction.

By week 4, the patient began receiving traditional acupuncture, with one session per day, six sessions per week, for a total of 9 weeks until discharge. Starting on week 5, the patient also underwent 40 sessions of rTMS. From week 8, he engaged in regular physiotherapy, occupational therapy, and speech therapy. Under this comprehensive multidisciplinary treatment, the patient regained voluntary movements in his right fingers and toes, was successfully weaned off the tracheostomy by week 11, and was discharged in week 12. This case represents an incomplete LIS subtype.

2. Treatments

1) Traditional acupuncture

The patient was treated following the revised Standards for Reporting Interventions in Clinical Trials of Acupuncture checklist [7]. Acupuncture was performed by a qualified acupuncture practitioner. Sterile disposable acupuncture needles (0.27 × 40 mm, Wujiang City Cloud & Dragon Medical Device Co., Ltd., China) were inserted at a depth of 15–20 mm into the selected acupoints and retained for 15 minutes before withdrawn. Bilateral LR3, SP3, SP4, K2, SP6, SP8, SP9, LI4, LI11, L10, and unilateral GV20 and EXTRA-1 (Shishencong) acupoints on the scalp were used. Beginning in week 8, EXTRA-8 (Yuyu, Jinjin) points, located on the outer edge of the jaw, were added to the acupoints used. The patient received 22–24 needle insertions per session. Manual stimulation was applied, with the needles rotated horizontally without changing their vertical levels. Because the patient had LIS, each point could not be verified whether it was De-Qi or not. However, at some points such as SP3 and SP4, the patient showed obvious muscle twitching when needles were inserted and rotated. During the acupuncture treatment, no specific adverse effects, such as massive bleeding, blood pressure fluctuation, or seizures, were noted.

2) Repetitive transcranial magnetic stimulations

The rTMS was executed by a neurologist. An air film coil (each coil had an external diameter of 70 mm) connected to a neurotherapeutic variant magnetic stimulator (Magstim Super Rapid2 Plus1, 4100-00; Magstim) was used, which provides intermittent theta burst stimulation (iTBS). The motor threshold was determined by delivering single-pulse TMS to the optimal scalp position, and the motor evoked potentials were recorded by the surface electromyography in the contralateral side. The rTMS was delivered to the scalp over the hotpot of the primary motor cortex corresponding to the hand, foot, and swallowing muscles. iTBS was adopted, with the intensity of 80% active motor threshold as the intervention. The iTBS consisted of 20 trains of 50-Hz three-pulse bursts applied at 200-ms intervals. Each train was 2-seconds long and repeated every 10 seconds for a total of 190 seconds (600 pulses). Two sessions of iTBS were applied on each treatment day. In total, the patient received 40 rTMS sessions. The patient did not report side effects such as headache, dizziness, and seizures after the intervention.

3) Intensity of physiotherapy, occupational therapy, and speech therapy

The patient received physiotherapy and occupational therapy 3–4 hours a day, five days a week. The speech therapist conducted bedside training 5 days a week. The frequency and intensity of the rehabilitation protocol have been proven relative to the motor and cognition function recovery in stroke patients [8].

3. Evaluation

1) Glasgow coma scale

The Glasgow coma scale (GCS) is typically used to examine functional abnormalities of the neurological system and the degree of consciousness of patients who had a stroke. Some studies have found that the GCS cannot accurately identify patients with infratentorial stroke who completely recovered and did not recover, proposing that the stroke location might influence the sensitivity of the scale [9].

2) National Institutes of Health Stroke Scale

The NIHSS has 11 components rated for different abilities on a scale ranging from zero to four. Higher score implies much impairment, whereas lower score implies relative recovery. The NIHSS has become a leading evaluation tool for both ischemic stroke and intracerebral hemorrhage [10].

4. Results

The improvements and the stage involving the treatments employed by a time axis in weeks post-stroke are presented in Fig. 3. At discharge, he could execute voluntary horizontal movements with all four limbs. After discharge, the patient had a follow-up visit 5 months post-stroke. He had continued his rehabilitation at a hospital, and his nasogastric tube had been removed since the third month. During the visit, the patient could respond verbally with short sentences. He could voluntarily raise both legs to bed level from a hanging position, shake hands by grasping with his right hand, perform slow thumb-to-finger touches, and sit upright beside the bed independently for approximately 10 minutes.

Figure 3. Post-stroke weeks of multidisciplinary treatments are shown in gray blocks. GCS, Glasgow coma scale; NIHSS, National Institutes of Health Stroke Scale; rTMS, repetitive transcranial magnetic stimulations; OT, occupational therapy; PT, physiotherapy; ICU, intensive care unit.

1. Acupoint selection

Given the limited literature on traditional acupuncture for LIS, our approach was based on protocols used for traumatic brain injury and diffuse axonal injury using GV20, EXTRA-1, and LR3 acupoints [10]. The patient exhibited fatigue and sweatiness, his pulse was deeper and weaker, and this is called the “weaker yang energy within the spleen and kidney meridian” based on Traditional Chinese Medicine theory. Therefore, SP3, SP4, and K2 were incorporated, as we assumed that stronger stimulations in the plantar region may influence the arousal center of the brain. This hypothesis aligns with the findings of a Japanese study, which proposed a neurological connection between the foot and brain [11]. When the patient entered week 8, EXTRA-8 (Yuyu and Jinjin) points were added. A study on CV23, which is similarly located near the hyoid bone, suggested that when stimulated, it may improve swallowing function and alleviate dysphagia [12].

2. Psychological support for the patient and family

Patients with LIS and their caregivers often experience various negative emotions, including shock, stress, irritability, anger, hopelessness, and caregiver role strain [13]. During the rehabilitation stage, patients frequently reported feelings of isolation [3] because others, may communicate primarily with family members, missing that the patient is conscious and could understand. Effective communication is essential for patients with LIS, as it helps maintain their sense of connection with the world. Tools such as using facial expression cards can be highly beneficial in facilitating communication [13].

In this case, both physical and psychological, are essential in the overall rehabilitation and emotional recovery.

3. Limitations

In patients with LIS, whose consciousness remains intact, improvements in the coma scale do not necessarily reflect functional recovery. Many cognitive assessments require manual responses, which are not feasible for patients with LIS who cannot move their hands. Our team did not utilize an appropriate assessment tool to accurately measure the patient’s progress. Thus, we need to address and improve this area in future cases to ensure a more effective evaluation of patient outcomes.

Conceptualization: THL. Data curation: THL. Formal analysis: THL. Funding acquisition: THL. Investigation: All authors. Methodology: THL. Project administration: THL. Resources: THL. Software: THL. Supervision: THL. Validation: THL. Visualization: THL. Writing – original draft: All authors. Writing – review & editing: All authors.

The authors have no conflicts of interest to declare.

None.

This research has formal approval by the Institutional Review Board of Shin-Kong WHS Memorial Hospital, Taipei, Taiwan (IRB no: 20241004R) and written informed consent was obtained.