Review Article: Acupuncture for functional recovery after stroke

43 Pages·2011·0.31 MB·English

Review Article:
Acupuncture for functional recovery after stroke: a
literature review of randomized clinical trials
Yi-Hung Chen1, Ching-Yuan Lai2, Ya-Ting Wu1, Jaung-Geng Lin2

1Graduate Institute of Acupuncture Science, China Medical University, No.91
Hsueh-Shih Road, Taichung, Taiwan.
2School of Chinese Medicine, China Medical University, No.91 Hsueh-Shih Road,
Taichung, Taiwan.

Correspondence should be addressed to: Jaung-Geng Lin, [email protected]
.
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Abstract:
This review systematically analyzed data from all randomized controlled trials
published in English and in Science Citation Index (SCI) journals from 2004 to 2011
that had investigated the effect of acupuncture on functional recovery after stroke
The findings were that acupuncture improves insomnia and spastic hypertonia, but
fails to improve cognition and quality of life in patients with acute and subcute stroke.
In patients with chronic stroke, acupuncture improves dysphagia, balance, and
cognition. It remains controversial as to whether acupuncture has beneficial effects on
quality of life or spasticity, although the majority of the reviewed studies indicated
positive effects. Moxibustion demonstrated efficacy for post-stroke urinary
symptoms.
Very few published randomized controlled trials describe the effects of
moxibustion on stroke patients. Moreover, the available acupuncture studies involve
small sample sizes. More randomized controlled trials should be undertaken in larger
sample populations and across different centers, to determine the effects of
acupuncture on stroke sequelae.
Keywords: Acupuncture, Stroke, Randomized controlled trials

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1. Introduction
Stroke remains a major cause of death and disability [1-3]. The most effective
measure known to reduce mortality and morbidity after acute stroke is
multidisciplinary care in an inpatient stroke unit [4], but major disability persists for
many stroke patients. The 5-year cumulative risk of new major disability after
first-ever stroke has been reported to be 36% [5]. Thus, effective adjunctive therapies
that may improve outcome from stroke rehabilitation should be considered [6].
Acupuncture, the practice of inserting thin solid needles into specific documented
points of the body to treat many different disorders, has been practiced in China since
2500 BC [7]. Acupuncture is gaining popularity in Western countries as an alternative
and complementary therapeutic intervention, and this therapeutic technique is also
growing in popularity worldwide [8, 9].
Two different strategies are used; manual acupuncture and electroacupuncture.
Electroacupuncture is a modified form of traditional manual acupuncture. The
advantage of manual acupuncture is in its combined therapeutic effects of
transcutaneous electric nerve stimulation (TENS) and manual acupuncture.
Electroacupuncture can be standardized by frequency, voltage, wave form, length, etc.
[10].
Acupuncture is based on the principles of traditional oriental medicine. There are
365 designated acupuncture points located along these meridians that can be used for
needling stimulation [11]. In addition, many new points and entire “microsystems” of
points have been described for specific body parts, e.g., scalp acupuncture and ear
acupuncture (auricular acupuncture). Acupuncture may be useful as an adjunct
treatment in comprehensive management programs and might be efficacious in the
treatment of pain [12] and in particular postoperative pain [13], benign prostate
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hyperplasia [14], nausea due to pregnancy, and postoperative and
chemotherapy-induced nausea and vomiting [11]. Scalp acupuncture therapy appears
to improve neurological deficits in patients with acute intracerebral hemorrhage [15].
Acupuncture is used widely in the Far East for stroke rehabilitation [16], but
evidence of the effectiveness of acupuncture in the rehabilitation of stroke patients is
inconsistent. Recent systematic reviews [17, 18], and a 1997 National Institutes of
Health consensus statement [19] suggest that acupuncture may be a useful adjunct to
stroke rehabilitation. A meta-analysis [20] of randomized controlled trials (RCTs) that
evaluated the benefits of acupuncture administered during the acute stage of recovery
from stroke concluded that when added to standard stroke rehabilitation, acupuncture
has no effect on motor recovery but may have an improved effect on disability. Data
concerning the benefits of acupuncture in long-term stroke survivors with long-term
symptoms are more limited.
This article reviews all trials published in Science Citation Index (SCI) journals
from 2004 to 2011 and provides an overview of those that have investigated the
clinical effectiveness of acupuncture in the treatment of stroke sequelae.
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2. Methods
2.1 Literature Search
A literature search was conducted in September 2011 using PubMed. English
language articles published between 2004 and 20011 were reviewed. The first search
combined the keywords “Stroke”, “Acupuncture”, “Randomized Controlled Trial”
and the second keyword search combined “Cerebrovascular”, “Acupuncture” and
“Randomized Controlled Trial”.

2.2 Inclusion and Exclusion Criteria
We included studies that met the following criteria: (1) RCTs that adopted a
double-blind, single-blind, or non-blind design; (2) participants met criteria for acute,
subacute or chronic stage stroke; (3) participants received acupuncture or
moxibustion treatment.
Exclusion criteria included (1) non-numeric data, (2) comments and replies, (3)
animal studies and (4) publication in a non-Science Citation Index (SCI) journal.

2.3 Data Extraction and Quality Assessment
Clinical trials on the treatment of stroke sequelae were selected based on the
predetermined inclusion and exclusion criteria. Data were extracted from study
reports by one reviewer and were verified by a second reviewer. The following key
information was extracted from each study: first author, publication year, study design,
sample size, characteristics of participants, main acupoints/sites selected, outcome
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measures, results reported.
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3. Results
An initial search identified 124 published articles from PubMed. Only 18 published
articles met our inclusion criteria and these were systematically reviewed (Table 1).
The excluded articles are shown in Figure 1.

3.1 Types of Studies
Three of the 18 included studies used a double-blind design and 15 used a
single-blind design.

3.2 Characteristics of Participants and Studies
A total of 934 subjects (including those in intervention groups and in control
groups) were enrolled in the 18 studies. According to the stroke stage, 10 studies
(n=618) were classified as acute and subacute stroke and the remaining eight studies
(n=316) were classified under the chronic stroke category. Trial endpoints that were
investigated included: (a) acute and subcute stroke category: post-stroke onset of
insomnia, emotional and cognitive function and quality of life, spastic hypertonia,
muscle and motor function, post-stroke urinary symptoms, and (b) chronic stroke
category: cognition and quality of life, aspiration and aspiration pneumonia, balance,
chronic post-stroke spasticity and motor function.
Of the 18 studies, 3 were from the United Kingdom and involved 254 subjects, 3
were from the United States and involved 56 subjects, 3 were from Taiwan and
involved 126 subjects, 2 were from Germany and involved 93 subjects, 2 were from
Korea and involved 69 subjects, 2 were from China and involved 183 subjects, 1 was
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from Sweden and involved 54 subjects, 1 was from Hong Kong and involved 62
subjects, and 1 was from Japan and involved 32 subjects.

3.3 Type of Intervention and Needling Method
Of 18 studies, 8 studies used acupuncture, 4 used electroacupuncture: 1 study
used (transcutaneous electrical stimulation); 3 studies used a combination of
acupuncture and electroacupuncture; 1 study used a combination of acupuncture and
electroacupuncture versus TENS alone; and 1 study used moxibustion.

3.4 Main Acupoints/Sites Selected
A summary of the main acupoints or sites selected for different indications in the
studies is presented in Table 2.

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4. Discussion
In this review, studies were classified into (1) acute and subcute stroke category
and (2) chronic stroke category according to patient status.

4.1 Acute and subcute stroke
4.1.1 Post-stroke onset of insomnia
It is estimated that ~50–60% of stroke patients suffer from insomnia. Post-stroke
onset of insomnia is mainly caused by anxiety resulting from hyperactivity of the
sympathetic nervous system [21, 22]. Insomnia should be taken into consideration in
the treatment and rehabilitation of stroke, because it affects stroke prognosis.
Our literature search revealed two studies that examined the effects of
acupuncture on post-stroke onset of insomnia. These two studies supported the
effectiveness of intradermal acupuncture on patients suffering from post-stroke
insomnia. Kim et al (2004) performed a randomized controlled trial to investigate the
effects of intradermal acupuncture on insomnia after stroke [23]. Hospitalized stroke
patients with insomnia were assigned into a real intradermal acupuncture group or a
sham acupuncture group. Effectiveness was measured by the Morning Questionnaire
(MQ), Insomnia Severity Index (ISI), and Athens Insomnia Scale (AIS). Repeated
measures analysis detected significant between-subjects effects in the MQ, the ISI and
the AIS. Intradermal acupuncture on Shenmen (HT7) and Neiguan (PC6) was
demonstrated to be a useful treatment for post-stroke onset of insomnia.
The double-blind randomized controlled trial reported by Lee et al (2009)
enrolled hospitalized stroke patients with insomnia, who were assigned to either a real
intradermal acupuncture group or a sham acupuncture group [24]. The effect of
acupuncture on insomnia was measured with the ISI and AIS at baseline and at three
days after treatment. The results provide further support for intradermal acupuncture
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on Shenmen (HT7) and Neiguan (PC6) as a useful therapeutic method for post-stroke
onset of insomnia.

4.1.2 Emotional and cognitive function and quality of life
Stroke is a major cause of disability both physically and mentally. In addition to
motor function disorder, it is also important to deal with other problems resulting
from stroke, such as impaired cognition and quality of life. Cognition is a complex
collection of mental skills including attention, perception, comprehension, learning,
memory, problem solving, and reasoning. Cognitive rehabilitation and medications
have been used to enhance cognition in patients who have had a stroke or other brain
injury. Quality of life (QOL) is often measured subjectively and may be influenced by
factors other than physical disabilities [25].
Our literature search revealed three studies concerning the effects of acupuncture
on emotional and cognitive function, as well as QOL. Rorsman and Johansson (2006)
assessed the effects of acupuncture combined with electroacupuncture and
transcutaneous electrical nerve stimulation on emotional and cognitive functioning [26].
Five to 10 days after stroke, patients with moderate or severe functional impairment
were randomized to 1 of 3 interventions: (i) acupuncture, including
electroacupuncture; (ii) sensory stimulation with high-intensity, low-frequency TENS
that induced muscle contractions; and (iii) low-intensity (subliminal) high-frequency
TENS (control group). A pooled analysis of treatment groups demonstrated
significant cognitive and emotional improvements, but there were no treatment effects
on emotional status or cognitive functioning.
Hopwood et al. (2008) investigated the efficacy of acupuncture on stroke
recovery compared to an inert placebo in patients between 4 and 10 days after their
first stroke [28]. Acupuncture with electrical stimulation was compared with mock
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