Acupuncture research in Cerebrovascular Accident induced hemiplegia.
By
Introduction to Cerebrovascular Accident and Hemiplegia
Cerebrovascular Accident also known as stroke can broadly be described as an interruption of the blood supply to the brain. Without blood the brain cells are staved of oxygen, and can begin to die within minutes if the blood supply is completely cut off. It is this cellular death which has the greatest influence on the sequelae or after math of the stroke. Hemiplegia is the most common sequelae of stroke, this medical condition characterised by paralyses of one side of the body. It is similar to, but should not be confused with hemiparesis which is when one side of the body is weak but still mobile. While the leading cause of hemiplegia is a Cerebrovascular Accident, it is not the only cause, other neural conditions such as a unilateral pyramidal (UMN) lesion may also cause hemiplegia. It is difficult to discuss Hemiplegia without also discussing Stroke, similar to cause and effect, if stroke is the cause then hemiplegia is effect. A sudden stroke can be deadly, and how well someone recovers or if they recover depends largely on how fast they receive treatment. In Australia the most popular method for identifying stroke is the FAST test: * Face – Check their face. Has their mouth dropped? * Arms – Can they lift both arms? * Speech – Is their speech slurred? Do they understand you? * Time – Time is critical. If you see any of these signs Call 000 now!
Thanks to implementation of tests such as this and advancements in emergency medical treatment of stroke, the numbers of stroke survivors is increasing, which is increasing the demand for effective treatments in stroke rehabilitation.
Relevant medical definitions:
Evolving stroke: The effects of stroke developing slowly over a period of hours (Gould, 2006)
Hemiparesis: Weakness on one side of the body. (Gould, 2006)
Hemiplegia: paralysis of the upper limb, trunk, and lower limb on one side of the body. (Tortora & Derrickson, 2006)
Cerebrovascular accident (CVA): Destruction of brain tissue (infarction)resulting from obstruction or rupture of blood vessels that supply the brain. Also called stroke or brain attack. (Tortora & Derrickson, 2006)
Rapid onset of cerebral deficit lasting more than 24 hours or leading to death, with no apparent cause other than a vascular one. (Kumar & Clark, 2005)
Infarction: A localized area of necrotic tissue, produced by inadequate oxygenation of the tissue. (Tortora & Derrickson, 2006)
Transient Ischaemic Attack (TIA): Focal deficit, such as a weak limb, aphasia or loss of vision lasting from a few seconds to 24 hours, with a complete recovery. (Kumar & Clark, 2005)
Aneurysm: Sac like enlargement of a blood vessel caused by a weakening of its wall. (Tortora & Derrickson, 2006)
Arteriosclerosis: Group of diseases characterized by thickening of the walls of arteries and loss of elasticity. (Tortora & Derrickson, 2006)
Stenoses: An abnormal narrowing or constriction of a duct or opening. (Tortora & Derrickson, 2006)
Apoplexy: Old medical term which can be used to mean bleeding in a Cerebrovascular accident
Epidemiology
The National Stroke Foundation of Australia advises that there are approximately 53,000 to 60,000 strokes every year in Australia, depending upon which paper you read, this equals over half a million stroke victims in the next 10 years. Most stroke suffers will have a disability as a result of the stroke, Hemiplegia is the most common. 89% of stroke victims will be admitted to hospital costing Australia $2.14 billion a year in treatment and rehabilitation. Cerebrovascular Accident is the second leading cause of death in Australia, however this number is decreasing from 12,266 deaths in 1999 to 11,973 deaths in the year 2008 (Australian bureau of Statistics, 2010), however the National stroke foundation warns that this number may rise due to the aging population unless more work is done to reduce the incidences. Stroke killed more women than men in the year 2008, stroke killed 4,727 men where as 7,246 women were killed by stroke. In fact Stroke was only the 3rd leading cause of death in men surpassed by trachea and lung cancer. The national stroke foundation advises that 80% of strokes occur in over 55, and one in every five people who suffer a stroke will die within one month, another three will die within the year! This leaves just one to continue rehabilitation.
Aetiology
The national stroke foundations out lined the following risk factors; stroke is more likely to occur in elder people, males rather than females and those who have a family history of stroke. These previous factors cannot be controlled where as others can, the following is a collection of risk factors retrieved from various sources: * High blood pressure * Cigarette smoking * High cholesterol * Poor diet and lack of exercise * Obesity * Diabetes * Alcohol * Sleep apnoea * Carotid artery stenosis/fibromuscular dysplasia. * Insulin resistance * Polycythemia * Increased lipoprotein * Hyperhomocysteinenia * Chlamydia pneumonia * Atrial fibrillation (irregular heart beat)
(Risk factors collected from Kumar & Clark 2005, Cance 2010, and National stroke foundation 2010)

High blood pressure is considered to be the most important risk factor in preventing stroke. High blood pressure can easily damage blood vessels which may lead to a stroke or heart attack, which can be avoided with adequate life style changes and medication.

Western Medical Science
Cerebrovascular accident from a western medical perspective it’s a kind of Cerebrovascular disease, where an pathogenic process in the blood vessels has caused and abnormality of the brain (Cance 2010). While the origin of the disease was vascular it progressed to affect the neurological system. The definition of stroke “rapidly developing episode of focal, and at times global (applied to patients in deep coma and to those with subarachnoid haemorrhage), loss of cerebral function with symptoms lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin” (Weatherall 1996). Signs and symptoms of stroke are very similar to that of a Transient ischaemic attack.
Differentiation of Cerebrovascular accident and Transient ischaemic attack
The Oxford text book of medicine Volume 3 published in 1996 defined a TIA as “acute loss of focal cerebral function with symptoms lasting less than 24 hour, which is (after investigation) assumed to be due to embolic or thrombolic vascular disease”. By this definition the main difference between CVA and TIA was the time, more than 24 hours was considered a stroke where as less than 24 hours was an TIA. Obviously the problem with this was that if a patient recovered within 25 hours or a few days without any disability then it was still called a stroke. A more recent definition of a transient ischaemic attack is “brief episode of neurological dysfunction caused by focal disturbance of the brain or retinal ischemia with clinical symptoms typically lasting less than one hour without evident of infarction” (Cance 2010). Essentially one could consider CVA the more serious of the two. The investigations and pathogenic processes of TIA an CVA are identical but a TIA is never caused by primary intercerebral haemorrhage.
Pathology
Disruption of blood supply (STROKE) Cellular death/damage via oxygen deprivation Impaired function (sequelae: Hemiplegia) or death
Disruption of blood supply
Broadly there are two main types of stroke Ischemic and Haemorrhagic.
Ischemic: Accounts for 80% of stroke types (Cance 2010), and is less deadly than the haemorrhagic type. Ischemia refers to a reduced blood supply to the brain, it may be caused by thrombosis, embolism, small vessel arteriopathy or spasm of a cerebral vessel.
Haemorrhagic stroke: when a haemorrhage occurs in the brain. This is usually from an artery rupturing due to hypertension or arteriosclerosis, trauma may also cause blood vessels to rupture. The bursting of an cerebral aneurysm can also cause a haemorrhagic stroke

Cellular death
When brain cells are deprived of oxygen they stop functioning properly, how well a person recovers from a stroke depends upon how long the blood supply to the brain has been cut off, how many cells have been damaged and to what degree. If the blood supply has been completely cut off, cells will begin to die within minutes. The location of the infarct will also determine the symptoms, for example if the damage has been sustained on the right side of the brain it will result in hemiplegia on the victims left side, if the right side is paralysed it means the left side of the brain is damaged.

Sequela: Hemiplegia
The quality of a person’s life post stroke truly depends upon the speed and quality of treatment received. While hemiplegia is one of the more common problems stroke survivors face there are other that are less obvious. Impaired a speech and language are another hurdle in recover, this is more common in those who have had a damage on the left side of the brain. Whereas damage on the right side of the brain is more likely to accompany spatial- perceptual deficits, impaired judgement of space, size, speed and movement.
Investigation and Diagnosis
Purpose of investigation into stroke or TIA is: * To confirm clinical diagnosis * To distinguish between haemorrhage and thrombo-embolic infarction. * To look for underlying causes of disease and to direct therapy, either medical or surgical
(Kumar & Clark 2005)
Investigations include:
Imaging via Computerised Tomography (CT) and Magnetic Resonance Imaging (MRI)- CT will show haemorrhage but no infraction, some infarctions will be detectable within one week but 50% are never detected. Diffusion-weighted imaging is useful in locating infracted areas.
Carotid Doppler and duplex scanning- are useful in identifying the state of arterial stenosis and occlusion.
Vascular imaging- Angiography (magnetic resonance angiography or digital subtraction angiography) is used for examining the anterior circulation usually to identify stenoses.
Lumbar puncture- Rarely used.
Other investigations include Routine bloods, Chest x-rays and ECG.

Treatment In terms of CVA the best treatment is prevention! It can be achieved by reducing the impact of risk factors such as: * High blood pressure * Cigarette smoking * High cholesterol * Poor diet and lack of exercise * Obesity * Diabetes * Alcohol * Sleep apnoea * Carotid artery stenosis/fibromuscular dysplasia. * Insulin resistance * Polycythemia * Increased lipoprotein * Hyperhomocysteinenia * Chlamydia pneumonia * Atrial fibrillation (irregular heart beat)
(Risk factors collected from Kumar & Clark 2005, Cance 2010, and National stroke foundation 2010)

Post stroke, factors likely to be responsible for CVA must be identified and addressed. Options include Antihypertensive therapy for those with high blood pressure, this is imperative in stroke prevention, Antiplatelet therapy taking an soluble aspirin (75mg daily) is successful at reducing recurrent embolic stroke by reducing platelet aggregation. Anticoagulants such as heparin and warfarin are used to manage cardiac abnormalities such as atrial fibrillation, however this therapy can be dangerous if the stroke was caused by haemorrhage.

Rehabilitation post stroke is also of vital importance, common sequelae that need to be tackled are hemiplegia and aphasia. Most of this responsibility is placed with physiotherapists and speech therapists. Physiotherapy is of greatest benefit soon after stroke it can help to relieve spasticity and help patients regain movement and control. And speech therapy is a must to help patients regain communication skills.
Traditional Chinese Medicine
Cerebrovascular accident answers to the name “Wind-stroke” in traditional Chinese medicine, the term wind was adopted to reflect the sudden onset, wide variety and rapid changes of symptoms that occur with Cerebrovascular accident. Similarly to Western Medicine, Traditional Chinese medicine theory says that while strokes appear to come on quite suddenly without warning, it is actually a collective of several factors which have been amounting over time. Wind stroke can be differentiated by an attack on the organs or an attack on the channels. Typically an attack on the organs is the most serious and this will cause a loss of consciousness, during a less serious attack on the channels there may be no loss of consciousness, this is also used to describe the sequela of stroke such as hemiplegia. While western research into stroke presented itself in a uniform manner Chinese theory did not, several authors equalled several varieties of patterns.
Aetiology
Giovanni Maciocia (2008) attributes the development of wind-stroke to four main aetiological factors:
Overwork and emotional stress: which can cause kidney yin deficiency progressing into a liver-yin deficiency allowing the liver yang to rise and turn into liver wind which causes apoplexy, coma, mental cloudiness and paralysis.
Irregular diet and physical overwork: weaken the spleen leaving the door open for phlegm to develop. Phlegm is responsible for numbness in the limbs, slurred speech and mental cloudiness.
Excessive sexual activity and inadequate rest: Can lead to a kidney- essence and marrow deficiency, if the marrow is deficient it cannot nourish the blood which will lead to a stasis of blood manifesting as stiffness and pain in the limbs.
Physical overwork and inadequate rest: weakens the spleen, muscles and channels. As a result blood deficiency develops in the channels leaving them open to invasion of internal wind. A combination of internal and external wind in the channels can also lead to a paralysis of the limbs.
Anshen Shi (2003) promotes four very similar aetiological factors:
Unconsolidated channels with the invasion of exterior wind: a combination of deficient protective qi and invasion of pathogenic qi, the external wind may also stir up internal phlegm to obstruct the channels. Similar to Giovanni’s “Physical over work and inadequate rest”.
Improper diet: inhibiting the spleens function, generating phlegm which may cover heart orifices or obstruct the channels. The same as Giovanni’s “irregular diet and physical overwork”, except Anshen Shi is attributing the spleens impaired function purely to improper diet.
Emotional stress: When excessive emotional stress is activated the heart fire flares and hyperactive liver yang creates wind, the two mutually aggravate each other and flare upwards towards the brain.
Prolonged exhaustion: can cause liver and kidney yin deficiency with liver yang rising. The qi and blood (possibly phlegm) then rebel upward following the liver yang rising, if phlegm is present it may obstruct the channels or cover the orifices.
While these factors are slightly differently worded they share the same core components, this is true for most of the subject matter reviewed.
Pathology
Giovanni considers that wind stroke is caused by a combination of at least three of the following four pathologies, accompanied by deficiency of Qi, blood or yin:
Wind: causing sudden loss of consciousness and hemiplegia
Phlegm: Is responsible for loss of consciousness and obstruction of the channels manifesting as numbness or tingling. Obstruction of the orifices causes aphasia and slurred speech.
Fire: injures the yin leading to malnourishment of the sinews and channels contributing to hemiplegia.
Blood stasis: Responsible for the rigidity and pain in limbs associated with the sequelae of wind-stroke.
Anshen also poses these four pathologies with the addition of “rebellious Qi” for a total of five pathologies. The involvement of rebellious qi: Liver and kidney yin deficiency cause the liver yang to rise and the qi and blood rise/rebel following the rising of liver yang.
Patterns
The following is a broad collection of patterns related to CVA. | Anshen Shi | Giovanni Maciocia | Kaptchuk | Channel involvement | Exterior wind invading into the unconsolidated channels | Hemiplegia | Cold mucus obstructing | | Wind yang disturbing upwards with liver and kidney yin deficiency | Aphasia (slurred speech) | | | | Hypertension | | | | Facial paralysis | | | | Incontinence of stools and urine | | | | Dizziness | | | | Stiffness and contraction of the muscles | | Organ involvement | Heat-type of closed disorder | Tense type | Wind mucus obstructing meridians, liver yang ascending | | Abandon disorder | Flaccid type | Yin and Yang collapsing | | Cold-type of closed disorder | | | | | | Mucus fire suddenly collapsing, liver fire blazing | Sequelae | Hemiplegia associated with qi deficiency and blood stasis | Stagnation of Qi and blood | Deficient Qi and congealed blood | | Hemiplegia associated with yin deficiency and yang rising | Yin deficiency with empty heat | Deficient liver yin and deficient kidney yin | | Dysphasia associated with wind-phlegm obstructing the channels | Wind-Phlegm | | | | Damp-Phlegm | | | Dysphasia associated with kidney essence deficiency | | | | Facial paralysis | | |

The amount of patterns collected can be directly related to how many authors are researched, many seem to add their own spin on at least one pathology. Common principals appear to be, the loss of consciousness during stroke indicates an attack on the organs, there are tense and flaccid types of stroke with the later being more severe (similar to haemorrhagic stroke), Hemiplegia can be associated with deficient of Qi, Yin or phlegm obstructing.
As pointed out by O’connor & Bensky the most common pattern for CVA is “penetrating wind”. Although this particular name is not mentioned previously the pattern is quite familiar, “Deficient Kidney or Liver Ying is unable to restrain the liver yang which flares upwards” followed by formation of wind, rebellious qi and blood ascending and possibility of phlegm obstructing the orifices causing loss of consciousness.
Treatment
Giovanni | Pattern | Treatment | Channel Involvement | Hemiplegia | Du 26, Du 20, BL 7.Arm paralysis: LI 15, TB 14, LI 11, LI 10, TB 5, LI 4, TB 3, SI 3Leg paralysis: BL 23, GB 30, GB 29, ST 31, GB31, ST 32, BL 40, GB 34, ST 36, BL 57, GB 39, ST 41, BL 60, GB 40 | | Aphasia (slurred speech) | Ren 23, HE 5, KD 6Reducing method <one month, and even method > one month | | Hypertension | LI 4, LR 3, reducing methodKI 3, reinforcing methodST 9 ST 36, GB 39, moxibustion | | Facial paralysis | LI 4, TB5, LR 3Local points | | Incontinence of stools and urine | BL 33, BL 25, Ren 6, Ren 4, SP 6, DU 4, BL 23 | | Dizziness | LR 3, BL 18, BL 23, KI 3, REN 4, reinforcing method, DU 20 and GB 20. | | Stiffness and contraction of the muscles | Shoulder: LI 15Elbow: LI 11Finger: LI 3, SI 3Extinguishing wind points: LI 4, LR 3, TB 17, GB 20 | Organ involvement | Tense type | Du 26, Du 20, DU 16, GB 20, KD 1, PC 7, PC 8, ST 40, Jing well points of the hand. Reducing method | | Flaccid type | Ren 6, Ren 4, Ren 8, St 36, Sp 6, PC 6, Du 4, BL 23. Reinforcing method and strong moxibustion | Sequelea | Stagnation of Qi and blood | Ren 17 with even method to move qi in order to invigorate blood. BL 17 SP 10 with even method to invigorate blood. | | Yin deficiency with empty heat | KD 6, KD 3, REN 4, with reinforcing method, HT 6, GB 20 reducing method | | Wind-Phlegm | DU 20, DU 16, GB 20 to extinguish windSt 40 LU 7, Ren 9, SP 6 to resolve phlegm. All with reducing method | | Damp-Phlegm | BL 20, REN 12, reinforcing to tonify the spleen and resolve phlegm. ST 40, LU 7, REN 9, SP 6 even method to resolve phlegm |

Anshen Channel involvement (Even method on the healthy side first, then the affected side) | General prescription | DU 20, BL 7, DU 16 | | Upper limb paralysis | LI 15, LI 11, TE 5, LI 4 | | Lower limb | GB 30, ST 36, ST 41, GB 34 | | Facial paralysis | ST 4, ST 6, LI 4, ST 44 | Organ involvement | Closed disorder | (reducing method) DU 20, Du 26, ST 40, LR 3, KD 11, 12-jingwell pointsLocked jaw: ST 7, ST 6, LI 4Rigid tongue and aphasia: DU 15, REN 23, HT 5 | | Abandon disorder | (moxibustion) REN 8, REN 6, REN 4. |

Clearly the different patterns will require different points be used so again there will be variance between authors. However regarding the treatment of hemiplegia specifically there is a large amount of similarity. Dr Yu Yong Chang writes that ST 36 and LI 10 should be considered main points when treating hemiplegia, He reinforces this with a quote from the Nei Jing “when treating wei (syndrome), use only the Yangming”, both these points have the property of being able to strengthen the qi of their respective channels. Almost every treatment for Hemiplegia includes ST 36 and LI 10 or LI 11. Some of the most common points for treating hemiplegia are:
Upper limbs-LI 15, 11 or 10, 4, TB5
Lower limbs- GB 30, 34, ST 36, ST 41
Questions still remain about which is the most promising needling technique, some theories say the healthy side should be needle, others say the effected side. A 2002 article in the journal of traditional Chinese medicine (Fan G, WU X & Xue Z) reviewed the treatments of healthy side needling against affected side treatment, poor translation was a factor but it concluded that needling the healthy side did have treatment value, however was unclear as to whether it was more effective than affected side needling. As pointed out by David Mayor (2009) most research has been done on treatment is with manual acupuncture being used on the healthy side and electro acupuncture used on the affected side, leading one to conclude that this is one of the most popular treatment approaches for hemiplegia.
Papers Reviewed
Influence of different needle-retaining time on the therapeutic effect of acupuncture in the treatment of ischemic stroke.
HE Yang-Zi, HAN Bing, HU Jing, YUAN Li, CHEN Zhuo-ming, LI Jing-ming, PENG Ju-xiu, WANG Li-na
World Journal of Acupuncture and Moxibustion 2006;16(1): 3-9

The objective of this study was “To explore the relationship between the needle-retaining time and the therapeutic effect of acupuncture in the treatment of ischemic stroke patients”. 245 ischemic stroke patients from the First Affiliated Hospital of Jinan University were selected for this trial. The criteria for ischemic stroke used was “The Key Points for Diagnosis of Different Cerebrovascular Diseases” published by the Chinese journal of neurology. The “Criteria for diagnosis and evaluation of the curative effect of apoplexy” (Journal Beijing University of Traditional Chinese medicine, 1996, 19(1):55) was used to diagnose the acute and convalescent stage of stroke. Confirmation of cerebral infarction was also achieved through computerized tomography (CT) or Magnetic resonance imaging (MRI). Patients with “concurrent disease” were also excluded, while some specific diseases were mentioned one line states “other organic diseases were exclude” leaving the reader to assume that the person was completely disease free apart from the stroke.

The 245 appropriate patients once selected were then divided into three groups using Xu’s stratified random method. Unfortunately this method was published in Chinese and is beyond my investigative powers, however it notes that the formation of the groups was based on the severity of the sickness (based on the neurological deficit scale with scores of <15 being mild, 16-30 moderate, 31-45 severe) duration of needle retention. But if it was using a random system then there would be no need to differentiate between the severity unless the random system was used to allocate the three already matched groups with the treatment time, which is my assumption. However “1.2 grouping” section was poorly communicated and difficult to understand.

The groups comparability was measured using the Kruskal-Wallis H test for age and duration of disease, and Chi-square test for gender and severity of disease. The results suggested that they groups were appropriately matched with P values of greater than .05. However even though these test showed no great difference its worthy of noting that the 60min group which preformed the best had the lowest average duration of disease at 11 days compared with 14 in the 40 and 60 min groups. The maximum duration in the 60 min group was 120 day which is significantly lower than that of the other two groups at 175 days each. This is important because its generally accepted that the sooner treatment is receive the better the recovery. Clearly there was no blinding during this trail as most people possessed the ability to tell time.

As for the treatment given it sufficiently list which points were used during the trial: * Universal points LI 15, LI 11, TE 5, LI4, ST32, ST 36, ST 41, LR 3 * Stiff tongue and difficulty in talking and swallowing: Ren 23 * Distorted mouth: ST 4, ST 6 * Mental confusion: DU 24, DU 20
The needles were inserted to “DESIRED” depth and manipulated with reinforcing AND reducing technique by twirling, lifting and thrusting continuously to get Qi. Then the points were then stimulated with 2Hz, Sparse waves and a strength which the patient felt comfortable, with the G6805-1 electric acupuncture therapeutic apparatus. Retention and stimulation time reflected by the respective groups. Whether the points were used bi laterally or uni laterally was not mentioned, neither were any details about the needles used.

The choice of points is reasonable however the report did not mention any specifics about how many patients and of what groups received the extra points. While the needles where inserted to desired depth we have no idea of what or who’s desire that is, as there was also no mention of the acupuncturists background or training. While the paper talked about what needle techniques were used it did not describe for which points which techniques were used (reinforcing or sedating). The strength of the electrical stimulation (based on patient tolerance) was too variable and should have been recorded. Failed to mention the location of the negative and positive leads.

In addition to this treatment the patients in all three groups also received standard western medicines for the treatment of stroke, what specifically is not mentioned, as well as Compound Danshen (red sage root) injection and Zhongfeng Huichun Wan (Bolus for treating stroke, 1.7g, b.i.d). It does not mention the amount of the injection or the location.

Treatments were once daily with 10 days being a course. “The criteria for scoring clinical Neurological Deficits (CSCND) of stroke patients” was used by the trail to evaluate the recovery of stroke patients. This criteria was accepted in ’95 by “the fourth session of national academic meeting on Cerebrovascular diseases” in China.

The criteria were as follows:
Disability degree, Grade 1=the patient could take care of their self and live independently, Grade 2=the patient could basically live independently and sometimes needed help, Grade 3= could take care of self but required help most of the time.
Basically cured: Clinical neurological deficit score decreased by 91%-100% with a disability degree of 0.
Remarkably improved: CNDS decreases of 46%-90%
Improved: CNDS decrease of 18%-45%
Ineffective: CNDS decrease or increase of 17%
Worsened: CNDS increase of 18%

The discussion of this paper claims that the authors of this paper believed 23 min and 37 min would be of the greatest benefit to observe, these times were rounded off and a 60 min group was added purely for comparison. Upon conclusion the paper states that the effect on the 60 min group was the greatest followed by the 40 min group and finally the 30 min group, as there was no 30 min group this is assumed to be a mistake for the 20 min group. This kind of error is concerning as one may wonder about which other digits may have been mistakenly typed.

Some issues with this paper are that there was no control group, which meant if acupuncture was in fact hampering their recovery it would prove that the 60 min group was the least effective. Also Acupuncture was used in combination with other therapies which means the claims of longer needle retention being more effective in treating stroke patients is not accurate, it should be longer needle retention in acupuncture when combined with western medicine and Chinese herbal medicine is more effective. Each patient was evaluated before and after the treatment course by the same physician, however no back ground of the physician or acupuncturist was provided, and its not clear if they were blinded or not. Its unclear where the funding came from.

The style of acupuncture was not explicitly mentioned, however in the discussion they did give a brief explanation of point rational and theories behind needle retention time. They included several references on the topic of retention time. Theory behind the retention time given was that the meridians are blocked by pathogenic wind and stagnation of qi and blood, if the needle retaining time is to short the meridians cannot be dredged. Or if the treatment is to long a weak/deficient person may be unable to bear it.
Stage-oriented Comprehensive Acupuncture Treatment plus Rehabilitation Training for Apoplectic Hemiplegia.
Mao Min, Chen Xin, Chen Yuefeng, Rao Ping &Liu Jian
Journal of traditional Chinese Medicine 2008; 28(2): 90-93

The Objective of this trail was to study the effect of stage-oriented comprehensive acupuncture treatment plus rehabilitation training for the recovery of apoplectic hemiplegia.
60 inpatients of the” Neurology Department of Chengdu Municipal Hospital of Integrated Traditional Chinese and Western Medicine” (during the period January 2004 to January 2005) were selected for the trail and randomly divided into two groups of 30. The text does not describe how random placement was achieved nor does it mention a power calculation or a number needed to treat.

Inclusion and exclusion criteria for case selection patients must have suffered and acute cerebral infarction or hemorrhage as according to “The diagnostic criteria for various cerebrovascular diseases” passed at the fourth national Academic conference on cerebrovascular diseases. Cerebrovascular accident was also confirmed by CT or MRI. This is quite a standard measure for selecting stroke patients however including infarction and haemorrhage stroke may affect the results as haemorrhagic patients have a poorer prognosis. The inclusion of both haemorrhagic and ischaemic stroke patients also causes the title to be misleading as apoplectic when referring to stroke means bleeding of the brain such as haemorrhage. Patients must also have stable vital signs, 48 hours after the stop of development of neuro graphic symptoms, within ten days of disease duration, the score of Glasgo Coma Scale (GCS) equal to or greater than 9 and have extremity dysfunction. Participants were excluded for having “active hepatic disease, hepatorenal insufficiency, congestive heart failure, malignant tumor, anamnesis of dementia or psychoses, deaf-mute, and extremital dysfunction”. Extremital dysfunction was measured using the Fugl-Meyer Assessment (FMA) of motor function patients were excluded for a score greater than or equal to 90.

The general data of the two groups was analysed through the chi squared test, and student t test using the mean and standard deviation. The two groups were found to be comparable with no significant statistical difference.

The standard treatment for both group, as was a standard of stroke care at the time, it consisted of being placed in bed with good posture with one turn every two house, and transfusion on the healthy side.

The treatment group receive acupuncture five times a week, treatment given depended on the Brunnstrom stage of hemiplegia recovery. Brunnstrom’s theory was made in the 1950’s and evaluates the patients recovery based on muscle tone and voluntary movement. Actually there are seven stages to Signe Brunnstrom’s theory they are:
1. Flaccid paralysis. No reflexes.
2. Some spastic tone. No voluntary movement. Synergies elicited through facilitation.
3. Spasticity is marked. Synergistic movements may be elicited voluntarily.
4. Spasticity decreases. Synergistic movements predominate.
5. Spasticity wanes. Can move out of synergies although synergies still present.
6. Coordination and movement patterns near normal. Trouble with more rapid complex movements. 7. Normal
But in the research paper they refer to the six stages of Brunnstrom’s theory, this maybe a translational error as the seventh stage is “normal” there for it would be unnecessary to treat someone with a score of seven, and treatment protocols would only have to be made for six stages. However the treatment protocol proposed in this study only goes up to level 5 on Brunnstrom’s theory, indicating level 6 may be the healthy level or that the authors didn’t expect anyone to reach that level. Other Chinese translated papers also refer to Brunnstrom’s 6 levels where as the western material talks about 7 levels.
Stage 1: Patients at stage one would receive REN4, PC6, DU26, SP6, bilaterally. HT 1, BL 40, LU5, LI4, GB40 on the affected side. Those who could endure it KD1 on the affected side it was needled perpendicularly to about .5-1.0 cun in depth maybe eliciting a flexion reaction of the lower limb. Needle method was lifting thrusting and twirling done every sixty seconds and repeated three times.
Stage 2: LI 15,11,4, LU10,ST32, GB34, ST36, ST41, LR 3 on the affected side with reducing method (strong stimulation). And ST 36,LI11, LI4, GB 20, DU14,B23, BL25, DU 3, on the unaffected side with uniform reinforcing-reducing method.
Points on the scalp used were MS6, anterior oblique line of the vertex-temporal, MS7 Posterior oblique line of vertex-temporal and DU 20. Reinforcing method was used, three needles were inserted evenly along the scalp lines. All needles were retained for 30 min and manipulated every 15 minutes, once everyday. Here you can see that they have started to use scalp acupuncture which is in no way related to TCM theory.
Stage 3: (Patients who identified with Brunnstrom’s stage 3 and 4) Points on the affected side PC7, LI4, Bizhong, LU5, PC2, Jianqian, St 32,ST34,SP10, SP9,SP6, BL 57 and SP1. Filiform needles were used with deep needling to achieve a strong needle sensation and relieve spasm, there was no needle retention, treatment lasted 30 minutes once daily.
Sage 4: (Brunnstroms stage 5)Scalp acupuncture on the affected side; anterior oblique line of vertex-temporal MS6, lateral line 1 and 2 of vertex MS9, and the lower lateral line of occiput MS14. Needle manipulation was identical to the previous stage. However the needles were retained and the patient required to do automatic functional exercise for half an hour to one hour, with the needles manipulated once every 15 minutes.
Reporting in this area has been reasonably good covering points, number of points, depth, stimulation and response however they failed to mention which type of needle was used during the trail.
In addition to this the acupuncture group also received standard modern rehabilitation treatment, which consisted of one to one systemic functional exercises preformed lying, sitting, standing, balanced standing, gait, and fine movements of the upper limbs preformed in this order. The reference to this exercise was in Chinese so its unclear to what it requires exactly. This treatment was preformed five days a week for one hour.
The control group received the same treatment negative the acupuncture. This was seemingly a good way to compare the affects of two treatments however there is a lack of information regarding the rehabilitation exercises used such as the specifics of the exercises and if they were also adjusted according to the stages of rehabilitation. If it was not adjusted it indicates that the acupuncture group was paid more attention which could be and factor in better recovery.
The results showed, according to the analyse process, that actually both groups improved but the acupuncture group improve the most. On average the treatment group improved by 45.28points on the FMA by the end of the treatment and the Control group improved by and average of 33.28 points on the FMA. Based on this information the authors conclusion cannot be refuted “based on brunnstrom’s theory of six-stage in the recovery of hemiplegia, the effect of stage-oriented comprehensive acupuncture therapy combined with rehabilitation training is very good, helpful in raising the daily life ability of patients”. But this conclusion is poorly worded and to simply say it is very good or helpful is not a reasonable conclusion for a research paper. A more appropriate conclusion would have been that stage orientated acupuncture treatment plus rehabilitation yield greater recover than rehabilitation alone.
While it says assessment was FMA and it was done before and three months after treatment there is no mention of the assessor or if there were different people performing the assessment. And they didn’t discuss how long the patients were being treated for, or if they were just being treated until they recovered. No blinding was preformed because its obvious if you’re getting needled or not. Its not clear who was funding the research but the TCM theory used was quite in-depth. This report briefly refers to Traditional Chinese medicine theory but only briefly and definitely has a much stronger focus on western medicine. And while it mentions the specific treatment times it does not explicitly specify the duration of the course, it refers to patients being measured three months after treatment, but it doesn’t specify if it was three moths after the first treatment or three months after the completion of a six month course.
Interpretation of the significance of research
Prognosis: Hemiplegia is not a deteriorating condition once someone develops hemiplegia it will not get any worse. Most people can expect some improvement in their condition without the aid of any other treatment, while improvement can be expected the most improvement will occur in the short term and start to reduce. However without appropriate treatment for CVA there may be another attack so risk factors need to be managed. The prognosis for haemorrhage patients is worse than for ischaemic type stroke, and abandonment patterns are less hopeful than closed disorders. While patients can expect improvement in their condition all professions agree that the sooner rehabilitation and treatment begins the better the result. The younger a person is the better chance they have for making a recovery, and the sooner treatment is received for acute stroke the better the prognosis for recovery. The post stroke sequela can be a truly traumatic experience in some cases patient cannot walk, talk or eat by themselves to work through this requires a lot of mental strength. There is also a risk of recurrent strokes and/or myocardial infarctions.
Treatment: Acupuncture has been used to treat wind stroke for thousands of years however as pointed out by just about every review I’ve read the place of acupuncture in treatment still remains to be scientifically substantiated. However in the treatment of post stroke hemiplegia acupuncture can play a vital supporting role. It would be foolish to treat a patient for sequela of stroke without any western medical input as stroke is a very serious disease and medication such as anticoagulants is sometime required. In this sense acupuncture should be one part of the ideal stroke rehabilitation, it should work alongside the medical practitioners to adjust medication as necessary and monitor cholesterol levels and other risk factors, physiotherapist and speech therapist to help patients to regain physical and mental control, and acupuncture to help facilitate these goals. While acupuncture and regular treatment in stroke recovery hasn’t been irrefutably proven to be superior to regular treatment alone the combination is really the comprehensive approach. However one problem with acupuncture treatment in the west is patients will only try some acupuncture treatment when they have had no success with western medicine. This means in cases of stroke maybe around the six or twelve month period when the patients self improvement has started to plateau they only then seek acupuncture treatment, Giovanni say “Best results are obtained if treatment is given within one month of the wind stroke attack and good results if within three months. It is difficult to treat wind stroke of more than six months” but notes it’s always worth a try no matter the time.
No new scope of practice is suggested here, treatments are still orientated at post stroke recovery patients. However it does present a great opportunity to bring acupuncture in to the mainstream for treatment of stroke recovery. For this to be a possibility it is likely that there needs to be more scientific evidence to support acupunctures effectiveness.
Points information: This research has made me think more about the channels used and there overall function rather than the point alone. This primarily due to the quote that caught my interest from the Nei Jing which says to use only the Yangming when treating wei syndromes. Although I haven’t heard that quote mentioned in many other research papers, all the treatments for hemiplegia use points on the Yangming. So I had to think about why would I use the Yangming and as I researched this I came to the conclusion that the Yangming is a really important channel for affecting the qi and blood and in cases of hemiplegia there tend to be a deficiency of qi and blood. There for the Yangming was chosen to have the greatest reinforcing effect on the qi and blood. It gave me a greater insight into the role of the channels and the levels at which they can affect the body.
Needle technique information: Before reading all these papers when I treated hemiplegia it never occurred to me to use a contra lateral treatment, perhaps because I’m still learning, but now I would definitely consider such a treatment. And as for reinforcing and reducing techniques its still a bit up in the air, not a lot of research was done on this topic which leads me to think its regarded as being of lesser importance. A lot of the difference of opinion on the needle technique used was because of the different theories involve, one such theory was that initial a hemiplegia affected limb is deficient and there for must be reinforced, but over time that limb becomes stiff and rigid giving it the characteristics of a full condition which needs to be reduced.
Other techniques: While there seems to still be some debate about whether or not to use the reinforcing or reducing methods, elector acupuncture looks like a great option for nerve stimulation and reducing muscle problems. Previous time when I have used electro, I’ve been using the same meridian, however reading O’Connor and Bensky introduced me to a technique where the electrodes could be connected across the meridian, the strength adjust appropriately for about thirty seconds and then turn it off for a few seconds before switching it on again, this process could be repeated 3 or 4 times. I found this process to be very interesting and am looking forward practicing it in clinic.
TCM theory: I don’t believe this research has provided any new insights or developments of Traditional Chinese medicine. But it does highlight that there are a number of different TCM theories out there and while most of them are very similar in nature, a lot of authors like to put their own spin on them which can make it difficult when analysing patterns. This is in contrast to western medicine which appears to be very uniform in comparison.
Research: All of the reviews I have read concluded with almost exactly the same sentence, there is not enough evidence to say if acupuncture has any affect on stroke rehabilitation and further research is recommend. There for current research hasn’t actually proven acupunctures role in stroke rehabilitation which is the first area which needs to be addressed, this needs to be done by larger, high quality randomised controlled trial. Questions on the effectiveness of needle technique in this area haven’t been researched nearly enough. Basic questions that arise out of this research are what exactly is acupunctures role in rehabilitation? Can acupuncture be effective without physiotherapy or is it better as a combination? And a major question I’m dying to ask is how come so many studies are so poorly designed that their conclusions are of no value? Research in this area needs to go back to the basics and identify how effective acupuncture is in treating stroke rehabilitation, through large, high quality randomised controlled trial, and build up from there.
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