Cerebrovascular Disease
Most frequent of all neurological problems Incidence: third leading cause of death in U.S. half a million people a year one third will die from it Due to blood vessel pathology:
Lesions on walls of vessels leading to brain Occlusions of vessel lumen by thrombus or embolus Vessel rupture Alterations of blood quality
Sudden weakness, paralysis, or numbness of the face, arm and the leg on one or both sides of the body Loss of speech, or difficulty speaking or understanding speech Dimness or loss of vision, particularly in only one eye Unexplained dizziness (especially when associated with other neurologic symptoms) unsteadiness, or sudden falls Sudden severe headache and/or loss of consciousness
Incidence
Highest risk > 65 years of age But about 1/3 (28%) are < 65 years old Tends to run in families More often seen in females More often seen in Blacks, perhaps due to increased incidence of hypertension
Three types :
Global hypoperfusion shock Ischemia thrombotic and embolic Hemorrhagic
Risk Factors
Arterial hypertension Heart disease
Myocardial infarction or endocarditis Atrial fibrillation
Elevated plasma cholesterol Diabetes mellitus Oral contraceptives Smoking Polycythemia and thrombocythemia
Occlusive strokes
Occurs with blockage of blood vessel by a thrombus or embolus May be temporary or permanent Thrombotic stroke:
3 clinical types: TIAs Stroke-in-evolution Completed stroke
Causes:
Thrombus formation
Atherosclerosis Arteritis Hypertension
Vasospasm Other:
Hypotension Anemia Polycythemia
Anterior or middle cerebral arteries contralateral monoparesis, hemiparesis, localized, tingling numbness in one arm, loss of right or left visual field or aphasia
Treatment
Without Tx 80% have a recurrence in symptoms, and 1/3 go on to have a full stroke within 5 years Give anticoagulants prophylactically , usually to 1 aspirin / day
Stroke-in-evolution
Can have abrupt onset, but develop in a step-by-step fashion over minutes to hours, occasionally, from days to weeks Characteristic of thrombotic stroke or slow hemorrhage
Thrombotic CVA
Involves permanent damage to brain due to ischemia, hypoxia and necrosis of neurons Most common form of CVA Causes:
Atherosclerosis assoc. with hypertension Diabetes mellitus, and vascular disease Trauma
May take years to develop, often asymptomatic until major narrowing of arterial lumen Anything that lowers systemic B.P. will exacerbate symptoms (60 % during sleep) Area affected depends on artery and presence of anastomoses Area affected initially is greater than damage due to edema Infarcted tissue undergoes liquifaction necrosis
What is Acupuncture?
Acupuncture is one of the oldest, most in the world. Originating in China commonly used systems of healing some 3,000 years ago, only in the last three decades has it become popular in the United States.
In 1993, the FDA estimated that Americans made up to 12 million visits per year to acupuncture practitioners and spent upwards of half a billion dollars on acupuncture treatments.
Acupuncture
Qi maintains balance in the body. 16 meridians 360 regular acupoints 40 commonly used extra points Acupoints influence the physiology
In China and Japan, an acupuncturist is likely to start therapy as soon as possible after a stroke Acupuncture is done on a daily basis in China. in Western countries, some acupuncturists with experience in treating stroke with acupuncture believe treatment 3 times a week is optimal. Several different approaches have been used to treat stroke, demonstrating that acupuncture for this disorder remains a healthcare art: Traditional Chinese Yang meridian point therapy, Chinese scalp acupuncture,
Dr. Yamamoto's YNSA Japanese scalp therapy, Korean Koryo Chim hand acupuncture, supplemental ear (auricular) acupuncture, and Xingnao KaiQiao (a newer therapy by Professor Shi Xuemin) are each advocated by a number of treatment centers in Oriental countries. One need not know in depth the approach of each, but it is important to know that more than one approach is available and used. Adding acupuncture to rehabilitation therapy obviously increases the cost; daily-to-3 times-weekly treatment is needed for 2-4 weeks or longer. Concern for added cost would perhaps disappear if the end result demonstrates more self-care and less dependence on family and health providers
Does acupuncture really work to help stroke victims improve? Many studies involving thousands of patients have been published in China and Japan, and 2 of 3 studies from Scandinavia, demonstrated significant help. These studies indicate that patients get well faster, perform better in self-care, require less nursing and rehabilitation therapy, and use less healthcare dollars.
Acupuncturetoday.Com
Acupuncture Study at Kansas Hospital Shows Dramatic Improvement in Stroke Patients (Jan.2004)
Media outlets throughout Kansas have reported that an acupuncture study conducted on stroke patients at Wesley Rehabilitation Hospital in Wichita has produced improvements so dramatic, officials have decided to stop the study early so that they can offer the service to all stroke patients who qualify. (continued)
Johansson et al (1993) 1 investigated the effectiveness of acupuncture as a supplement to physical therapy in recovery from stroke. 78 patients suffering from severe hemiparesis of the left or right side within ten days of stroke onset were randomly divided into a control group (n=40) who received daily physical therapy and a treatment group who additionally received two acupuncture treatments per week for ten weeks. Patients receiving acupuncture recovered faster and to a larger extent than controls with significant differences in measures of balance, mobility, quality of life index, and days spent in hospitals/nursing homes.
Shin et al
Mendapatkan bahwa akupunktur dapat meningkatkan LPO (lipid peroksidase) dan TAX 2 darah , meningkatkan SOD ( Superoxide dismutase) dan PGI2 Dg peningkatan aktifitas dari SOD mk kerusakan neuron akibat LPO dapat dihambat PGI2 dan TAX2 merupakan faktor penting dlm mempertahankan sirkulasi darah dan mencegah pembentukan trombus
Zheng et al
Akupunktur dapat mengurangi kerusakan jaringan otak akibat iskemi melalui mekanisme regulasi neuromediator,RNA sel dan Genom dalam inti sel shg timbul perlindungan terhadap sel otak yg menghambat proses kerusakan jaringan.
Jun et al
EA dapat mengurangi jmlh apoptosis pd daerah infrak dikorteks serebri, mengurangi neurotoksisitas dari asam amino yg dihasilkan oleh proses iskemi dan menghambat ekspresi c-fos serta memperkuat ekspresi dari protei bcl-2 yg dapat menghambat apoptosis
Terapi Akupunktur
1. Pada CVA ischemi terapi dianjurkan sedini mungkin, sebaiknya dilakukan 48 jam setelah tanda vital stabil (WHO) 2. Pada CVA haemorhage umumnya dilakukan 3 minggu setelah serangan setelah sadar dan tanda vital terutama tekanan darahnya stabil, dimulai dengan rangsangan ringan dan scr bertahap rangsangan ditingkatkan
Rencana terapi
1. Pada periode syok otak Digunakan jarum halus Bisa digunakan EA dg gel yg jarang Sehari sekali selama 20-30 menit satu seri terapi 10 kali Istirahat 2 hari sebelum msk seri kedua Merangsang sisi yg sehat
Rencana terapi
2. Periode Spastik Digunakan jarum halus Bisa digunakan EA dg gel yg jarang Sehari sekali selama 20-30 menit satu seri terapi 10 kali Istirahat 2 hari sebelum msk seri kedua Merangsang otot antagonis dr otot yg spastis, meredakan tonus tinggi otot yg spastik, memulihkan posisi tubuh shg menjadi normal
Rencana terapi
3. Periode pemulihan Saat ini dapat ditambahkan akupuktur kulit kepala untuk meningkatkan vaskularisasi dan merangsang hidup sel neuron titik yg digunakan fengchi, gongxue (lebar 2 jari tgk lurus dibawah fengchi), Shishencong
Bell's Palsy
Bell's Palsy is presumably due to an inflammatory reaction in or around the facial nerve near the stylomastoid foramen Bell's palsy, also known as idiopathic facial paralysis because of its unclear etiology. It is the most common disease of the facial nerve that causes important functional, aesthetic, and psychosocial disturbances in the patients.
Bell's Palsy
Pada umumnya bersifat akut Tiba tiba biasanya disadari saat bangun tidur Pada anamnesa penderita sering ada riwayat terkena angin waktu berkendaraan atau tidur dg jendela terbuka
1. 2. 3. 4. 5.
6.
Akibat kelumpuhan serabut somatomotoris n fasialis Dahi tidak dapat dikerutkan Mata tidak dapat menutup (lagopthalmus) Dalam usaha menutup mata bola mata kerap berputar keatas ( bells phenomen) Lipat nasolabial jadi datar Mulut tidak bisa diangkat baik scr spontan maupun atas perintah Sudut mulut tertarik ke arah sisi yg sehat, gangguan perasaan pengecapan pd 2/3 anterior lidah ( sisi kelainan) akibat kelumpuhan serabut viscerosensoris n facialis
Rangsangan penjaruman atau dengan EA Setiap kali dirangsang 5-6 buah titik 3 kali perminggu
INTRODUCTION
A 56-year-old white female presented with a 3-month history of severe right facial pain, weakness, and paralysis. This patient was referred to an otolaryngologist and a neurologist at Johns Hopkins, but did not achieve symptomatic relief.
PRESENTING COMPLAINT
The patient's right facial paralysis developed overnight. Associated symptoms included pain in her face, difficulty speaking clearly, aud hypersensitivity to sound in the right ear. She was unable to close her right eyelid, and experienced difficulty with drinking and mastication. She was evaluated and treated by an otolaryngologist, and placed on a steroid taper and acyclovir; symptomatic improvement in facial muscle strength did not occur. Her facial disfigurement and difficulty speaking impacted on her occupation (restaurant owner and operator). She developed mild depression and a secluded behavior.
MEDICATIONS
Prednisolone, Premarin, Acyclovir, DHEA, vitamins, minerals, and a natural Synthroid substitute.
DIAGNOSTIC TESTS Autoimmune and serology were negative. Lyme titer was negative. Thyroid function tests indicated that she was euthyroid with a slightly decreased TSH level. REVIEW OF SYSTEMS Neck pain, lower back pain, joint pain, depression, right facial pain and sensitivity to sounds in the right ear, with difficulty speaking clearly.
TREATMENT
Chinese medicine attributes this condition to Wind and Cold of external origin which invade the meridians traversing the face and disrupt the flow of Qi and Blood, preventing the vessels and muscles from receiving the necessary nourishment. Treatment is directed toward spreading the Qi through the meridians of the face (1). The patient was treated with an integrated approach of acupuncture models. Points from a neuroanatomical model, or for classical indications, were included at each treatment and primarily used unilaterally. Other points utilized the energetic approach, and were treated bilaterally.
The following acupuncture points were used without electrical stimulation. The local points were treated only on the right side, while the distal points were needled bilaterally. The principal points included GB 20 (Fengchi), GB 14 (Yangbai), ST 4 (Dicang), ST 2 (Sibai), and LI 4 (Hegu). The supplemental points included GV 26 (Renzhong), M-HN 18 [Jiachengjiang] (1), M-HN 9 (Taiyang), ST 7 (Ziagnuan), ST 36 (Zusanli), ST 44 (Neiting), and LI 19 (Heliao).
PATIENT RESPONSE
1. The patient was initially graded with a House-Brackmann grade 5 paralysis in the right facial muscles (4). After 10 acupuncture treatments over a 4-week period: She showed significant motion in her forehead and had total closure of her eye with maximal effort. However, with normal effort, she had 1 to 2 mm of scleral fill with good protection of her cornea. She also had good buccal movement and increased movement in the muscles supplied by the mandibular branch of her facial nerve. After a total of 15 acupuncture treatments over an 8-week period, she exhibited normal upper division motion and intact tone in the lower division, with only a mild decrease in motor strength in this division. Her strength was graded at approximately a House-Brackmann 2. She had full eye closure, and intact conjunctivae with slight ectropion.
2.
According to Liu (1995), when acupuncture was initiated within three days post-onset in 684 cases of facial nerve paralysis, 100 percent of the patients were cured or there was a marked improvement (5). Other studies (Gao, Chen, 1991) revealed that 80% of cases that were treated at more than 2 months post-onset, and 83 percent of severe cases, were cured or had excellent effect (6). Treatment, as with this patient, may include numerous diagnostic procedures, different classes of medications, lifestyle alterations, and still, continued suffering. Acupuncture may often lead to significant clinical improvement (7).
Abstract: Background Bells palsy involves acute facial paralysis due to inflammation of the facial nerve. Acupuncture and moxibustion (acu-moxi) is beneficial in treating facial palsy. In order to verify the efficacy of acu-moxi on Bells palsy, a randomized single-blind, multicenter clinical trial was performed. Methods A total of 480 patients from four clinical centers were involved in this trial, of whom 439 completed the trial and 41 did not. All patients were randomly assigned to either the control group or to one of two treatment groups. The control group was treated with prednisone, vitamin B1, vitamin B12, and dibazole; the treatment groups were treated either with acu-moxi alone or in combination with prednisone, Vitamin B1, vitamin B12, and dibazole. Symptoms and signs, the HouseBrackmann scale, and facial disability index (FDI) scores were assessed and determined both pre- and post-treatment to evaluate the effectiveness of the treatment methods.
Results The characteristics of the control and two treatment groups were comparable without statistically significant differences before treatment. There were significant differences between the control and treatment groups after treatment (2=15.265, P=0.018). According to evaluations based on the House-Brackmann scale and FDI scores, the effectiveness of treatment in the two treatment groups was better than in the control group and was most effective in patients receiving acu-moxi treatment alone (Z=-2.827, P=0.005). Conclusion The efficacy of acu-moxi treatment for Bells palsy is verified scientifically.
Treatment group 1 was given acu-moxi treatment. The acupuncture points used were Dicang (ST4), Jiache (ST6), Hegu (LI4), Yangbai (GB14), Xiaguan (ST7), and Yifeng (SJ17) on the affected side, and Hegu (LI4) bilaterally.1 Filiform needles (1-1.5 cun, 0.32 mm) were used with moderate stimulation to get an acupuncture sensation, and the needles were retained for 30 minutes. Hanging moxibustion was applied for five minutes at each point, once a day, five times a week, for a total of four weeks.
The House-Brackmann scale is specifically designed to evaluate the results of the treatment of facial paralysis disorders.7 Facial nerve function is graded by the HouseBrackmann scale into 6 grades: , Normal; , Mild dysfunction; , Moderate dysfunction; , Moderately severe dysfunction; , Severe dysfunction and , Total paralysis. The House-Brackmann scale is generally accepted as effective in evaluating facial nerve function.
RESULTS: (1) Acupuncture was effective for the Bell's palsy in active stage, resting stage and recovery stage (all P<0. 01); (2) The obvious effective rate of acupuncture for treatment of Bell's palsy in the active stage group was obviously superior to those of resting stage group and recovery stage (both P<0. 01). (3) There was no significant difference of the obvious effective rate between the resting stage group and the recovery stage group (P>0. 05). CONCLUSION: Acupuncture has a good therapeutic effect for treatment of Bell's palsy, and the therapeutic effect is most obvious with intervention of treatment in the active stage.