The Efficacy of Different Acupuncture Methods in Patients with Disorders of Consciousness Based on Electroencephalography: an autocontrol trial

The Efficacy of Different Acupuncture Methods in Patients with Disorders of Consciousness Based on Electroencephalography: an autocontrol trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Efficacy of Different Acupuncture Methods in Patients with Disorders of Consciousness Based on Electroencephalography: an autocontrol trial Ziyuan Cao, Hao Zhang, Guan Fu, Binbin Huang, Hongwei Li, Wei Li This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5218469/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective This study aimed to investigate the effects of Xingnao Kaiqiao (XNKQ) needling method and the Xingnao Kaiqiao needling method combined with Shixuan and Yongquan points (XNKQSY needling method) on brain function in patients with different levels of consciousness. Methods Thirty-three patients with disorders of consciousness (DOCs) were divided into minimally conscious state (MCS) (n=16) and unresponsive wakefulness syndrome (UWS) (n=17) groups according to their Coma Recovery Scale-Revised (CRS-R) scores. The patients in both groups were treated using XNKQ and XNKQSY needling methods. XNKQ needling method was administered on day 1, whereas the techniques in XNKQSY needling method were administered at the same time on next day. The MMN and CRS-R scores were measured before acupuncture treatment (T0), after single treatment with XNKQ needling method (T1), and after single treatment with XNKQSY needling method (T2). The electroencephalography (EEG) data were acquired using a 64-channel wireless EEG amplifier. Results (1) MCS group: The patients with MCS showed a significant increase in MMN amplitude after the application of XNKQ needling method (T1) compared with pre-treatment (T0) (0.84 [0.67, 1.05)] vs 1.21 [0.96, 1.92], respectively, p=0.001). Although increased MNN amplitude was observed after the application of XNKQSY needling method (T2), the difference was not statistically significant (0.84 [0.67, 1.05] vs 1.05 [0.72, 1.53], respectively, p=0.867). (2) UWS group: Compared with pre-treatment (T0), the patients with UWS showed significant increases in MMN amplitude after the application of both XNKQ needling methods (T1) (0.34 [0.26, 0.59] vs 0.72 [0.55, 1.22], respectively, p=0.049) and XNKQSY needling method (T2) (0.34 [0.26, 0.59] vs 1.15 [0.93, 1.87], respectively, p<0.001), with a more significant increase for XNKQSY needling method (0.72 [0.55, 1.22] vs 1.15 [0.93, 1.87], p=0.049). Conclusion As measured by MMN, Xingnao Kaiqiao needling method appears to be more suitable for patients with MCS, whereas Xingnao Kaiqiao needling method combined with Shixuan and Yongquan points may be more suitable for those with UWS. MMN can be used as an auxiliary evaluation tool during acupuncture treatment. There may be a delay in behavioural changes in patients with DOCs compared to changes in brain function during the assessment of consciousness. acupuncture disorders of consciousness event-related potentials mismatch negativity coma recovery scale-revised Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction With continued advances in medical technology, the survival rates in patients with stroke, traumatic brain injury (TBI), and hypoxic ischaemic encephalopathy (HIE) have seen a significant improvement [ 1 ] . Nevertheless, most survivors have prolonged disorders of consciousness (pDOC), leading to an annual increase in the pDOC patient population. The pathophysiological basis of disorders of consciousness (DOCs), which primarily manifest as changes in arousal and/or state of consciousness [ 2 ] , usually involves impaired neuronal functions in the neocortex, thalamus, and striatum, resulting in reduced excitatory synaptic activity throughout the brain [ 3 , 4 ] . pDOC is classified into three conditions: coma, unresponsive wakefulness syndrome (UWS, previously referred to as vegetative state [VS]), and minimally conscious state (MCS) [ 5 ] . A loss of consciousness that intensifies progressively or persists for several months may lead to more serious consequences such as disability or death [ 6 ] . This condition severely undermines patient quality of life and exerts considerable economic strain on their families and society at large [ 7 ] . Therefore, the development of effective treatment strategies is urgently needed to improve patients’ state of consciousness. In current clinical practice, the diagnosis of pDOC remains imprecise, and no single treatment is effective in all patients [ 2 ] . Therefore, individualised treatment assessments are required to determine the most effective personalised treatment plan in each patient. Numerous clinical methods are used to diagnose pDOC, including the Glasgow Coma Scale (GCS) [ 8 ] , Full Outline of Nonresponsiveness (FOUR), and Coma Recovery Scale-Revised (CRS-R) [ 9 ] . Among these tools, the CRS-R is the most widely recognised and comprehensive behavioural assessment scale for detecting signs of consciousness in patients emerging from a coma [ 10 ] . However, these clinical rating scales are subjective in assessing the level of consciousness and do not fully or accurately reflect a patient's actual state of consciousness [ 11 ] . Consequently, methods for monitoring brain function, such as electroencephalography (EEG), functional magnetic resonance imaging (fMRI), and functional near-infrared spectroscopy (fNIRS), have been tested to provide more objective assessments of patient consciousness, aid in prognosis, and inform treatment decisions [ 12 , 13 ] . In EEG technology, event-related potential (ERP) techniques, which provide high temporal resolution and non-invasiveness, have emerged as valuable tools for clinical research [ 14 ] . Furthermore, mismatch negativity (MMN) has emerged as a crucial indicator of consciousness levels in patients with DOCs. The in-depth study of the pathophysiological mechanisms of pDOC have resulted in the application of a variety of therapies in the clinical setting, including pharmacological (e.g., amantadine, levodopa, etc.) [ 15 ] and non-pharmacological (e.g., transcranial direct current stimulation [tDCS], repetitive transcranial magnetic stimulation [TMS], etc.) treatments [ 16 , 17 ] . However, few therapies have shown efficacy in improving the conscious state and prognosis in comatose patients. In Chinese medicine, acupuncture has been advocated as a long-established clinical treatment to promote recovery of consciousness [ 18 ] . Acupuncture is a safe and well-tolerated therapy that enhances neuronal excitability and decreases cortical inhibition, thereby aiding in the improvement of consciousness and cognitive function in patients with DOCs [ 19 , 20 ] . In particular, the Xingnao Kaiqiao (XNKQ) needling method, one of the most commonly used wakefulness-promoting acupuncture methods in traditional Chinese medicine (TCM), has demonstrated significant wakefulness-promoting efficacy [ 21 , 22 ] . In addition, the Shixuan and Yongquan acupoints are commonly used to promote the awakening of comatose patients, with the effect of opening the orifices to restore the yang, draining heat, and opening and closing [ 23 – 25 ] . However, no study has investigated whether the combination of the Xingnao Kaiqiao needling method with Shixuan and Yongquan acupoints (NXKQSY needling method) can produce a more significant awakening effect. Therefore, the purpose of this study was to use MMN to explore the effects of the XNKQ needling method and NXKQSY needling method on the brain function in patients with different levels of consciousness. Methods 1. Participants Written informed consent was obtained from the legal guardians of each patient. The study was approved by the Ethics Committee of the Affiliated Hospital of Binzhou Medical College under the ethical approval number KYLL-186. The inclusion criteria were age 18–80 years; meeting the definition of pDOC, diagnosed with coma, VS/UWS, and MCS according to the CRS-R Scale; no history of epilepsy or other unrelated central nervous system diseases; no use of central excitatory medications during the treatment period; and signed informed consent provided by the patients' and their families' consent before enrolment. Informed consent for treatment was obtained from patients and their families before enrolment. Exclusion criteria included unstable vital signs (respiratory or haemodynamic instability), severe cardiac, hepatic, renal, or pulmonary damage, or other serious illnesses; history of epileptic seizures; red, swollen, broken, or infected skin at the acupuncture points; cranial defects and intracranial retention of metal objects; and inability to cooperate with the assessments or treatments administered by TCM practitioners. 2. Study Design and Settings This study recruited 34 patients attending the Rehabilitation Department of the Affiliated Hospital of Binzhou Medical College between January 2024 and July 2024, who met the subject selection criteria. First, all patients underwent CRS-R assessment five times within 10 days (one assessment every other day). The highest score was used as the final result, based on which the patients were classified into MCS (n = 17) and UWS (n = 17) groups. The patients in both groups received conventional rehabilitation therapy during the trial period. On the morning of the 11th day of the study, patients in both groups were treated using the XNKQ needling method; on the 12th day, the patients in both groups were treated using the XNKQSY needling method at the same time. The needles were kept in place for 30 min in each acupuncture session. MMN and CRS-R scores were measured at three time points: before acupuncture treatment (T0), after XNKQ needling method (T1), and after XNKQSY needling method (T2) (Fig. 1 ). Professional researchers recorded the CRS-R scores and MMN data before and after the two treatments and analysed the MMN amplitudes for all patients. We processed the data using IBM SPSS Statistics for Windows, version 25.0, and evaluated the effectiveness of the different acupuncture methods in promoting awakening in both groups of patients based on the calculated results. Interventions All participants underwent routine treatment and rehabilitation training. We used Yunlong brand disposable sterile acupuncture needles 0.3 mm in diameter and 40 mm in length. The treatment processes were all aseptic and needles were left inserted for 30 min. XNKQ needling method used the Neiguan(PC6), Renzhong(GV26), Sanyinjiao(SP6), Jiquan(HT1), Chize(LU5), and Weizhong(BL40) acupoints. During treatment, we first stabbed bilateral PC6, 1.25–2.5 cm straight, using twisting, lifting, and inserting methods combined with diarrhoea, applying the technique for 1 min; followed by stabbing GV26 obliquely towards the nasal septum 0.75–1.25 cm in depth, using the sparrow-pecking method such that the eyeballs were wet or watery. SP6 was then stabbed obliquely at a 45° angle along the medial edge of the tibia bone with the skin limb, 2.5–3.75 cm in depth, using a lifting and inserting motion to complement the method. For HT1, the original point along the meridian moved down 2.5 cm, avoiding the axillary hair, stabbing straight to a depth of 2.5–3.75 cm 1, using the lifting and inserting diarrhoea method. For LU5, the elbow was flexed to 120°, stabbing 2.5 cm straight, using the lifting and inserting diarrhoea method. For BL40, with the patient lying on their back, straight leg elevation was performed to access the acupuncture point. The point was stabbed straight to a depth of 1.25–2.5 cm, using the lifting and inserting diarrhoea application method. XNKQSY needling method additionally added Shixuan (EX-UE11) and Yongquan (KL) to XNKQ needling method: straight puncture of EX-UE11 and maintenance of qi in the needle for 30 min. The needle was inserted into KL by approximately 0.75 cm and maintained for 30 min, with some twisting appearing in the dorsiflexion of the ankle of the affected foot. The remaining points were treated according to XNKQ needling method. Details of the Acupuncture are shown in Table 1 . Table 1 Acupoints used in the present study Acupuncture Acupoint combination Location XingnaoKaiqiao acupuncture Neiguan (PC6) *2 On the palmar side of the forearm, 2 inches above the transverse carpal line, situated between the tendons of the palmaris longus and flexor carpi radialis. Renzhong (GV26) On the line on the face where the upper third of the nasolabial fold meets the lower two-thirds. Sanyinjiao (SP6) *2 3 cun (approximately the width of four fingers) directly above the apex of the medial malleolus, positioned on the rear edge of the tibia. Jiquan (HT1) *2 In the centre of the axilla, where the axillary artery pulses. Weizhong (BL40) *2 In the posterior knee region, at the midpoint of the transverse popliteal crease, within the centre of the popliteal fossa. Chize (LU5) *2 On the front side of the elbow, along the transverse elbow crease, in the depression at the radial edge of the biceps tendon. Shixuan (EX-UE11) *2 The tip of the finger, 0.25 cm from the free edge of the nail. Yongquan (KL) *2 In the front depression of the sole, about 1/3 chu of the line connecting the head end of the toe seam of the 2nd and 3rd toes and the heel. Remarks: *2 regards to acupoints on both sides of the body Clinical Assessments Clinical presentation remains the definitive standard for diagnosing Disorders of Consciousness (DOC). The CRS-R with a maximum score of 23 evaluates five key domains: motor, visual, auditory, and oral motor functions, communication, and arousal. In this study, CRS-R assessments were conducted by an independent physician not involved in the acupuncture treatments. Diagnosis was determined based on the highest score from five CRS-R evaluations conducted over a 10-day period, classifying patients as either VS/UWS or MCS. ERP Data Acquisition and Analysis Auditory ERP Recording (MMN Paradigm) In this study, auditory stimuli were presented binaurally through earphones at a sound pressure level of 90 dB HL, utilizing MATLAB software. A double-frequency oddball paradigm was used to elicit the mismatch negativity (MMN). In this paradigm, pure tones of 800 Hz served as the standard stimuli, whereas tones of 1200 Hz were used as the deviant stimuli. In the following, the standard stimulus will be called SS; deviants will be called DS. The experimental protocol consisted of 1000 auditory stimuli, each lasting 200 ms, with an inter-stimulus interval (ISI) of 500 ms. The stimuli were presented in a continuous, randomised sequence, with the SS and DS occurring at probabilities of 0.8 and 0.2, respectively. The entire data acquisition process spanned approximately 13 min (Fig. 2 ). Electrophysiological Data Acquisition and Analysis The ERP experiment was conducted in a shielded, interference-free enclosure. The EEG data were collected with a 64-channel wireless amplifier (NeuSen.W64; Neuracle, Changzhou, China) adhering to the international 10–20 system. The electrodes were sampled at a rate of 1000 Hz, ensuring impedances remained below 5 kΩ. FCz served as the online reference electrode and AFz as the ground. Based on previous studies, the scalp channels included Fp1, Fp2, F3, F4, C3, C4, P3, P4, T7, T8, Fz, Cz, and Pz as the electrodes of interest. MATLAB (Version 2020a) and the EEGLAB toolbox were utilised for EEG signal preprocessing and segmentation. The initial steps involved filtering the EEG data in EEGLAB with a high-pass filter at 0.1 Hz, a low-pass filter at 40 Hz, and a notch filter between 48–52 Hz to reduce electrical line noise interference. Subsequently, the data were downsampled to 500 Hz for further analysis. Segmentation was based on the moment of stimulus presentation to partition the data into single-trial segments of 700 ms, inclusive of 200 ms pre-stimulus data as baseline and 500 ms of post-stimulus data. All single-trial data underwent baseline correction, and trials with corrected amplitudes > 80 µV in absolute value were excluded. To extract the MMN component precisely, each deviant trial was subtracted point-by-point from the preceding standard trial to calculate the difference wave. Independent component analysis (ICA) was utilised to eliminate artefacts caused by eye movements and blinks, with the ICLabel toolbox facilitating the automatic detection and labelling of artefact components. The final step in data processing involved referencing the EEG data to an average reference to ensure that the analysis occurred within a unified reference framework. Safety Monitoring Patients' vital signs were continuously monitored during the experiment. Adverse reactions reported or observed by the patients' families were also recorded. Statistical Analysis Statistical analyses of the ERP data (MMN amplitudes) were conducted with IBM SPSS Statistics for Windows, version 25.0. ERP measures and CRS-R scores normally distributed, as verified by the chi-square test, were represented as (‾x ± s) and analysed using one-way ANOVA. For measures not following a normal distribution, non-parametric tests were employed. The level of statistical significance was set at p < 0.05. Results 1. Clinical Characteristics of the Participants In this study, all patients completed the assessment and treatment processes with good overall compliance, except for one patient in the MCS group who was discharged. Finally, the statistical analysis included 16 patients in the MCS group and 17 in the UWS group. No adverse events were observed during the study. No significant differences were observed between the two groups in all baseline variables (Table 2 ). Table 2 Baseline characteristics Variable All participants (n = 33) MCS (n = 6) UWS (n = 17) p value Age, y 55.48 ± 2.10 54.94 ± 2.77 56.00 ± 3.21 0.805 Sex 1.000 Male 28 (84.8) 14 (87.5) 14 (82.4) Female 5 (15.2) 2 (12.5) 3 (17.6) Notes: MCS, minimally conscious state; UWS, unresponsive wakefulness syndrome. 2. Changes in Assessment before and after Treatment In the MCS group, non-parametric test showed significant differences between the amplitudes of MMN collected at each time point, with MMN amplitudes of 0.84 µV (0.67, 1.05), 1.21 µV (0.96, 1.92), and 1.05 µV (0.72, 1.53) at T0, T1, and T2, respectively (Z = 14.625, p = 0.001) (Table 3 , Fig. 3 ). Further pairwise comparative analyses revealed significant differences in MMN amplitudes between T0 and T1 (0.84 [0.67, 1.05] vs 1.21 [0.96, 1.92], respectively, p < 0.001) and between T1 and T2 (1.21 [0.96, 1.92] vs 1.05 [0.72, 1.53], respectively, p < 0.024) but not between T0 and T2 (0.84 [0.67, 1.05] vs 1.05 [0.72, 1.53], respectively, p = 0.867). In addition, although MMN amplitudes varied across time points, the CRS-R scores did not differ significantly between T1 and T2, T1 and T3, and T2 and T3 (p > 0.05) (Table 5 ). In the UWS group, the median (25th and 75th percentiles) MMN amplitudes at T0, T1, and T2 were 0.34 µV (0.26, 0.59), 0.72 µV (0.55, 1.22), and 1.15 µV (0.93, 1.87), respectively, and differed significantly (non-parametric test, Z = 23.059, p < 0.001) (Table 4 , Fig. 4 ). Further pairwise comparative analyses revealed significant differences in MMN amplitudes between T1 and T0 (0.72 [0.55, 1.22] vs 0.34 [0.26,0.59], respectively, p = 0.049), T2 and T0 (1.15 [0.93, 1.87] vs 0.34 [0.26, 0.59], respectively, p < 0.001), T1 and T2 (0.72 [0.55, 1.22] vs 1.15 (0.93, 1.87], respectively, p 0.05) (Table 5 ). Table 3 MMN amplitudes before and after treatment in the MCS group Time point MMN amplitude Z p value T0 0.84 (0.67, 1.05) 14.625 0.001 T1 1.21 (0.96, 1.92) a T2 1.05 (0.72, 1.53) b Notes: a differences from T0; b differences from T1. MMN, mismatch negativity; MCS, minimally conscious state. Table 4 MMN amplitudes before and after treatment in the UWS group Time point MMN amplitude Z p value T0 0.34(0.26, 0.59) 23.059 < 0.001 T1 0.72 (0.55, 1.22)a T2 1.15(0.93, 1.87)ab Notes: a differences from T0; b differences from T1. MMN, mismatch negativity; UWS, unresponsive wakefulness syndrome. Table 5 CRS-R scores before and after treatment in both groups Group Time point CRS-R score F p value MCS T0 8.81 ± 2.14 0.032 > 0.05 T1 9.00 ± 2.07 T2 8.86 ± 2.22 UWS T0 4.06 ± 1.20 0.035 > 0.05 T1 4.12 ± 1.32 T2 4.18 ± 1.38 Notes: a differences from T0; b differences from T1. CRS-R, the coma recovery scale-revised. Discussion The MMN used in this study is an important component of the ERP and is commonly used as an outcome measure in clinical electrophysiological assessments of patients with DOC [ 26 ] . MMN reflects the brain's ability to compare automatically and can be elicited below the level of attention even during sleep and coma [ 27 ] . MMN amplitudes increase with the recovery of consciousness and a sudden enhancement of MMN amplitudes precedes patient communication with the external environment [ 28 ] . Thus, MMN can be used to objectively assess changes in patient consciousness over a relatively short period. Therefore, this study evaluated the changes of brain function caused by acupuncture treatment by observing the changes of MMN before and after treatment. This study included 33 patients with pDOC, with the MCS and UWS groups comprising 16 and 17 patients respectively. By comparing the changes in MMN amplitude before and after treatment, we found that the two acupuncture methods had different effects on the changes in MMN in patients with different levels of consciousness. The study observed that XNKQ needling method significantly increased MMN amplitude in the MCS group. This may be because XNKQ needling method helps improve the metabolism of brain cells, which play a role in releasing the inhibitory state of the cerebral cortex and activating the brainstem reticular wakefulness system [ 29 ] , thus promoting the recovery of patient consciousness. Ying et al [ 30 ] . demonstrated that acupuncture was more likely to cause an increase in cerebral cortical excitability in patients with MCS, who had milder injuries than those in PVS group. Because patients still retain some degree of consciousness and cognitive function, they may be more sensitive to treatment with this type of needles. Theoretically, augmenting the number of stimulating interventions aimed at achieving arousal should yield better therapeutic outcomes. However, compared with patients with UWS, the application of additional arousal-promoting acupoints failed to induce greater cerebral activation in those with MCS. One explanation for this disparity may lie in the differing extents of preserved neural functionality between patients with UWS and those with MCS. In individuals with UWS, numerous latent pathways within the nervous system may remain to be activated, thereby offering heightened responsiveness to increased stimulus. Conversely, patients with MCS likely regain consciousness and neural function, rendering the additional stimulus insufficient to provoke further brain activity. In contrast, XNKQSY needling method resulted in a more significant increase in MMN amplitude in the UWS group. The projection area of the hand in the cerebral cortex is the largest, and the number of associated neurons in the cortex is inevitably higher. Stimulation of the Ten Xuan points may reflexively increase the activity of the associated neurons, thus demonstrating a wakefulness-promoting effect. Zheng et al. also showed that acupuncture at the Yongquan point activated the brain and promoted wakefulness [ 31 ] . The consciousness of the patients with UWS was extremely reduced, and the treatment added Shixuan and Yongquan points based on the original acupoints to provide stronger stimulation, which was helpful to stimulate the sensory and some nerve functions in the patients, thus causing a significant increase in the amplitude of MMN after treatment. Therefore, it can be inferred that more aggressive treatment is needed for UWS patients with severely impaired consciousness. In both groups, although MMN amplitude showed statistically significant changes after acupuncture treatment, these changes were not correspondingly reflected in the CRS-R scores, suggesting a possible discrepancy between the patients' EEG activity and their behavioural functioning performance. Moreover, alterations in the patients' consciousness may precede the behavioural aspects of their functioning, which requires further exploration to understand the mechanisms behind this phenomenon. In addition, the patient population in this study was controlled before and after the application of different needling techniques, which provided homogeneous baseline conditions and ensured the reliability of the results and comparability before and after treatment. However, after treatment, the two needling methods showed different wakefulness-promoting effects in patients with different levels of consciousness, thus emphasising the potential of personalised medicine in precision diagnosis and treatment. Moreover, MMN can be used as an adjunctive assessment tool during rehabilitation wakefulness-promoting treatments and inform the development of clinical treatment protocols. The present study also has some limitations, including small sample size, insufficient insight into the mechanism of action of different acupuncture techniques, and a lack of long-term efficacy follow-up. Future studies are needed with larger samples to validate the results of the present study, further explore the specific effects of different acupuncture techniques on brain function and structure, and determine the relationship between these changes and improved consciousness. Conclusion The results of this study showed that the brain responses in patients with DOCs at different levels of consciousness were enhanced after the treatment of Xingnao Kaiqiao needling method and Xingnao Kaiqiao needling method combined with Shixuan and Yongquan points. Specifically, the Xingnao Kaiqiao needling method appears to be more suitable for patients with MCS, whereas the Xingnao Kaiqiao needling method combined with Shixuan and Yongquan points is more applicable for those with UWS. MMN can be used as an auxiliary evaluation tool for acupuncture treatment. Changes in MMN and CRS-R scores before and after treatment suggest that the onset of behavioural changes in patients may be delayed compared with changes in brain function. Safety Analysis The safety of acupuncture is well-documented, with no significant adverse reactions reported. In this study, all patients tolerated acupuncture without experiencing any negative effects. However, acupuncture punctures the skin barrier; thus, clinicians must fully sterilise the needled area in patients during acupuncture treatment. Moreover, some patients are more sensitive to pain than others, requiring clinicians to pay close attention to their status during acupuncture treatment. Declarations Ethics approval and consent to participate: This trial was approved by the Ethics Committee of the Affiliated Hospital of Binzhou Medical College on 1 January 2024 and was registered as a clinical trial with the hospital's Ethics Committee under the registration number KYLL-186. Consent for publication: Not applicable Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests Funding: This project was supported by the Shandong Provincial Health Commission. Chinese Medicine Science and Technology Programme (Grant No. Q2022122). The funding agency provided sufficient financial support for the study design, data collection, analysis and interpretation, and manuscript writing. Authors' contributions: All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Wei Li, Hao Zhang, Guan Fu, Binbin Huang, Hongwei Li. The first draft of the manuscript was written by Ziyuan Cao and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Acknowledgements: In the process of writing this paper, he was carefully guided by teachers Li Wei from the beginning to the end. From the topic selection of this paper, to the guidance of the ideas of the paper, the organization of the text, the arrangement of the structure, the collection and collation of the data, and to the revision of the paper, he is rigorous in his academic studies. The teachers have put a lot of effort into it, so that I can successfully complete the writing of this paper. At the same time, the meticulous and touching humanistic care of senior brothers and senior sisters makes people feel like spring breeze, and provides many pertinent and valuable opinions for the writing of this article. 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Front Neurol, 2022, 13: 930546. doi: 10.3389/fneur.2022.930546. Liu Y, Sun N, Xiong J, et al. Modulation of cerebral cortex activity by acupuncture in patients with prolonged disorder of consciousness: An fNIRS study. Front Neurosci, 2022, 16: 1043133. doi: 10.3389/fnins.2022.1043133. Mingjun Y, Qiping X, Zhiliang, et al. Research progress on Xingnaokaiqiao acupuncture in the treatment of craniocerebral injury. Chinese Traditional Chinese Medicine Emergency, 2021, 30(06): 1117-1120. Bao Y C, Zhang F, Li Q, et al. [Xingnao Kaiqiao acupuncture on promoting wake-up of vegetative state after brain injury]. Zhongguo Zhen Jiu, 2021, 41(11): 1225-1228. doi: 10.13703/j.0255-2930.20201101-k0002. Yingcun B, Fang Z, Qun L, et al. Awakening effect of "Xingnaokaiqiao" acupuncture on patients with vegetative state after brain trauma. Chinese Acupuncture, 2021, 41(11): 1225-1228. Chuan Y, Bin S. Effects of bloodletting at Shixuan point on neurological function in patients with acute cerebral infarction. Shanghai Journal of Acupuncture, 2014, 33(02): 111-112. Zheng L. [Acupuncture treatment for persistent vegetative state after operation of acute subdural hematoma]. Zhongguo Zhen Jiu, 2005, 25(2): 82-84. Qiang Z, Xiangyun F. Comparison of the effects of acupuncture at different meridian groups combined with Yinaotongqiao prescription on EEG signals and wake-promoting effects in patients with stroke coma. Chinese Journal of Traditional Chinese Medicine, 2022, 40(03): 224-228 King J R, Faugeras F, Gramfort A, et al. Single-trial decoding of auditory novelty responses facilitates the detection of residual consciousness. Neuroimage, 2013, 83: 726-738. doi: 10.1016/j.neuroimage.2013.07.013. Wang X, Fu R, Xia X, et al. Spatial properties of mismatch negativity in patients with disorders of consciousness. Neurosci Bull, 2018, 34(4): 700-708. doi: 10.1007/s12264-018-0260-4. Wijnen V J, van Boxtel G J, Eilander H J, et al. Mismatch negativity predicts recovery from the vegetative state. Clin Neurophysiol, 2007, 118(3): 597-605. doi: 10.1016/j.clinph.2006.11.020. Qian M, Jianguo Z, Wei Z, et al. The efficacy of Xingnaokaiqiao acupuncture in promoting consciousness disorder in acute stroke. Chinese Clinical Rehabilitation, 2006, (11): 142-143 Y, Ling L, Yaping Q, et al. Application of nonlinear electroencephalogram dynamic analysis method to study the effect of acupuncture on patients with different disorders of consciousness. Chinese Journal of Cerebrovascular Diseases, 2009, 6(09): 461-465. Zheng L. [Acupuncture treatment for persistent vegetative state after operation of acute subdural hematoma]. Zhongguo Zhen Jiu, 2005, 25(2): 82-84. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5218469","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":365906221,"identity":"813e9f60-8d00-4f4f-8124-2f266810e4e1","order_by":0,"name":"Ziyuan Cao","email":"","orcid":"","institution":"Binzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ziyuan","middleName":"","lastName":"Cao","suffix":""},{"id":365906222,"identity":"0bca72f5-c696-4623-8aeb-ef355f77b63c","order_by":1,"name":"Hao Zhang","email":"","orcid":"","institution":"Shandong Provincial Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hao","middleName":"","lastName":"Zhang","suffix":""},{"id":365906223,"identity":"a98723e3-ca7f-4ee1-9997-0402beb80738","order_by":2,"name":"Guan Fu","email":"","orcid":"","institution":"Binzhou Medical University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Guan","middleName":"","lastName":"Fu","suffix":""},{"id":365906224,"identity":"21e06202-aa70-4603-9821-d8edfd37dea3","order_by":3,"name":"Binbin Huang","email":"","orcid":"","institution":"Binzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Binbin","middleName":"","lastName":"Huang","suffix":""},{"id":365906225,"identity":"70f0beb8-d39b-48e4-94d8-01404497cdf3","order_by":4,"name":"Hongwei Li","email":"","orcid":"","institution":"Binzhou Medical University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hongwei","middleName":"","lastName":"Li","suffix":""},{"id":365906226,"identity":"6f8a29fe-94c5-40cb-b580-dc105e19f56f","order_by":5,"name":"Wei Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYDACZgY2ECUDIg98MLCxI1oLD4g8OKMgLZkYeyBawNp5PhxibCCk3uA4+7MHH3fU8vBJJB88bGNwgJmB/fDRDXi1HOYxN5x55jgPm0RawuEcgzt8DDxpaTcIaGGT5m07BiRzDIBanjEzSPCYEdDC/kz6L1hL/ofDFgaHGRsIa2Ewk2ZsqwHZwnCYgRgtkod5zCR72w7wsMk/MzjYY5CWzEbIL3znjz+T+NlWJyffc/jxhx9/bOz42Q8fw6tF4QCYOowQYcOnHATkG8BUHSF1o2AUjIJRMJIBADqwSODORrIlAAAAAElFTkSuQmCC","orcid":"","institution":"Binzhou Medical University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Wei","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2024-10-07 13:23:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5218469/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5218469/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":67281336,"identity":"8088f7b7-0fb4-410a-b2cd-f597cd4f734f","added_by":"auto","created_at":"2024-10-23 09:04:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":144168,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic diagram of the process of this study.\u003c/p\u003e","description":"","filename":"F1.png","url":"https://assets-eu.researchsquare.com/files/rs-5218469/v1/2b84f319cbca8b4bd8b68c63.png"},{"id":67283319,"identity":"fdd37c9f-2f6e-406f-9303-544022d252a1","added_by":"auto","created_at":"2024-10-23 09:12:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":62121,"visible":true,"origin":"","legend":"\u003cp\u003eStimulus sequences. 1000 pure sound stimuli (lasting for 200 ms) with SOA of 1000 ms are presented to a subject to elicit the MMN ERP response. The frequencies of SS and DS are 80 Hz and 1200 Hz, and the numbers of trials are 800 and 200. SS and DS represent the standard and the deviant stimulus respectively. ERP, event-related potential; MMN, mismatch negativity\u003c/p\u003e","description":"","filename":"F2.png","url":"https://assets-eu.researchsquare.com/files/rs-5218469/v1/f916b1b374c5db5b65a5a267.png"},{"id":67281339,"identity":"2fac3961-e18a-4c99-a7fd-7a822722ed9c","added_by":"auto","created_at":"2024-10-23 09:04:04","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":27328,"visible":true,"origin":"","legend":"\u003cp\u003eMMN amplitudes before and after treatment in the MCS group. T0, T1, and T2 refer to the time points for MMN measurement in the study: before treatment, with Xingnao Kaiqiao needling, and Xingnao Kaiqiao needling method combined with Shixuan and Yongquan points, respectively. ns, no statistically significant difference; **p\u0026lt;0.05; ***p\u0026lt;0.001. MCS, minimally conscious state; MMN, mismatch negativity\u003c/p\u003e","description":"","filename":"F3.png","url":"https://assets-eu.researchsquare.com/files/rs-5218469/v1/7e56ce224bde00137505f399.png"},{"id":67281338,"identity":"d7e0d7dc-9c2e-4255-b49a-67445b658b6b","added_by":"auto","created_at":"2024-10-23 09:04:04","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":28840,"visible":true,"origin":"","legend":"\u003cp\u003eMMN amplitudesbefore and after treatment in the UWS group. T0, T1, and T2 refer to the time points for MMN measurement in the study: before treatment, with Xingnao Kaiqiao needling, and Xingnao Kaiqiao needling method combined with Shixuan and Yongquan points, respectively. ns, no statistically significant difference; **p\u0026lt;0.05; ***p\u0026lt;0.001. MMN, mismatch negativity; UWS, unresponsive wakefulness syndrome.\u003c/p\u003e","description":"","filename":"F4.png","url":"https://assets-eu.researchsquare.com/files/rs-5218469/v1/ff9d419e4fc92dc14aef6065.png"},{"id":67283926,"identity":"57a57212-d7ec-42d1-b20f-d843c2e2fb97","added_by":"auto","created_at":"2024-10-23 09:20:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":773790,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5218469/v1/a6a93b17-9298-4cb6-81ea-091e86e86647.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eThe Efficacy of Different Acupuncture Methods in Patients with Disorders of Consciousness Based on Electroencephalography: an autocontrol trial\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWith continued advances in medical technology, the survival rates in patients with stroke, traumatic brain injury (TBI), and hypoxic ischaemic encephalopathy (HIE) have seen a significant improvement\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Nevertheless, most survivors have prolonged disorders of consciousness (pDOC), leading to an annual increase in the pDOC patient population. The pathophysiological basis of disorders of consciousness (DOCs), which primarily manifest as changes in arousal and/or state of consciousness\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e, usually involves impaired neuronal functions in the neocortex, thalamus, and striatum, resulting in reduced excitatory synaptic activity throughout the brain\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. pDOC is classified into three conditions: coma, unresponsive wakefulness syndrome (UWS, previously referred to as vegetative state [VS]), and minimally conscious state (MCS) \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. A loss of consciousness that intensifies progressively or persists for several months may lead to more serious consequences such as disability or death\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. This condition severely undermines patient quality of life and exerts considerable economic strain on their families and society at large\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Therefore, the development of effective treatment strategies is urgently needed to improve patients\u0026rsquo; state of consciousness.\u003c/p\u003e \u003cp\u003eIn current clinical practice, the diagnosis of pDOC remains imprecise, and no single treatment is effective in all patients\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Therefore, individualised treatment assessments are required to determine the most effective personalised treatment plan in each patient. Numerous clinical methods are used to diagnose pDOC, including the Glasgow Coma Scale (GCS)\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e, Full Outline of Nonresponsiveness (FOUR), and Coma Recovery Scale-Revised (CRS-R)\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Among these tools, the CRS-R is the most widely recognised and comprehensive behavioural assessment scale for detecting signs of consciousness in patients emerging from a coma\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. However, these clinical rating scales are subjective in assessing the level of consciousness and do not fully or accurately reflect a patient's actual state of consciousness\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. Consequently, methods for monitoring brain function, such as electroencephalography (EEG), functional magnetic resonance imaging (fMRI), and functional near-infrared spectroscopy (fNIRS), have been tested to provide more objective assessments of patient consciousness, aid in prognosis, and inform treatment decisions\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. In EEG technology, event-related potential (ERP) techniques, which provide high temporal resolution and non-invasiveness, have emerged as valuable tools for clinical research\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. Furthermore, mismatch negativity (MMN) has emerged as a crucial indicator of consciousness levels in patients with DOCs. The in-depth study of the pathophysiological mechanisms of pDOC have resulted in the application of a variety of therapies in the clinical setting, including pharmacological (e.g., amantadine, levodopa, etc.)\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e and non-pharmacological (e.g., transcranial direct current stimulation [tDCS], repetitive transcranial magnetic stimulation [TMS], etc.) treatments\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. However, few therapies have shown efficacy in improving the conscious state and prognosis in comatose patients.\u003c/p\u003e \u003cp\u003eIn Chinese medicine, acupuncture has been advocated as a long-established clinical treatment to promote recovery of consciousness\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. Acupuncture is a safe and well-tolerated therapy that enhances neuronal excitability and decreases cortical inhibition, thereby aiding in the improvement of consciousness and cognitive function in patients with DOCs\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. In particular, the \u003cem\u003eXingnao Kaiqiao\u003c/em\u003e (XNKQ) needling method, one of the most commonly used wakefulness-promoting acupuncture methods in traditional Chinese medicine (TCM), has demonstrated significant wakefulness-promoting efficacy\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. In addition, the \u003cem\u003eShixuan\u003c/em\u003e and \u003cem\u003eYongquan\u003c/em\u003e acupoints are commonly used to promote the awakening of comatose patients, with the effect of opening the orifices to restore the yang, draining heat, and opening and closing\u003csup\u003e[\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. However, no study has investigated whether the combination of the \u003cem\u003eXingnao Kaiqiao\u003c/em\u003e needling method with \u003cem\u003eShixuan\u003c/em\u003e and \u003cem\u003eYongquan\u003c/em\u003e acupoints (NXKQSY needling method) can produce a more significant awakening effect. Therefore, the purpose of this study was to use MMN to explore the effects of the \u003cem\u003eXNKQ\u003c/em\u003e needling method and NXKQSY needling method on the brain function in patients with different levels of consciousness.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch3\u003e1. Participants\u003c/h3\u003e\n\u003cp\u003e Written informed consent was obtained from the legal guardians of each patient. The study was approved by the Ethics Committee of the Affiliated Hospital of Binzhou Medical College under the ethical approval number KYLL-186.\u003c/p\u003e \u003cp\u003eThe inclusion criteria were age 18\u0026ndash;80 years; meeting the definition of pDOC, diagnosed with coma, VS/UWS, and MCS according to the CRS-R Scale; no history of epilepsy or other unrelated central nervous system diseases; no use of central excitatory medications during the treatment period; and signed informed consent provided by the patients' and their families' consent before enrolment. Informed consent for treatment was obtained from patients and their families before enrolment. Exclusion criteria included unstable vital signs (respiratory or haemodynamic instability), severe cardiac, hepatic, renal, or pulmonary damage, or other serious illnesses; history of epileptic seizures; red, swollen, broken, or infected skin at the acupuncture points; cranial defects and intracranial retention of metal objects; and inability to cooperate with the assessments or treatments administered by TCM practitioners.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2. Study Design and Settings\u003c/h2\u003e \u003cp\u003eThis study recruited 34 patients attending the Rehabilitation Department of the Affiliated Hospital of Binzhou Medical College between January 2024 and July 2024, who met the subject selection criteria. First, all patients underwent CRS-R assessment five times within 10 days (one assessment every other day). The highest score was used as the final result, based on which the patients were classified into MCS (n\u0026thinsp;=\u0026thinsp;17) and UWS (n\u0026thinsp;=\u0026thinsp;17) groups. The patients in both groups received conventional rehabilitation therapy during the trial period. On the morning of the 11th day of the study, patients in both groups were treated using the XNKQ needling method; on the 12th day, the patients in both groups were treated using the XNKQSY needling method at the same time. The needles were kept in place for 30 min in each acupuncture session. MMN and CRS-R scores were measured at three time points: before acupuncture treatment (T0), after XNKQ needling method (T1), and after XNKQSY needling method (T2) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Professional researchers recorded the CRS-R scores and MMN data before and after the two treatments and analysed the MMN amplitudes for all patients. We processed the data using IBM SPSS Statistics for Windows, version 25.0, and evaluated the effectiveness of the different acupuncture methods in promoting awakening in both groups of patients based on the calculated results.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInterventions\u003c/h3\u003e\u003cp\u003eAll participants underwent routine treatment and rehabilitation training. We used Yunlong brand disposable sterile acupuncture needles 0.3 mm in diameter and 40 mm in length. The treatment processes were all aseptic and needles were left inserted for 30 min. XNKQ needling method used the Neiguan(PC6), Renzhong(GV26), Sanyinjiao(SP6), Jiquan(HT1), Chize(LU5), and Weizhong(BL40) acupoints. During treatment, we first stabbed bilateral PC6, 1.25\u0026ndash;2.5 cm straight, using twisting, lifting, and inserting methods combined with diarrhoea, applying the technique for 1 min; followed by stabbing GV26 obliquely towards the nasal septum 0.75\u0026ndash;1.25 cm in depth, using the sparrow-pecking method such that the eyeballs were wet or watery. SP6 was then stabbed obliquely at a 45\u0026deg; angle along the medial edge of the tibia bone with the skin limb, 2.5\u0026ndash;3.75 cm in depth, using a lifting and inserting motion to complement the method. For HT1, the original point along the meridian moved down 2.5 cm, avoiding the axillary hair, stabbing straight to a depth of 2.5\u0026ndash;3.75 cm 1, using the lifting and inserting diarrhoea method. For LU5, the elbow was flexed to 120\u0026deg;, stabbing 2.5 cm straight, using the lifting and inserting diarrhoea method. For BL40, with the patient lying on their back, straight leg elevation was performed to access the acupuncture point. The point was stabbed straight to a depth of 1.25\u0026ndash;2.5 cm, using the lifting and inserting diarrhoea application method.\u003c/p\u003e \u003cp\u003eXNKQSY needling method additionally added \u003cem\u003eShixuan\u003c/em\u003e (EX-UE11) and \u003cem\u003eYongquan\u003c/em\u003e (KL) to XNKQ needling method: straight puncture of EX-UE11 and maintenance of qi in the needle for 30 min. The needle was inserted into KL by approximately 0.75 cm and maintained for 30 min, with some twisting appearing in the dorsiflexion of the ankle of the affected foot. The remaining points were treated according to XNKQ needling method. Details of the Acupuncture are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAcupoints used in the present study\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcupuncture\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAcupoint combination\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLocation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eXingnaoKaiqiao acupuncture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeiguan (PC6) *2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOn the palmar side of the forearm, 2 inches above the transverse carpal line, situated between the tendons of the palmaris longus and flexor carpi radialis.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRenzhong (GV26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOn the line on the face where the upper third of the nasolabial fold meets the lower two-thirds.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSanyinjiao (SP6) *2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 cun (approximately the width of four fingers) directly above the apex of the medial malleolus, positioned on the rear edge of the tibia.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJiquan (HT1) *2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIn the centre of the axilla, where the axillary artery pulses.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWeizhong (BL40) *2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIn the posterior knee region, at the midpoint of the transverse popliteal crease, within the centre of the popliteal fossa.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChize (LU5) *2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOn the front side of the elbow, along the transverse elbow crease, in the depression at the radial edge of the biceps tendon.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShixuan (EX-UE11) *2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe tip of the finger, 0.25 cm from the free edge of the nail.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYongquan (KL) *2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIn the front depression of the sole, about 1/3 chu of the line connecting the head end of the toe seam of the 2nd and 3rd toes and the heel.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRemarks: *2 regards to acupoints on both sides of the body\u003c/p\u003e\n\u003ch3\u003eClinical Assessments\u003c/h3\u003e\n\u003cp\u003eClinical presentation remains the definitive standard for diagnosing Disorders of Consciousness (DOC). The CRS-R with a maximum score of 23 evaluates five key domains: motor, visual, auditory, and oral motor functions, communication, and arousal. In this study, CRS-R assessments were conducted by an independent physician not involved in the acupuncture treatments. Diagnosis was determined based on the highest score from five CRS-R evaluations conducted over a 10-day period, classifying patients as either VS/UWS or MCS.\u003c/p\u003e\n\u003ch3\u003eERP Data Acquisition and Analysis\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eAuditory ERP Recording (MMN Paradigm)\u003c/h2\u003e \u003cp\u003eIn this study, auditory stimuli were presented binaurally through earphones at a sound pressure level of 90 dB HL, utilizing MATLAB software. A double-frequency oddball paradigm was used to elicit the mismatch negativity (MMN). In this paradigm, pure tones of 800 Hz served as the standard stimuli, whereas tones of 1200 Hz were used as the deviant stimuli. In the following, the standard stimulus will be called SS; deviants will be called DS. The experimental protocol consisted of 1000 auditory stimuli, each lasting 200 ms, with an inter-stimulus interval (ISI) of 500 ms. The stimuli were presented in a continuous, randomised sequence, with the SS and DS occurring at probabilities of 0.8 and 0.2, respectively. The entire data acquisition process spanned approximately 13 min (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eElectrophysiological Data Acquisition and Analysis\u003c/h3\u003e\n\u003cp\u003eThe ERP experiment was conducted in a shielded, interference-free enclosure. The EEG data were collected with a 64-channel wireless amplifier (NeuSen.W64; Neuracle, Changzhou, China) adhering to the international 10\u0026ndash;20 system. The electrodes were sampled at a rate of 1000 Hz, ensuring impedances remained below 5 kΩ. FCz served as the online reference electrode and AFz as the ground. Based on previous studies, the scalp channels included Fp1, Fp2, F3, F4, C3, C4, P3, P4, T7, T8, Fz, Cz, and Pz as the electrodes of interest. MATLAB (Version 2020a) and the EEGLAB toolbox were utilised for EEG signal preprocessing and segmentation. The initial steps involved filtering the EEG data in EEGLAB with a high-pass filter at 0.1 Hz, a low-pass filter at 40 Hz, and a notch filter between 48\u0026ndash;52 Hz to reduce electrical line noise interference. Subsequently, the data were downsampled to 500 Hz for further analysis. Segmentation was based on the moment of stimulus presentation to partition the data into single-trial segments of 700 ms, inclusive of 200 ms pre-stimulus data as baseline and 500 ms of post-stimulus data. All single-trial data underwent baseline correction, and trials with corrected amplitudes\u0026thinsp;\u0026gt;\u0026thinsp;80 \u0026micro;V in absolute value were excluded. To extract the MMN component precisely, each deviant trial was subtracted point-by-point from the preceding standard trial to calculate the difference wave. Independent component analysis (ICA) was utilised to eliminate artefacts caused by eye movements and blinks, with the ICLabel toolbox facilitating the automatic detection and labelling of artefact components. The final step in data processing involved referencing the EEG data to an average reference to ensure that the analysis occurred within a unified reference framework.\u003c/p\u003e\n\u003ch3\u003eSafety Monitoring\u003c/h3\u003e\n\u003cp\u003ePatients' vital signs were continuously monitored during the experiment. Adverse reactions reported or observed by the patients' families were also recorded.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses of the ERP data (MMN amplitudes) were conducted with IBM SPSS Statistics for Windows, version 25.0. ERP measures and CRS-R scores normally distributed, as verified by the chi-square test, were represented as (\u0026oline;x\u0026thinsp;\u0026plusmn;\u0026thinsp;s) and analysed using one-way ANOVA. For measures not following a normal distribution, non-parametric tests were employed. The level of statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e1. Clinical Characteristics of the Participants\u003c/h2\u003e \u003cp\u003eIn this study, all patients completed the assessment and treatment processes with good overall compliance, except for one patient in the MCS group who was discharged. Finally, the statistical analysis included 16 patients in the MCS group and 17 in the UWS group. No adverse events were observed during the study. No significant differences were observed between the two groups in all baseline variables (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll participants (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMCS (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUWS (n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, y\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.48\u0026thinsp;\u0026plusmn;\u0026thinsp;2.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.94\u0026thinsp;\u0026plusmn;\u0026thinsp;2.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56.00\u0026thinsp;\u0026plusmn;\u0026thinsp;3.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.805\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (84.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (87.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (82.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (15.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (17.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNotes: MCS, minimally conscious state; UWS, unresponsive wakefulness syndrome.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e2. Changes in Assessment before and after Treatment\u003c/h2\u003e \u003cp\u003eIn the MCS group, non-parametric test showed significant differences between the amplitudes of MMN collected at each time point, with MMN amplitudes of 0.84 \u0026micro;V (0.67, 1.05), 1.21 \u0026micro;V (0.96, 1.92), and 1.05 \u0026micro;V (0.72, 1.53) at T0, T1, and T2, respectively (Z\u0026thinsp;=\u0026thinsp;14.625, p\u0026thinsp;=\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Further pairwise comparative analyses revealed significant differences in MMN amplitudes between T0 and T1 (0.84 [0.67, 1.05] vs 1.21 [0.96, 1.92], respectively, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and between T1 and T2 (1.21 [0.96, 1.92] vs 1.05 [0.72, 1.53], respectively, p\u0026thinsp;\u0026lt;\u0026thinsp;0.024) but not between T0 and T2 (0.84 [0.67, 1.05] vs 1.05 [0.72, 1.53], respectively, p\u0026thinsp;=\u0026thinsp;0.867). In addition, although MMN amplitudes varied across time points, the CRS-R scores did not differ significantly between T1 and T2, T1 and T3, and T2 and T3 (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the UWS group, the median (25th and 75th percentiles) MMN amplitudes at T0, T1, and T2 were 0.34 \u0026micro;V (0.26, 0.59), 0.72 \u0026micro;V (0.55, 1.22), and 1.15 \u0026micro;V (0.93, 1.87), respectively, and differed significantly (non-parametric test, Z\u0026thinsp;=\u0026thinsp;23.059, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Further pairwise comparative analyses revealed significant differences in MMN amplitudes between T1 and T0 (0.72 [0.55, 1.22] vs 0.34 [0.26,0.59], respectively, p\u0026thinsp;=\u0026thinsp;0.049), T2 and T0 (1.15 [0.93, 1.87] vs 0.34 [0.26, 0.59], respectively, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), T1 and T2 (0.72 [0.55, 1.22] vs 1.15 (0.93, 1.87], respectively, p\u0026thinsp;\u0026lt;\u0026thinsp;0.049). However, the CRS-R scores at the same time points did not differ significantly for T1 vs. T2, T1 vs. T3, and T2 vs. T3 (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMMN amplitudes before and after treatment in the MCS group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMMN amplitude\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eZ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.84 (0.67, 1.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.625\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.21 (0.96, 1.92)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.05 (0.72, 1.53)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNotes: \u003csup\u003ea\u003c/sup\u003edifferences from T0; \u003csup\u003eb\u003c/sup\u003edifferences from T1.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMMN, mismatch negativity; MCS, minimally conscious state.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMMN amplitudes before and after treatment in the UWS group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMMN amplitude\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eZ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.34(0.26, 0.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.059\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.72 (0.55, 1.22)a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.15(0.93, 1.87)ab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNotes: \u003csup\u003ea\u003c/sup\u003edifferences from T0; \u003csup\u003eb\u003c/sup\u003edifferences from T1.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMMN, mismatch negativity; UWS, unresponsive wakefulness syndrome.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCRS-R scores before and after treatment in both groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCRS-R score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e8.81\u0026thinsp;\u0026plusmn;\u0026thinsp;2.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e9.00\u0026thinsp;\u0026plusmn;\u0026thinsp;2.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e8.86\u0026thinsp;\u0026plusmn;\u0026thinsp;2.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUWS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.06\u0026thinsp;\u0026plusmn;\u0026thinsp;1.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.035\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.18\u0026thinsp;\u0026plusmn;\u0026thinsp;1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNotes: \u003csup\u003ea\u003c/sup\u003edifferences from T0; \u003csup\u003eb\u003c/sup\u003edifferences from T1.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCRS-R, the coma recovery scale-revised.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe MMN used in this study is an important component of the ERP and is commonly used as an outcome measure in clinical electrophysiological assessments of patients with DOC\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. MMN reflects the brain's ability to compare automatically and can be elicited below the level of attention even during sleep and coma\u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. MMN amplitudes increase with the recovery of consciousness and a sudden enhancement of MMN amplitudes precedes patient communication with the external environment\u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e. Thus, MMN can be used to objectively assess changes in patient consciousness over a relatively short period. Therefore, this study evaluated the changes of brain function caused by acupuncture treatment by observing the changes of MMN before and after treatment.\u003c/p\u003e \u003cp\u003eThis study included 33 patients with pDOC, with the MCS and UWS groups comprising 16 and 17 patients respectively. By comparing the changes in MMN amplitude before and after treatment, we found that the two acupuncture methods had different effects on the changes in MMN in patients with different levels of consciousness.\u003c/p\u003e \u003cp\u003eThe study observed that XNKQ needling method significantly increased MMN amplitude in the MCS group. This may be because XNKQ needling method helps improve the metabolism of brain cells, which play a role in releasing the inhibitory state of the cerebral cortex and activating the brainstem reticular wakefulness system\u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e, thus promoting the recovery of patient consciousness. Ying et al\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. demonstrated that acupuncture was more likely to cause an increase in cerebral cortical excitability in patients with MCS, who had milder injuries than those in PVS group. Because patients still retain some degree of consciousness and cognitive function, they may be more sensitive to treatment with this type of needles. Theoretically, augmenting the number of stimulating interventions aimed at achieving arousal should yield better therapeutic outcomes. However, compared with patients with UWS, the application of additional arousal-promoting acupoints failed to induce greater cerebral activation in those with MCS. One explanation for this disparity may lie in the differing extents of preserved neural functionality between patients with UWS and those with MCS. In individuals with UWS, numerous latent pathways within the nervous system may remain to be activated, thereby offering heightened responsiveness to increased stimulus. Conversely, patients with MCS likely regain consciousness and neural function, rendering the additional stimulus insufficient to provoke further brain activity.\u003c/p\u003e \u003cp\u003eIn contrast, XNKQSY needling method resulted in a more significant increase in MMN amplitude in the UWS group. The projection area of the hand in the cerebral cortex is the largest, and the number of associated neurons in the cortex is inevitably higher. Stimulation of the Ten Xuan points may reflexively increase the activity of the associated neurons, thus demonstrating a wakefulness-promoting effect. Zheng et al. also showed that acupuncture at the Yongquan point activated the brain and promoted wakefulness \u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e. The consciousness of the patients with UWS was extremely reduced, and the treatment added Shixuan and Yongquan points based on the original acupoints to provide stronger stimulation, which was helpful to stimulate the sensory and some nerve functions in the patients, thus causing a significant increase in the amplitude of MMN after treatment. Therefore, it can be inferred that more aggressive treatment is needed for UWS patients with severely impaired consciousness.\u003c/p\u003e \u003cp\u003eIn both groups, although MMN amplitude showed statistically significant changes after acupuncture treatment, these changes were not correspondingly reflected in the CRS-R scores, suggesting a possible discrepancy between the patients' EEG activity and their behavioural functioning performance. Moreover, alterations in the patients' consciousness may precede the behavioural aspects of their functioning, which requires further exploration to understand the mechanisms behind this phenomenon.\u003c/p\u003e \u003cp\u003eIn addition, the patient population in this study was controlled before and after the application of different needling techniques, which provided homogeneous baseline conditions and ensured the reliability of the results and comparability before and after treatment. However, after treatment, the two needling methods showed different wakefulness-promoting effects in patients with different levels of consciousness, thus emphasising the potential of personalised medicine in precision diagnosis and treatment. Moreover, MMN can be used as an adjunctive assessment tool during rehabilitation wakefulness-promoting treatments and inform the development of clinical treatment protocols.\u003c/p\u003e \u003cp\u003eThe present study also has some limitations, including small sample size, insufficient insight into the mechanism of action of different acupuncture techniques, and a lack of long-term efficacy follow-up. Future studies are needed with larger samples to validate the results of the present study, further explore the specific effects of different acupuncture techniques on brain function and structure, and determine the relationship between these changes and improved consciousness.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe results of this study showed that the brain responses in patients with DOCs at different levels of consciousness were enhanced after the treatment of Xingnao Kaiqiao needling method and Xingnao Kaiqiao needling method combined with Shixuan and Yongquan points. Specifically, the Xingnao Kaiqiao needling method appears to be more suitable for patients with MCS, whereas the Xingnao Kaiqiao needling method combined with Shixuan and Yongquan points is more applicable for those with UWS. MMN can be used as an auxiliary evaluation tool for acupuncture treatment. Changes in MMN and CRS-R scores before and after treatment suggest that the onset of behavioural changes in patients may be delayed compared with changes in brain function.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSafety Analysis\u003c/h2\u003e \u003cp\u003eThe safety of acupuncture is well-documented, with no significant adverse reactions reported. In this study, all patients tolerated acupuncture without experiencing any negative effects. However, acupuncture punctures the skin barrier; thus, clinicians must fully sterilise the needled area in patients during acupuncture treatment. Moreover, some patients are more sensitive to pain than others, requiring clinicians to pay close attention to their status during acupuncture treatment.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003col\u003e\n \u003cli\u003eEthics approval and consent to participate:\u0026nbsp;This trial was approved by the Ethics Committee of the Affiliated Hospital of Binzhou Medical College on 1 January 2024 and was registered as a clinical trial with the hospital\u0026apos;s Ethics Committee under the registration number KYLL-186.\u003c/li\u003e\n \u003cli\u003eConsent for publication:\u0026nbsp;Not applicable\u003c/li\u003e\n \u003cli\u003eAvailability of data and materials:\u0026nbsp;The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/li\u003e\n \u003cli\u003eCompeting interests:\u0026nbsp;The authors declare that they have no competing interests\u003c/li\u003e\n \u003cli\u003eFunding:\u0026nbsp;This project was supported by the Shandong Provincial Health Commission. Chinese Medicine Science and Technology Programme (Grant No. Q2022122). The funding agency provided sufficient financial support for the study design, data collection, analysis and interpretation, and manuscript writing.\u003c/li\u003e\n \u003cli\u003eAuthors\u0026apos; contributions: All authors contributed to the study conception and design. \u0026nbsp;Material preparation, data collection and analysis were performed by Wei Li, Hao Zhang, Guan Fu, Binbin Huang, Hongwei Li. \u0026nbsp;The first draft of the manuscript was written by Ziyuan Cao and all authors commented on previous versions of the manuscript. \u0026nbsp;All authors read and approved the final manuscript.\u003c/li\u003e\n \u003cli\u003eAcknowledgements:\u0026nbsp;In the process of writing this paper, he was carefully guided by teachers Li Wei from the beginning to the end. \u0026nbsp; From the topic selection of this paper, to the guidance of the ideas of the paper, the organization of the text, the arrangement of the structure, the collection and collation of the data, and to the revision of the paper, he is rigorous in his academic studies. \u0026nbsp; The teachers have put a lot of effort into it, so that I can successfully complete the writing of this paper. At the same time, the meticulous and touching humanistic care of senior brothers and senior sisters makes people feel like spring breeze, and provides many pertinent and valuable opinions for the writing of this article.\u003c/li\u003e\n \u003cli\u003eClinical trial number: This trial has been registered with the Ethics Committee of the Affiliated Hospital of Binzhou Medical College before it started, and after the study and review of the Ethics Committee, it was approved to conduct this clinical trial, and the registration number of the clinical trial is KYLL-186.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWang L, Wu Q, Yang Z, et al. Preliminary study of vagus nerve magnetic modulation in patients with prolonged disorders of consciousness. Neuropsychiatr Dis Treat, 2022, 18: 2171-2179. doi: 10.2147/NDT.S381681.\u003c/li\u003e\n\u003cli\u003eEdlow B L, Claassen J, Schiff N D, et al. 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Recovery of consciousness and functional outcome in moderate and severe traumatic brain injury. JAMA Neurol, 2021, 78(5): 548-557. doi: 10.1001/jamaneurol.2021.0084.\u003c/li\u003e\n\u003cli\u003eCavalli L, Briscese L, Cavalli T, et al. Role of acupuncture in the management of severe acquired brain injuries (sABIs). Evid Based Complement Alternat Med, 2018, 2018: 8107508. doi: 10.1155/2018/8107508.\u003c/li\u003e\n\u003cli\u003eTeasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet, 1974, 2(7872): 81-84. doi: 10.1016/s0140-6736(74)91639-0.\u003c/li\u003e\n\u003cli\u003eSeel R T, Sherer M, Whyte J, et al. Assessment scales for disorders of consciousness: evidence-based recommendations for clinical practice and research. Arch Phys Med Rehabil, 2010, 91(12): 1795-1813. doi: 10.1016/j.apmr.2010.07.218.\u003c/li\u003e\n\u003cli\u003eGiacino J T, Kalmar K, Whyte J. 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Effect of acupuncture for disorders of consciousness in patients with stroke: A systematic review and meta-analysis. Front Neurol, 2022, 13: 930546. doi: 10.3389/fneur.2022.930546.\u003c/li\u003e\n\u003cli\u003eLiu Y, Sun N, Xiong J, et al. Modulation of cerebral cortex activity by acupuncture in patients with prolonged disorder of consciousness: An fNIRS study. Front Neurosci, 2022, 16: 1043133. doi: 10.3389/fnins.2022.1043133.\u003c/li\u003e\n\u003cli\u003eMingjun Y, Qiping X, Zhiliang, et al. Research progress on Xingnaokaiqiao acupuncture in the treatment of craniocerebral injury. Chinese Traditional Chinese Medicine Emergency, 2021, 30(06): 1117-1120.\u003c/li\u003e\n\u003cli\u003eBao Y C, Zhang F, Li Q, et al. [Xingnao Kaiqiao acupuncture on promoting wake-up of vegetative state after brain injury]. Zhongguo Zhen Jiu, 2021, 41(11): 1225-1228. doi: 10.13703/j.0255-2930.20201101-k0002.\u003c/li\u003e\n\u003cli\u003eYingcun B, Fang Z, Qun L, et al. Awakening effect of \u0026quot;Xingnaokaiqiao\u0026quot; acupuncture on patients with vegetative state after brain trauma. Chinese Acupuncture, 2021, 41(11): 1225-1228.\u003c/li\u003e\n\u003cli\u003eChuan Y, Bin S. Effects of bloodletting at Shixuan point on neurological function in patients with acute cerebral infarction. Shanghai Journal of Acupuncture, 2014, 33(02): 111-112.\u003c/li\u003e\n\u003cli\u003eZheng L. [Acupuncture treatment for persistent vegetative state after operation of acute subdural hematoma]. Zhongguo Zhen Jiu, 2005, 25(2): 82-84.\u003c/li\u003e\n\u003cli\u003eQiang Z, Xiangyun F. Comparison of the effects of acupuncture at different meridian groups combined with Yinaotongqiao prescription on EEG signals and wake-promoting effects in patients with stroke coma. Chinese Journal of Traditional Chinese Medicine, 2022, 40(03): 224-228\u003c/li\u003e\n\u003cli\u003eKing J R, Faugeras F, Gramfort A, et al. Single-trial decoding of auditory novelty responses facilitates the detection of residual consciousness. Neuroimage, 2013, 83: 726-738. doi: 10.1016/j.neuroimage.2013.07.013.\u003c/li\u003e\n\u003cli\u003eWang X, Fu R, Xia X, et al. Spatial properties of mismatch negativity in patients with disorders of consciousness. Neurosci Bull, 2018, 34(4): 700-708. doi: 10.1007/s12264-018-0260-4.\u003c/li\u003e\n\u003cli\u003eWijnen V J, van Boxtel G J, Eilander H J, et al. Mismatch negativity predicts recovery from the vegetative state. Clin Neurophysiol, 2007, 118(3): 597-605. doi: 10.1016/j.clinph.2006.11.020.\u003c/li\u003e\n\u003cli\u003eQian M, Jianguo Z, Wei Z, et al. The efficacy of Xingnaokaiqiao acupuncture in promoting consciousness disorder in acute stroke. Chinese Clinical Rehabilitation, 2006, (11): 142-143\u003c/li\u003e\n\u003cli\u003eY, Ling L, Yaping Q, et al. Application of nonlinear electroencephalogram dynamic analysis method to study the effect of acupuncture on patients with different disorders of consciousness. Chinese Journal of Cerebrovascular Diseases, 2009, 6(09): 461-465.\u003c/li\u003e\n\u003cli\u003eZheng L. [Acupuncture treatment for persistent vegetative state after operation of acute subdural hematoma]. Zhongguo Zhen Jiu, 2005, 25(2): 82-84.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"acupuncture, disorders of consciousness, event-related potentials, mismatch negativity, coma recovery scale-revised","lastPublishedDoi":"10.21203/rs.3.rs-5218469/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5218469/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study aimed to investigate the effects of \u003cem\u003eXingnao Kaiqiao \u003c/em\u003e(XNKQ)\u003cem\u003e \u003c/em\u003eneedling method and the \u003cem\u003eXingnao Kaiqiao \u003c/em\u003eneedling method combined with \u003cem\u003eShixuan\u003c/em\u003e and \u003cem\u003eYongquan \u003c/em\u003epoints (XNKQSY needling method) on brain function in patients with different levels of consciousness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThirty-three patients with disorders of consciousness (DOCs) were divided into minimally conscious state (MCS) (n=16) and unresponsive wakefulness syndrome (UWS) (n=17) groups according to their Coma Recovery Scale-Revised (CRS-R) scores. The patients in both groups were treated using XNKQ and XNKQSY needling methods. XNKQ needling method was administered on day 1, whereas the techniques in XNKQSY needling method were administered at the same time on next day. The MMN and CRS-R scores were measured before acupuncture treatment (T0), after single treatment with XNKQ needling method (T1), and after single treatment with XNKQSY needling method (T2). The electroencephalography (EEG) data were acquired using a 64-channel wireless EEG amplifier.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(1) MCS group: The patients with MCS showed a significant increase in MMN amplitude after the application of XNKQ needling method (T1) compared with pre-treatment (T0) (0.84 [0.67, 1.05)] vs 1.21 [0.96, 1.92], respectively, p=0.001). Although increased MNN amplitude was observed after the application of XNKQSY needling method (T2), the difference was not statistically significant (0.84 [0.67, 1.05] vs 1.05 [0.72, 1.53], respectively, p=0.867).\u003c/p\u003e\n\u003cp\u003e(2) UWS group: Compared with pre-treatment (T0), the patients with UWS showed significant increases in MMN amplitude after the application of both XNKQ needling methods (T1) (0.34 [0.26, 0.59] vs 0.72 [0.55, 1.22], respectively, p=0.049) and XNKQSY needling method (T2) (0.34 [0.26, 0.59] vs 1.15 [0.93, 1.87], respectively, p\u0026lt;0.001), with a more significant increase for XNKQSY needling method (0.72 [0.55, 1.22] vs 1.15 [0.93, 1.87], p=0.049).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs measured by MMN, \u003cem\u003eXingnao Kaiqiao\u003c/em\u003e needling method appears to be more suitable for patients with MCS, whereas \u003cem\u003eXingnao Kaiqiao\u003c/em\u003e needling method combined with\u003cem\u003e Shixuan\u003c/em\u003e and \u003cem\u003eYongquan \u003c/em\u003epoints may be more suitable for those with UWS. MMN can be used as an auxiliary evaluation tool during acupuncture treatment. There may be a delay in behavioural changes in patients with DOCs compared to changes in brain function during the assessment of consciousness.\u003c/p\u003e","manuscriptTitle":"The Efficacy of Different Acupuncture Methods in Patients with Disorders of Consciousness Based on Electroencephalography: an autocontrol trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-23 09:03:59","doi":"10.21203/rs.3.rs-5218469/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"03ca744c-6f02-4ee4-b0a7-073626fe9a68","owner":[],"postedDate":"October 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-10-23T09:04:01+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-23 09:03:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5218469","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5218469","identity":"rs-5218469","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}