A Case Report on the Use of Korean Medicine Treatment for a Patient with Dysarthria Caused by Progressive Bulbar Palsy (PBP)

Article information

Acupunct. 2017;34(1):49-58
Publication date (electronic) : 2017 February 20
doi : https://doi.org/10.13045/acupunct.2017074
Department of Acupuncture & Moxibustion Medicine, College of Korean Medicine, Kyung Hee University
*Corresponding author : Department of Acupuncture & Moxibustion Medicine, Kyung Hee University Korean Medicine Hospital, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Republic of Korea, Tel : +82-2-958-9202 E-mail : ljdacu@khmc.or.kr
Received 2017 January 05; 2017 January 25; Accepted 2017 February 01.

Abstract

Objectives

To introduce a rare case of a patient with Progressive Bulbar Palsy (PBP) and suggest the possibility of treatment using electroacupuncture and Korean Medicine.

Methods

A 61-year-old man with PBP, complaining of dysarthria, was treated with electroacupuncture and Korean Medicine, from June 16 to July 10, 2015. Improvements in symptoms were measured using the speech mechanism screening test (SMST), measurement of tongue and orbicularis oris motility, and speech handicap index (SHI).

Results

The scores of SMST, motility of tongue and orbicularis oris showed a tendency for gradual improvement with 25 days of Korean Medicine Treatment after admission, but conversation was still impossible. In SHI scores, one point increased in the speech domain and one point decreased in the psycho-social domain, and three points increased in the other domain.

Conclusion

Electroacupuncture and Korean Medicine Treatment improved dysarthria caused by PBP, but not completely. Korean Medicine Treatment seems effective in the management of accompanying symptoms such as black hairy tongue, dry mouth, and general condition. The symptoms of PBP are similar to those of amyotrophic lateral sclerosis and there is controversy regarding the classification of PBP. The most important aspect of treating a patient with PBP is an early diagnosis and devising appropriate rehabilitation strategies.

Trans Abstract

목적

진행성 구마비 (Progressive Bulbar Palsy) 환자의 증례를 보고하고 한의치료의 가능성을 제안하는 바이다.

방법

진행성 구마비로 구음장애를 호소하는 61세 남환에게 2015년 6월 6일부터 2015년 7월 10일까지 복합 한의치료를 적용하였다. 증상의 개선은 Speech Mechanism Screening test (SMST), 혀와 구륜근의 움직임 변화, Speech Handicap Index (SHI)로 평가하였다.

결과

26일의 입원치료 후 SMST의 점수와 혀와 구륜근의 움직임은 모두 점진적으로 개선되었지만 여전히 대화는 불가능하였다. 치료과정에서 정서적인 안정이 많이 되었으나 SHI 점수는 개선이 없었다.

결론

한의치료를 통해 진행성 구마비로 인한 구음장애 증상을 개선했으나 완전한 호전을 기대하기는 어려웠다. 한의치료는 진행성 구마비 환자의 주증상 뿐만 아니라 동반증상인 흑태, 입 마름, 전반적 건강 상태의 개선에 도움을 주었다. 진행성 구마비의 증상들은 근위축성 축삭 경화증 (ALS) 의 증상들과 비슷하여 진행성 구마비의 분류에 대한 논란이 많다. 따라서 진행성 구마비 환자를 치료함에 있어서 가장 중요한 것은 조기에 진단을 하여 적절한 재활을 시작할 수 있도록 하는 것이다.

I. Introduction

Progressive Bulbar Palsy (PBP) is a motor neuron disease that attacks the nerves supplying the bulbar muscles. It is characterized by selective degeneration of motor neurons of the lower brainstem1). This specifically involves the glossopharyngeal nerve (IX), vagus nerve (X), and hypoglossal nerve (XII)2). PBP produces symptoms such as dysarthria, dysphagia, atrophy and fasciculations of the musculature of the tongue, and excessive accumulation of secretions3). Effective treatment is not yet known and the prognosis of PBP is poor. Patients commonly die due to aspiration pneumonia and malnutrition 2–4 years from the commencement of symptoms4).

There have been four case reports36) of PBP introducing the disease itself, one case report7) of analgesic treatment applied to a PBP patient complaining of masseter spasticity, and one case report8) of using Korean Medicine to treat PBP. Thus, there have been only a few case reports dealing with PBP, and there have been no reports of treating dysarthria as one of the representative symptoms of PBP. In this paper, we report the results of applying electroacupuncture and Korean Medicine treatment to a patient suffering from dysarthria caused by PBP.

II. Case study

1. Subject of study

1) Patient

  • Hong ○ ○. Man, 61 years old

  • (Height: 170cm, Weight: 55kg)

2) Symptoms

  1. Dysarthria

  2. Dysphagia

3) Onset

2012, July.

4) Past medical history

  1. Left cataract operation (2012, June)

5) Family history

None

6) Present history

  1. 2010: Blurred vision and bleary eyes.

  2. June, 2012: Left eye was operated upon for cataract and the symptoms deteriorated.

  3. July, 2012: Dysarthria, dysphagia and paralysis of tongue suddenly appeared after a nap.

  4. August, 2012: The patient visited a neurosurgery specialist and magnetic resonance imaging (MRI) of the brain was entirely normal.

  5. August, 2013: Over time, the symptoms worsened and he visited a neurology department. Brain MRI and thyroid function tests were normal. After electrodiagnostic examination of his whole body including the tongue, PBP, a motor neuron disease, was diagnosed.

  6. September, 2013: He visited another neurology specialist. After electromyography of the right side, he was diagnosed as not having amyotrophic lateral sclerosis (ALS). He started taking medication to increase peripheral circulation and follow up electromyographic examinations were performed every 12 months until he visited our hospital.

  7. June 15, 2015: The symptoms continued to worsen and he received admission treatment in a hospital of Korean Medicine.

7) Findings at first visit

  1. Dysarthria

    Almost no spontaneous movement of the tongue was observed, and fasciculation of the tongue was accompanied. Conversation was impossible. However, the sensations of tongue and lips were normal. There was difficulty in puckering lips.

  2. Four diagnostic examinations of Korean Medicine

    • ① Physical appearance: Darkish complexion, skinny body type.

    • ② Digestion: Good condition

    • ③ Stool: Once a day, good condition

    • ④ Urination: Good condition

    • ⑤ Sleep: Profuse dreaming

    • ⑥ Emotion: Stress, anxiety

    • ⑦ Cold and heat: Upper body heat

    • ⑧ Sweat: No abnormal findings

    • ⑨ Mouth and tongue: Dry mouth

    • ⑩ Tongue diagnosis: Black hairy tongue, sticky saliva

    • ⑪ Pulse diagnosis: Floating pulse

8) Examination results

  1. Neurological examination

    Mental state: Alert

    Biceps reflex: Normal

    Knee reflex: Normal

    Babinski sign: Normal

    Ankle clonus: Normal

    Cranial nerve examination: The functions of olfactory nerve (I), optic nerve (II), oculomotor nerve (III), trochlear nerve (IV), trigeminal nerve (V), abducens nerve (VI), facial nerve (VII), vestibulocochlear nerve (VIII), and accessory nerve (XI) were intact, and functions of glossopharyngeal nerve (IX), vagus nerve (X), and hypoglossal nerve (XII) were not intact (Table 1).

    Cranial Nerve Examination

  2. Electrodiagnostic examination

    • ① Electromyography (EMG)

      (August 7, 2013)

      Multifocal denervation of the bilateral tongue, masseter, cervical paraspinalis, and the left flexor carpi ulnaris were suggested.

      (May 4, 2015)

      Monopolar needle EMG of right first dorsal interosseus, tongue, masseter, C5, C7, T1, T5, T7 muscles showed mild to moderate degree denervation potentials.

      EMG of right dorsal interosseous, tongue, and masseter muscles showed giant motor unit action potential (MUAPs) with reduced recruitments.

      EMG of right biceps brachii, vastus lateralis, tibialis anterior, L2, L3, L4, L5, and S1 paraspinal muscles were normal.

      There was electrophysiologic evidence of denervation and reinnervation potentials in the right craniobulbar segments and denervation potentials in thoracic paraspinal muscles. There was also electrophysiologic evidence of cervical radiculopathy (C8).

    • ② Repetitive nerve stimulation

      (August 30, 2013)

      Repetitive nerve stimulation (2, 3, 5, 30 hertz) was performed in the ulnar, spinal accessory, and facial nerves. The recordings were performed on the abductor digiti minimi, trapezius, and orbicularis oculi. There was no equivocal electrophysiologic dysfunction.

    • ③ Nerve Conduction Study (NCS)

      (May 4, 2015)

      Right median, ulnar motor, sensory, F responses were normal.

      Right posterior tibial, peroneal motor, F responses were normal.

      Right sural sensory response was normal.

      Bilateral soleus H-reflexes were normal.

  3. Other examinations

    Antinuclear Antibody (ANA) Test: Negative

    Kennedy disease genetic analysis: Negative

Cranial Nerve Examination

2. Treatment method

1) Electroacupuncture treatment

Electroacupuncture treatment was conducted by a resident, training at the Oriental Medicine Hospital of Kyung Hee University. The treatment was performed from June 16 to July 10, 2015 for a total of 25 days, using single-use stainless steel 0.25 × 40 millimeter needles (DongBang acupuncture Inc, Korea). The patient lied down supine and the acupoints Sugu (GV26) and Seungjang (CV24) were used to target orbicularis oris muscle, and two points 5 millimeter beside Yeomcheon (CV23) were used to target genioglossus muscle. The needle was inserted in Sugu (GV26) and Seungjang (CV24) 15 millimeter obliquely, and Yeomcheon (CV23) 20 millimeter perpendicularly. Two-hertz electroacupuncture (STN-111, Stratek, Korea) treatment was performed once a day for 30 minutes.

2) Speech therapy

Speech therapy was performed once a day for 30 minutes from June 17 to July 10 by a speech therapist.

3) Dysphagia treatment

Dysphagia rehabilitation and electrical stimulation were performed once a day from June 25 to July 10.

4) Acupuncture treatment

Ten acupuncture needles using single-use stainless steel 0.25 × 40 millimeter needles (DongBang acupuncture Inc, Korea) were inserted 1 millimeter in posterior cervical muscles and the upper trapezius muscle including Pungji (GB20), Pungbu (GV16), Gyeonjeong (GB21), Daechu (GV14) once a day from June 16 to July 10 for 20 minutes.

5) Pharmacopuncture treatment

After checking for allergic reactions using a skin test, a single dose of 1:30,000, 0.1cc of bee-venom pharmacopuncture was performed using a single-use syringe was administered in the posterior neck and back regions, once a day from June 16 to July 10.

6) Cupping treatment

Cupping treatment was administered on posterior neck and back region once a day for 5 minutes from June 16 to July 10.

7) Herbal medicine treatment

Prescription named‘補心瀉火淸肝湯’ (Bosimsahwacheonggan-tang) was administered 2 hours after breakfast and lunch and‘ 荊防瀉白散’ (Hyeongbangsabaeksan) 2 hours after each dinner (Table 2).

Herbal Medicine Treatment

8) Western Medicine treatment

Western Medicine was prescribed since September, 2013. Buspirone HCl 10 milligram, Ginkgo biloba leaf extract 40 milligram, and nicergoline 30 milligram were administered after breakfast and dinner, ascorbic acid 1000 milligram, and tocopherol 400 international units after every meal.

3. Assessment methods

1) Speech Mechanism Screening test (SMST)

SMST9) consists of three categories. Among them, only the items evaluating the structure and function of the articulators were evaluated because the patient had problems with articulation. In total, 13 items for evaluating structure and 17 items for evaluating function, divided into face, lips, tongue, jaw and tooth, soft and hard palate, pharynx, and respiration area. All items were evaluated using audiovisual observation. Each item was rated on a scale of zero to two, with zero indicating ‘serious abnormality’, one indicating ‘slightly abnormal’, and two indicating ‘normal’. The total score of the structural items wea 26 points and the total score of the functional items was 34 points. The evaluation was performed on June 16, before treatment, and on July 8, after 23 days of treatment.

2) Tongue motility

Tongue motility evaluation was based on Bachher’s seven methods10) for evaluating tongue motility, to see the recovery process after partial glossectomy. Seven movements of the tongue (protrusion, to upper teeth, to palate, curl back, lateralize, elevate, and depress) were evaluated. In Bachher’s research, the evaluator scored three grades of poor, fair, and excellent, but in this study, we described lengths and subjective expressions to see the specific changes in each movement. The method of measuring the protrusion distance of the tongue was based on the method of Lee et al11) which evaluated the tongue mobility in patients with ankyloglossia. In their research, the evaluator measured the distance from the edge of the upper lip to the tip of the tongue after protruding the tongue forward as far as possible. However, the patient was unable to protrude his tongue with the mouth shut, so the distance was measured from the corner of the mouth to the tip of the tongue (Fig. 1). The evaluation was performed every 3–4 days, and the patient was placed in front of a wall in a standing posture.

Fig. 1.

Protrusion distance measured from the corner of the mouth to the tongue tip

3) Orbicularis oris motility

To evaluate the motility of orbicularis oris, the length between the two corners of the lips was measured and the patient was asked to encircle his mouth. The evaluation was performed every 3–4 days, and the patient was placed in front of a wall in a standing posture (Fig. 2).

Fig. 2.

Measurement of the length between two corners of the lip while encircling the lips

4) Speech Handicap Index (SHI) (Appendix 1)

SHI was developed by Rinkel et al12) and this 30-item speech questionnaire was modeled after the Voice Handicap Index (VHI) designed by Jacobson13) It consists of 14 items of speech domain, 14 of psycho-social domain, and two other items. The answer to each question is to choose between zero (no), one (few), two (occasionally), three (often), and four (always). The higher the score, the higher is the discomfort felt by the patient. It is a questionnaire that can help understand the discomfort of and changes in patients with speech disorders.

4. Assessment results

1) Speech Mechanism Screening test (SMST)

In the initial evaluation, pronunciation and accuracy were decreased due to the problems of the articulation. Especially, the range of the movements of the tongue (protrusion, laterality, and elevation) and lip closure were decreased. The structural score improved from 19 to 23, and the functional score improved from six to 14 (Table 3). Lip closure time increased from within 1 minute to more than 6 minutes, and the control ability of the muscle tone of the tongue increased during protrusion.

Structural and functional scores of the articulators

2) Tongue motility

The protrusion distance increased from 1.5cm to 2.2cm, but this improvement was not maintained. The ability to touch the upper teeth and palate, lateralize, and elevate was absent at the initial evaluation but became possible through treatment. Curling back and depressing the tongue was impossible until the end of the treatment (Table 4, Fig. 3).

Measurement of Tongue Motility

Fig. 3.

The site of the tongue tip having the patient perform tongue to palate

3) Orbicularis oris motility

The length between the two corners of the lips decreased from 5.5cm to 4.8cm, which implies improvement of the orbicularis oris (Table 5, Fig. 4).

Length between the two corners of the lips while encircling

Fig. 4.

Increased motility of orbicularis oris muscle

(A) 5.5cm at June 15

(B) 4.8cm at July 8

4) Speech Handicap Index (SHI)

One point increased in the speech domain and one point decreased in the psycho-social domain. The score of the item “My speech problem causes me to lose income”, which is an objective index, increased from one point to four points, and the total score increased from 90 points to 93 points (Table 6).

Score of Speech Handicap Index

5) Changes in other symptoms

Black hairy tongue, dry mouth, and general condition were improved. Breathing while lying supine was a little easier and according to the patient’s subjective expression, swallowing improved by 20% due to the improvement of the tongue motility.

6) Follow up after discharge

Follow up was performed via a phone call five months after discharge. The grasping power of both hands and muscle strength of the limbs weakened and respiration worsened slightly. EMG was performed several times, but the patient was still not diagnosed of ALS.

III. Discussion

1. Diagnosis process

In neurological examination, no upper neuron signs were observed clinically. The functions of the peripheral nerves, glossopharyngeal nerve (IX), vagus nerve (X), and hypoglossal nerve (XII) were decreased. This is consistent with the characteristics of PBP. Electrodiagnostic examination showed normal EMG and NCS of the limbs and denervation potentials in craniobulbar segments, which implies that the patient had pure bulbar symptoms. Myasthenia gravis was ruled out by the results of repetitive nerve stimulation, though the patient had blurred vision and bleary eyes at the first time.

The examination results showed that the symptoms had only lower motor neuron bulbar involvement.

2. Therapeutic significance

This patient had disorders of motility of the tongue and encircling the mouth. Therefore, genioglossus, which is responsible for depressing and protruding the tongue, and orbicularis oris, which is responsible for circling the mouth, were the targets of electroacupuncture treatment. Based on the results of a study by Abdulhakeem14), which indicated that a short-time, low-frequency electrical stimulation positively affected the speed and accuracy of motor axonal regeneration, 2-hertz electroacupuncture treatment was performed for 30 minutes.

Speech therapy is recommended by speech therapists to ameliorate language impairment due to motor neuron disease15). Therefore, speech therapy was performed. In addition, dysphagia treatment was administered because food intake was low and weight loss occurred due to swallowing disorder.

Decreased motility of the tongue and mouth caused excessive use of muscles in the neck and upper shoulder, resulting in increased tension. In order to relieve the muscles and to help the flow of qi and blood, acupuncture, pharmacopuncture, and cupping treatment were performed in the posterior neck and back region.

Herbal medicine bosimsahwacheonggan-tang was prescribed to relieve stress and anxiety, and hyeongbangsabaeksan was prescribed according to the soyangin constitution to cure upper body heat and black hairy tongue.

Western Medicine was administered for increasing peripheral circulation and decreasing anxiety disorders.

The patient showed increase in the structural and functional scores of the articulators in SMST, and the motility of tongue and orbicularis oris muscle after Korean Medicine Treatment. Although the emotional stability was high in the treatment process, only one point decreased in the psycho-social domain. The second evaluation was performed right after the recommendation of a neurologist that there was no possibility of improvement, and this might have had an effect on the score. In addition, black hairy tongue, dry mouth, and general condition improved after 25 days of treatment.

3. Disease Review (Compared to ALS)

The symptoms of PBP are similar to those of ALS, and there is controversy regarding the classification of PBP. To be diagnosed with ALS, patients must have signs and symptoms of both upper and lower motor neuron damage that cannot be attributed to other causes. Unless patients with PBP have evidence of both upper and lower motor neuron signs, they are not considered as probable ALS according to the El Escorial criteria (EEC)16). Patients with only lower motor neuron bulbar involvement are hard to classify.

This patient could not be diagnosed as having ALS because there was no upper motor neuron injury or limb muscle weakness. However, some neurologists consider PBP as a subset of ALS that always evolves into ALS after a few months or more17). In a study by Chafic et al1), they reviewed patients with PBP who had normal limb EMG and only pure bulbar symptoms, and found that almost all patients with PBP developed into ALS.

Due to the potential for PBP to develop into ALS, it is important to make an early diagnosis and appropriate rehabilitation for patients with only bulbar palsy. This is also emphasized in two case reports3,4) of PBP.

References

1. Karam Chafic, Stephen N Scelsa, Macgowan Daniel JL. The clinical course of progressive bulbar palsy. Amyotroph Lateral Scler 2010;11(4):364–8.
2. Hughes TAT, Wiles CM. Neurogenic dysphagia: the role of the neurologist. J Neurol Neurosurg Psychiatry 1998;64(5):569–72.
3. Talacko AA, Reade PC. Progressive bulbar palsy: a case report of a type of motor neuron disease presenting with oral symptoms. Oral Surg Oral Med Oral Pathol 1990;69(2):182–4.
4. Cerero Lapiedra R, Moreno López LA, Esparza Gómez GC. Progressive bulbar palsy: a case report diagnosed by lingual symptoms. J Oral Pathol Med 2002;31(5):277–9.
5. Motoi Y, Satoh K, Matsumine H, et al. A 49-year-old man with progressive bulbar palsy and respiratory failure. No To Shinkei 1998;50(1):93–100.
6. Shin KM, Chee SH. Syndrome of Progressive Bulbar Palsy in Amyotrophic Lateral Sclerosis. A Case Report. Ewha Med J 1980;3(1):33–8.
7. Fujiwara Y, Oguri K, Shimada Y. Masseter spasticity successfully treated with neuroablations of the bilateral mandibular nerves for a patient with progressive bulbar palsy. Anesth Analg 2005;101(3):927.
8. Kim TK, Moon SK. A case report of a progressive bulbar palsy patient. Uirim 2001;275:86–8.
9. Jung SY, Shin MJ. Characteristics of speech mechanism and motor abilities in adults who stutter. Audiology and Speech Research (ASR) 2016;12(3):164–75.
10. Bachher GK, Dholam K, Pai PS. Effective rehabilitation after partial glossectomy. Indian J Otolaryngol Head Neck Surg 2002;54(1):39–43.
11. Lee HJ, Hong SP, Park BS, Choi JW, Koo SK. The Improvement of Tongue Mobility and Articulation after Frenotomy in Patient with Ankyloglossia. Korean J Otorhinolaryngol-Head Neck Surg 2010;53(8):491–6.
12. Rinkel RN, Verdonck-de Leeuw IM, van Reij EJ, Aaronson NK, Leemans CR. Speech handicap index in patients with oral and pharyngeal cancer: better understanding of patients’ complaints. Head Neck 2008;30(7):868–74.
13. Jacobson G, Johnson A, Grywalski C, et al. The Voice Handicap Index (VHI) : development and validation. AmJ Speech Lang Pathol 1997;6:66–70.
14. Al-Majed AA, Neumann CM, Brushart TM, Gordon T. Brief electrical stimulation promotes the speed and accuracy of motor axonal regeneration. J Neurosci 2000;20(7):2602–8.
15. Howard RS, Orrell RW. Management of motor neurone disease. Postgrad Med J 2002;78(926):736–41.
16. Brooks BR, Miller RG, Swash M, Munsat TL. El Escorial revisited: revised criteria for the diagnosis of amyotrophic lateral sclerosis. Amyotroph Lateral Scler Other Motor Neuron Disord 2000;1(5):293–9.
17. Adams RD, Victor M, Ropper AH. Chapter 39 Degenerative diseases of the nervous system. In : Adams RD, Victor M, Ropper AH, eds. Principles of Neurology 6th edth ed. New York: McGraw Hill; 1997. p. 1091.

Appendices

Appendix 1. Speech Handicap Index (SHI)

Article information Continued

Item
  1. My speech makes it difficult for people to understand me

  2. I run out of air when I speak

  3. The intelligibility of my speech varies throughout the day

  4. My speech makes me feel incompetent

  5. People ask me why I’m hard to understand

  6. I feel annoyed when people ask me to repeat

  7. I avoid using the phone

  8. I’m tense when talking to others because of my speech

  9. My articulation is unclear

  10. People have difficulty understanding me in a noisy room

  11. I tend to avoid groups of people because of my speech

  12. People seem irritated with my speech

  13. People ask me to repeat myself when speaking face-to-face

  14. I speak with friends and neighbors or relatives less often because of my speech

  15. I feel as though I have to strain to speak

  16. I find other people don’t understand my speaking problem

  17. My speaking difficulties restrict my personal and social life

  18. The intelligibility is unpredictable

  19. I feel left out of conversations because of my speech

  20. I use a great deal of effort to speak

  21. My speech is worse in the evening

  22. My speech problem causes me to lose income *

  23. I try to change my speech to sound different *

  24. My speech problem upsets me

  25. I am less outgoing because of my speech problem

  26. My family has difficulty understanding me when I call them throughout the house

  27. My speech makes me feel handicapped

  28. I have difficulties to continue a conversation because of my speech

  29. I feel embarrassed when people ask me to repeat

  30. I’m ashamed of my speech problem

How do you rate your own speech at this moment please circle the right answer?
Excellent(0) Good(30) Average(70) Bad(100)
Questions in bold are the one used to calculate scores of speech domain
Questions not in bold (except with*) were used to calculate scores of psycho-social domain

Fig. 1.

Protrusion distance measured from the corner of the mouth to the tongue tip

Fig. 2.

Measurement of the length between two corners of the lip while encircling the lips

Fig. 3.

The site of the tongue tip having the patient perform tongue to palate

Fig. 4.

Increased motility of orbicularis oris muscle

(A) 5.5cm at June 15

(B) 4.8cm at July 8

Table 1.

Cranial Nerve Examination

Cranial nerve Function
Olfactory (I) Intact
Optic (II) Intact
Oculomotor (III) Intact
Trochlear (IV) Intact
Trigeminal (V) Intact
Abducens (VI) Intact
Facial (VII) Only the movement of the mouth was decreased and other parts of the face were intact
Vestibulocochlear (VIII) Intact
Glossopharyngeal (IX) Gag reflex
Vagus (X) Dysphagia, hoarseness
Accessory (XI) Intact
Hypoglossal (XII) Degradation of the tongue and fasciculation were observed

Table 2.

Herbal Medicine Treatment

Herbal medicine Compositions of herbal medicine
補心瀉火淸肝湯 Bosimsahwacheonggan-tang Longanae arillus 12g, Acori graminei rhizoma 8g, Zizyphi spinosae semen 8g, Crataegi fructus 8g, Pinelliae rhizoma 6g, Citri pericarpium 6g, Hoelen 6g, Bambusaecaulis in taeniam 4g, Aurantii immaturus fructus 4g, Gardeniae frutus 3g, Moutan radicis cortex 3g, Fossilia ossis mastodi 3g, Ostreae concha 3g, Glycyrrhizae radix 2g, Zingiberis rhizoma crudus 10g, Jujubae fructus 6g
荊防瀉白散 Hyeongbangsabaeksan Rehmanniae radix 12g, Hoelen 8g, Alismatis rhizoma 8g, Anemarrhenae rhizoma 4g, Gypsum 4g, Ostericiradix 4g, Angelicae pubescentis radix 4g, Schizonepetae spica 4g, Saposhnikoviae radix 4g, Arctii fructus semen 2g

Table 3.

Structural and functional scores of the articulators

Total score June 16 July 8
Structure (26) 19 23
Function (34) 6 14

Table 4.

Measurement of Tongue Motility

Tongue motility June 15 June 19 June 22 June 25 June 29 July 3 July 8
Protrusion 1.5cm 1.7cm 1.8cm 1.9cm 2.2cm 1.7cm 1.8cm
To upper teeth unable Able to touch the inner part of the upper teeth
To palate unable See Fig 2
Curl back unable unable unable unable unable unable unable
Lateralize unable Able to touch the right corner of the mouth, but unable to lateralize to the left Able to touch the right corner of the mouth, and lateralize a little to the left
Elevate unable unable a little a little a little a little a little
Depress unable unable unable unable unable unable unable

Table 5.

Length between the two corners of the lips while encircling

Orbicularis oris motility June 15 June 19 June 22 June 25 June 29 July 3 July 8
5.5cm 5.2cm 5cm 4.8cm 4.5cm 4.9cm 4.8cm

Table 6.

Score of Speech Handicap Index

Domain Jun 15 Jul 9
speech domain 40 41
psycho-social domain 46 45
Etc. 4 7

total score 90 93