ACUPUNCTURE & STROKE

Prepared by: Tilda Teo

Does Acupuncture really work to help stroke victims improve?

Benefits of Acupuncture

Control of Pain Improve motor functions Increase sensation Improve neurological functions in stroke Respiratory disorders Strengthening immune system Emotional and psychological disorders Musculoskeletal disorders (ie: frozen shoulder, OA) ETC

What is Acupuncture?

insertion of solid filiform acupuncture needles into the skin at specific points on the body to achieve a therapeutic effect encourage natural healing, improve mood and energy, reduce or relieve pain and improve function of affected areas of the body dull, heavy, or aching feeling often occurs when the needle is inserted needles are left in place for 15-30 minutes

Terminologies
Qi : Vital energy flows through the channels of Meridiens and regulates bodily functions Meridiens : Transmission lines of communication among the organs and the body

Acupoints : Locations on the body along meridiens

Manual-Acupuncture : Acupuncture performed at acupoints Mechanical Stimulation

Electro-Acupuncture : Needles which are electrically stimulated by various frequencies and voltages Electrical Stimulation

Effect of acupuncture on motor recovery in acute stroke patients

Effect of EA and MA on motor recovery in stroke patients-- Acute

A Cochrane review review of 14 trials insufficient evidence to determine the benefits of acupuncture due to the small sample size (Zhang et al 2005)

Johansson et al (2001)
Hypotheses : 1) Sensory stimulation by acupuncture (including EA) improves motor function and/or ADL after stroke 2) Sensory stimulation by highintensity low-frequency TENS, that induces muscle contractions comparable to those induced by EA, improves motor function and/or ADL after stroke

Acupuncture and

Transcutaneous Nerve Stimulation in Stroke Rehabilitation. A RCT. Outcome Measures : 1) Barthel Index 2) Rivermead Mobility Index

3) Nine Hole Peg Test

4) 10m Walk test 5) Nottinghan Health Profile

Johansson et al (2001)

Acupuncture and

Transcutaneous Nerve Stimulation in Stroke Rehabilitation. A RCT.

Johansson et al (2001)

Acupuncture and

Transcutaneous Nerve Stimulation in Stroke Rehabilitation. A RCT.

Johansson et al (2001)
Results : No clinically important or statistically significant differences were observed between groups for any outcome variables.

Acupuncture and

Transcutaneous Nerve Stimulation in Stroke Rehabilitation. A RCT. Discussion : Although stimulation in the control group was subliminal, there might be some degree of sensory input . Placement of electrodes on the skin are likely to stimulate mechanosensitive nerve fibers.

Sze et al (2002)
Aims:

Does Acupuncture have additional

value to standard poststroke motor rehabilitation? Outcome Measures : 1) Fugl-Meyer Assessment of Physical Performance 2) Barthel Index 3) Functional Independence Measure 4) Abbreviated Mental Test 5) NIH Stroke Scale

1) Examine whether acupuncture has additional value to standard poststroke motor rehabilitation.

Sze et al (2002)

Does Acupuncture have additional

value to standard poststroke motor rehabilitation?

Sze et al (2002)

Does Acupuncture have additional

value to standard poststroke motor rehabilitation?

Sze et al (2002)
Results : 1) No statistically significant differences were observed between the 2 arms for any outcome measures at week 10.

Does Acupuncture have additional

value to standard poststroke motor rehabilitation? Discussion : 1) Comparability assessment between the 2 groups was based on admission BI, and not on the TCM classification of stroke and its characteristics. 2) Flexibility of selecting acupoints leading to poor standardization or protocol

Effect of EA and MA on motor recovery in stroke patients-- Acute

Study Subject Rx
MA Flexible 30min 35X

Outcome measures
BI

Finding
No

Sze et al 106 acute (2002) stroke moderate to severe motor disabilities Johanss on et al (2001)
150

acupoints

FIM

FMA

further improvement Compare with patients solely involved in motor rehabilitation programme

8 week
BI RMI 9 No

acute stroke moderate to severe functional impairment

EA

and MA Fixed acupoints 30 min 2 X /week 10 weeks

holes Peg test time to complete a 10m walk

further improvement No additional benefit to conventional stroke rehab

Effect of acupuncture on motor recovery in chronic stroke patients

Wayne et al (2005)
controlled study Aims: 1) Examine whether active acupuncture improves UE ROM, spasticity and motor function.

Acupuncture for Upper-

Extremity Rehabilitation in chronic stroke: A randomized sham-

Outcome Measures : 1) Fugl-Meyer Assessment 2) Modified Ashworth Scale

2) Assess whether active acupuncture improves ADLs, QOL and mood

3) UE ROM
4) Grip Strength 5) Barthel Index 6) Nottingham Health Profile

Wayne et al (2005)
controlled study

Acupuncture for Upper-

Extremity Rehabilitation in chronic stroke: A randomized sham-

Wayne et al (2005)
controlled study

Acupuncture for Upper-

Extremity Rehabilitation in chronic stroke: A randomized sham-

Wayne et al (2005)
controlled study Results : 1) Intention-to-treat analyses found no statistically significant differences in outcomes between active and sham acupuncture groups. 2) Analyses of protocol-compliant subjects showed significant improvements in wrist spasticity, both wrist and shoulder ROM and improvement trends in UE motor function.

Acupuncture for Upper-

Extremity Rehabilitation in chronic stroke: A randomized sham-

Discussion : 1) Use of sham blunt-tipped needle that did not penetrate the skin was a effective concealable control.

Schaechter et al (2007)
1) Examine whether changes in brain activation differs in stroke patients treated with verum or sham acupuncture.

Correlated change in

Upper Limb Function and motor cortex activation after verum and sham acupuncture in patients with chronic stroke. Aims: Outcome Measures : 1) MR image acquisition

Schaechter et al (2007)

Correlated change in

Upper Limb Function and motor cortex activation after verum and sham acupuncture in patients with chronic stroke.

Schaechter et al (2007)
1) There is a significant positive correlation between changes in function of the affected UL (spasticity and ROM) and activation of ipsilesional motor cotex.

Correlated change in

Upper Limb Function and motor cortex activation after verum and sham acupuncture in patients with chronic stroke. Results: Discussion : 1) Acupuncture helps restore activity along spared descending motor pathways, thereby improving cortical modulation of lower motor neuron excitability involved in spasticity and ROM.

Effect of EA and MA on motor recovery in stroke patients-- Chronic

Study Subject
33

Rx
EA

Outcome measures
UE

Finding
Active

Wayne et al (2005)

chronic stroke severe to moderate upper limb functional disabilities

+ MA Flexible yet standard Acupoint 20-30 minutes 2X/ week a mean period of 10.5week

motor function FMA Spasticity MAS Grip strength ROM ADL QOL Mood
fMRI

acupuncture: A significant improvement: Ashworth wrist score (p<0.1) shoulder, wrist (p<0.1) and digits (p<0.06) ROM FMA (p<0.09) in patients receiving active acupuncture No difference in the FMA, MAS, grip strength and ROM between the sham and active acupuncture group.
improvement

Schaechter et al (2007)

chronic stroke

MA

+EA X2/week 10 weeks

UE

function ROM Spasticity

in ROM and spasticity of the affected limb with increase motor cortex activation

Effect of EA and MA on motor recovery in stroke patients-- summary

Acute:

Do not support additional benefit for patients receiving conventional stroke rehabilitation May have a role in improving upper limb function Small sample size

Chronic:

So does Acupuncture really work to help stroke victims improve?

Clinical Implication

The safety Only 1 study noticed a harmful effect of EA (Sui, Lo, Leung 2004b) inappropriate acupoint used Acupoint: animal studies a few fixed acupoints were used Human highly recommendable that a different set of acupuncture points to be used for individual patients based on their presentation instead of using fixed prescription acupoint for all patients. (Sze et al 2002)

Conclusion

Effects of MA and EA on motor recovery No strong evidence in further enhancing motor recovery in chronic and acute stroke patients.
Further studies if MA or EA treatment able to improve functional status