European Journal of Neurology 2003, 10: 265–269

Cutaneous stimulation improves function of a chronic patient
with cerebellar damage
A. S. Chana, W-J. Hea, M-C. Cheunga, Z-K. Baia, W-S. Poonb, D. Sunb, X-L. Zhub
and Y-L. Chanc
a

Department of Psychology, The Chinese University of Hong Kong, Hong Kong, China; bDepartment of Surgery, The Chinese University
of Hong Kong, Hong Kong, China and cDepartment of Radiology and Organ Imaging, The Chinese University of Hong Kong, Hong Kong,

China

Keywords:

cerebellar damage, cutaneous stimulation
Received 10 June 2002
Accepted 12 December 2002

The prognosis of cerebellar hemorrhage with brain stem compression is known to be
poor, and patients who can usually survive are severely disabled with limited benefit
from conventional rehabilitation. An innovative cutaneous stimulation was administered to a chronic patient (2 years after the incidence) who has severe ataxia, gait
imbalance and limb spasticity caused by cerebellar hemorrhage. After 8 months of
intervention, patient’s function as evaluated by two functional measures has improved
by 40%. In addition, the patient’s ataxia and hypotonia have improved significantly in
which he has regained the abilities to grasp objects, sit upright, control his equilibrium,
and monitor an electric wheelchair. The present case study demonstrated a significant
improvement of a chronic severely disabled patient who received the intervention
2 years after the accident, suggesting that the cutaneous stimulation may be a possible
effective neurologic intervention.

Introduction
Developing an effective intervention program to
enhance the recovery of neurologic patients has been an
endeavor chosen by many researchers. Although several
studies reported positive results of various rehabilitation programs (Ottenbacher and Jannell, 1993;
Kwakkel et al., 1997; Volpe et al. 2000; Kelly et al.
2001), the treatment effect is usually small or highly
specific to the trained skills (Wagenaar and Meyer,
1991a, b; Langhorne et al., 1996; Kwakkel et al., 1997).
As a result, many researchers agree that there are lack
of convincing evidence on the therapeutic value of
neurological interventions (Gladman et al., 1996).
To help establish effective interventions for neurological patients, we evaluated the effectiveness of a
cutaneous stimulation intervention that was developed
in China since the 18th century through a chronic,
severely disabled patient who had cerebellar hemorrhage and brain stem compression. Whilst the prognosis is poor for these patients (Macdonell et al., 1987;
Kase et al., 1993; Turgut et al., 1996), there is no
known effective rehabilitation program (Ott et al.,
1974; Triarhou, 1997; Bellenir, 1999). In addition, the
intervention was implemented to this patient 32 months
after the onset of the accident. Therefore, any observed
Correspondence: Agnes Chan, PhD, Department of Psychology,
The Chinese University of Hong Kong, Shatin, NT, China
(fax: 852 2603 5019; e-mail: aschan@psy.cuhk.edu.hk).

Ó 2003 EFNS

improvement would unlikely be due to spontaneous
recovery.
Medical history of the patient

Patient CH, a 13-year-old-boy, suffered from sudden
cerebellar hemorrhage that compressed onto the brain
stem on 29 April 1998. On arrival at the hospital, the
patient was in coma with Glasgow Coma Scale (GCS)
of 3. The computed tomography scans taken on
admission showed an extensive cerebellar hematoma
with extension into the ventricles. After an emergency
operation to evacuate a blood clot and excise a cerebellar arterio–venous malformation of 2 cm in diameter, the patient was admitted into the intensive care
unit. When the patient was transferred to a convalescence hospital in June 1998, he was still comatose
(GCS ¼ 6), had spastic tetraplegia with limited voluntary limbs movement, and required tracheotomy.
The magnetic resonance imaging scan performed in
May 2001 showed that the posterior fossa was predominantly occupied by cerebral–spinal fluid as a
result of marked loss of cerebellar tissue. The
remaining cerebellum was represented by the central
cerebellar white matter and the adjacent atrophic
cerebellar hemispheres. Apart from the anterior rim
forming the roof of the fourth ventricle, the cerebellar
vermis was totally lost. Moderate hydrocephalus with
dilatation of the lateral and third ventricles was also
noted (Fig. 1).

265

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A. S. Chan et al.

Figure 1 Magnetic resonance imaging T2-weighted horizontal images of patient CH showed (a) a marked loss of cerebellar tissue, and a
total loss of the right cerebellar vermis; (b) moderate hydrocephalus with dilatation of the lateral and third ventricles.

Intervention method

Cutaneous stimulation is one of the intervention
approaches in traditional Chinese medicine that has a
history of over 1000 years, and the specific method used
in the current study was first described by Dr Sun
Huiquing in 1919. By observing some older methods of
cutaneous stimulation, such as beating epileptic
patients with willow twigs and scraping the skin of
stroke patients, Dr Sun understood that the essence of
the cutaneous stimulation therapies in the Chinese
traditional medicine was to cause temporary cutaneous
pain without damage to the skin or organs. To minimize the impact on the skin and yet provide stimulation, a special tool called the dermatoneural medical
hammer was designed by the first author based upon
the description by Dr Sun. The tool is a 13-inch-long
medical hammer with a fitted head where seven dull
needles (48°, 5 mm long, 1 mm in diameter) are tied
together. Given the specific design of the tool, this stimulation can provide a stinging sensation without
making any damage to the skin.

A session of the intervention is about 15 min, and
was conducted by a trained therapist five times per
week. The manipulation of the tool is called Ôspring
stabÕ in which the wrist moves swiftly up and down
quickly onto the skin. The stimulation was applied
onto the two sides (about half an inch) along the spine
from the lumbar to the thoracic regions, along the
midline on the front of the body, and the dorsal and
posterior parts of the head. Other target areas included
the lateral sides of the neck. Each stimulation site was
tapped three times, with the interval of 2 cm between
each tap. As these stimulation areas were primarily
developed from deduction approach through the clinical observation and experience of Dr Sun, the underlying nature of its therapeutic effect remains unknown.
However, two hypotheses have been put forward to
explain the effect. It has been suggested that the treatment effect is related to the stimulation of sympathetic
nervous system that is distributed along the spines,
abdomen and upper body (Bai, 1989). Tapping the skin
in high frequency is believed to generate some bioelectric signals that can restore the energy of the brain.

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Cutaneous stimulation

Another hypothesis, based upon the meridians (channels) system in traditional Chinese medicine, suggests
that its therapeutic effect is related to restore the energy
of the Ren (along the midline of the front body) and Du
(along the spine) channels.
Baseline measure

CH began the intervention in December 2000. He has
received conventional rehabilitation prior to this intervention, including occupational therapy once per week
and physiotherapy daily.
Overall function
CH was totally dependent on the others for his selfcare, and was bedridden most of the time. His overall
function as measured by the Functional Independence
Measure (FIM, Granger and Hamilton, 1996) was 34/
126, and by the Functional Status Rating System
(FSRS, Forer, 1996) was 60.5/120 (Table 1). This
measure suggested that the conventional rehabilitation
had very limited effect to improve the function of this
patient. Although he was physically disabled, his
cognitive function was relatively intact. He was orientated, able to follow commands, and remember the
past and present events.
Motor ability
Severe ataxia with jerky movement of four limbs was
noticeable. His motor control ability, as measured by
the Finger–Nose Test, was impaired, which he failed
to perform by both hands (Fig. 2). He was also
unable to pick up an object placed in front of him by
either hand. Vestibular ataxia with unsteadiness of
gait was observed that CH was not able to sit up on
a chair without restriction. Hypotonia and spasticity
in the four limbs was also noticed. Specifically, his
Table 1 The functional measures of patient
CH before and after 8 months of the
cutaneous stimulation therapy

Measures

left wrist arched inwardly for approximately 60° and
was unable to lay flat. Both of his ankles bent
inwardly for about 60°. Some muscle contraction of
upper limbs, but not the lower limbs, was possible.
Dysarthria was also observed and his speech was
unintelligible.
Quality of life
CH rarely left the nursing home because of his motor
problem. In addition, CH’s daily activity was very
limited because he was unable to walk or control an
electric wheelchair. Failing to swallow fluid and being
choked during oral feeding, CH was totally dependent
on the feeding tube. He was somewhat low in energy
and not very motivated. He scored 4 of 10 in the
Quality of Life Index (Spitzer, 1996) representing a
relatively low level of living quality.
Treatment effect

CH has received the cutaneous stimulation for
8 months till August, 2001. He was evaluated monthly,
and the summary of the assessment results were as
follows:
Overall function
After 8-month of intervention, his overall function
raised to 60 and 77.5 on the FIM and the FSRS,
respectively (Table 1). The results represented a functional improvement of 20–40% from the baseline. The
areas improved most significantly included mobility,
communication, psychosocial cognition and self-care,
and his cognitive function remained relatively the same.
Motor ability
Improvement on the ataxia was observed with reduced
jerky movement of four limbs. After 3 months of

Baseline

The Functional Independence Measure
(a) Self-care
6/42
(b) Sphincter control
2/14
(c) Mobility
3/21
(d) Locomotion
3/14
(e) Communication
8/14
(f) Social cognition
12/21
Total
34/126
The Functional Status Rating System
(a) Self-care
10.5/36
(b) Mobility
5.5/20
(c) Communication
16/28
(d) Psychosocial adjustment
11/16
(e) Cognitive function
17.5/20
Total
60.5/120

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267

After 8 months
of intervention

Percentage of
improvement

13/42
6/14
8/21
5/14
10/14
18/21
60/126

54
67
63
40
20
33
43

15/36
9.5/20
19.5/28
15.5/16
18/20
77.5/120

30
42
18
29
3
22

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A. S. Chan et al.

Baseline

1

2

3

4

2

3

4

2

3

4

Three months after treatment

1
Eight months after treatment

1

Figure 2 The improvement of patient’s ataxia by cutaneous stimulation. The patient failed to perform the Finger–Nose test at the baseline
level, and regain the ability to perform the test after 3 months of intervention. After 8 months, the involuntary jerky movement has
reduced to the point that the patient was able to control an electric wheelchair.

treatment, CH was able to perform the tests assessing
his motor control ability. Specifically, on the Finger–
Nose Test, CH completed the task within 3 s for the
right hand, and within 7 s for the left hand (Fig. 2). On
the Grip Strength Test, CH yielded on 3.5 kg for the
left hand and 3 kg for the right hand whilst on the
Finger Tapping Test, CH performed three taps in 10 s
for the right hand. His left hand still failed to perform
the task. CH was also able to reach and grasp the object
that was put on his chest within 60 s by his right hand.
His muscle power was increased and contraction of the
lower limbs began to be noticed. Hypotonia and spasticity of the four limbs improved indicated by the ability
of CH was able to lay his left hand flat on the bed.
Bending of his both ankles reduced to about 30°, and a
new pair of shoes with smaller correction angles was
made for fitting his legs. His speech became more

intelligible and the force of his tone became more natural.
CH’s motor strength has continued after 8 months of
intervention. He yielded 7 kg for the left hand and 6 kg
for the right hand on the Grip Strength Test. On the
Finger Tapping Test, he obtained six and four taps for
the left and right hands, respectively. His motor function had improved to the extent that he was able to sit
on a wheelchair without being tied up, and control the
electric wheelchair independently (Fig. 2).
Quality of life
The most significant improvement of CH was his ability
to control the electric wheelchair (with standby supervision) and his equilibrium to the extent that he could
get into and out of a taxi with assistance. He was now
more independent, and more home visits were made.

Ó 2003 EFNS European Journal of Neurology 10, 265–269

Cutaneous stimulation

Although CH was still dependent on the feeding tube,
he was able to swallow about 5–15 ml fluid and solid
food daily. CH appeared more alert, cheerful and
motivated, and became more co-operative during
intervention. The measure on his quality of life yielded
a score of 7 of 10, that is, about 40% improvement
from the baseline.

Discussion
Whilst most studies on the effectiveness of rehabilitation programs are performed on acute neurological
patients who are mildly to moderately impaired
(Kwakkel et al., 1997; Volpe et al., 2000; Kelly et al.,
2001), the present study evaluated an intervention for a
chronic severely disabled patient. To the contrary of a
common belief that chronic patients benefit little from
interventions, the present study demonstrated that the
cutaneous stimulation intervention improved the function of a patient with cerebellar stroke who had been
severely disabled for over 2 years.
Although this case study demonstrated some therapeutic effect of a cutaneous stimulation, this result is
still limited by its single case study approach without
control comparison. Whilst clinically it is unusual to
observe spontaneous recovery of patients after 2 years
of accident and the improvement found in this patient is
conceivable to be related to the cutaneous stimulation,
other possible unexpected effect (e.g. placebo effect)
cannot be ruled out at this point. Therefore, this case
study may not be conclusive enough to imply that the
cutaneous intervention is an effective therapy for
neurologic problems and these encouraging results
warrants further studies.
This result raises an issue of the Ôwindow of recoveryÕ.
It is well understood that functional recovery of neurological patients mostly occurs within the first year
after the accident. However, the present study demonstrated a significant improvement of a patient who
received the intervention 2 years after the accident.
Thus, continuous recovery may be possible in neurologic patients if appropriate interventions are provided.

Acknowledgement
This study is supported by a grant from the Culture
Homes Ltd.

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