Inspired by Li et al 2022.
EA – electroacupuncturekey to acronyms
MA – manual acupuncture
TENS – transcutaneous electrical nerve stimulation
CT – computed tomography
MRI – magnetic resonance imaging
NIHSS – Nation Institutes of Health Stroke Scale
BI – Barthel Index
MAS – Modified Ashworth Scale
ADL – activities of daily living
This 3-armed trial from Guangzhou is probably the biggest individual trial (n=497) of acupuncture for stroke rehabilitation to date.
I have to confess that I lost interest in the use of acupuncture for stroke rehabilitation just over 20 years ago with the publication of Barbro Johansson’s sham-controlled trial in the journal Stroke. The results suggested that acupuncture contributed to the sensory environment in rehabilitation, but that contribution was not dependent on the needles ie real EA was not statistically superior to subliminal TENS. We had all been excited some years before when she suggested that acupuncture might improve rehabilitation, and in particular balance, in a couple of small open trials.
Of course, in East Asia, acupuncture is in widespread use for neurorehabilitation, and the most recent Cochrane review on acupuncture for stroke rehabilitation does acknowledge that acupuncture may have benefits with no obvious serious adverse events.
The current trial randomised individuals diagnosed with ischaemic stroke by CT or MRI from 2 weeks to 12 months previously into 3 groups. Two groups received different acupuncture protocols and the control group received standard rehabilitation. The two different acupuncture protocols were developed by expert consensus based on either the most common 12 points used in the ancient literature or the most common 12 points used in more modern evaluations. The latter appears to have been influenced by laboratory research. The ancient arm used these points – GV20, GV26, PC9, ST6, ST4, LI15, LI11, LI4, GB30, GB31, GB34, and GB39. The modern arm used these points – GV20, PC6, LI11, LI10, TE5, LI4, GB30, ST36, GB34, SP6, ST41, and LR3. As you can see, 5 of the points overlapped between the two protocols.
Treatment was applied with patients in side lying with the affected side facing up and treatment was applied to the affected side only, apart from the points PC9 and PC6, which were needled on both sides. Treatment was applied 5 times per week for 2 weeks, and needles were retained for 30 minutes.
Three different outcome measures were used – NIHSS, BI, and MAS. The NIHSS was developed for the t-PA trial in acute stroke and is effectively a way of scoring the relevant items of neurological examination. It has 11 items and is scored from 0 to 40. The BI is an assessment of a patient’s ability to self-care on 10 ADL items and is scored from 0 to 100 in 5-point increments. The MAS is used to measure increased motor tone in affected muscles and is scored from 0 to 4.
NIHSS was the primary outcome, and at 2 weeks after 10 sessions of acupuncture there was a significant difference between the 3 arms with the acupuncture groups achieving a greater reduction in the score. The BI showed a significant improvement in the acupuncture arms compared with control at both 2 weeks (after treatment) and 4 weeks (telephone follow-up). No significant differences were seen on the MAS. Unsurprisingly, there was no significant difference between the two acupuncture protocols on any of the outcome measures.
1 Li L, Zhu W, Lin G, et al. Effects of Acupuncture in Ischemic Stroke Rehabilitation: A Randomized Controlled Trial. Front Neurol 2022;13:897078. doi:10.3389/fneur.2022.897078
2 Johansson BB, Haker E, von Arbin M, et al. Acupuncture and transcutaneous nerve stimulation in stroke rehabilitation: a randomized, controlled trial. Stroke 2001;32:707–13. doi:10.1161/01.str.32.3.707
3 Johansson K, Lindgren I, Widner H, et al. Can sensory stimulation improve the functional outcome in stroke patients? Neurology 1993;43:2189–2189. doi:10.1212/WNL.43.11.2189
4 Magnusson M, Johansson K, Johansson BB, et al. Sensory stimulation promotes normalization of postural control after stroke. Stroke 1994;25:1176–80. doi:10.1161/01.str.32.3.707
5 Yang A, Wu HM, Tang J-L, et al. Acupuncture for stroke rehabilitation. Cochrane Database Syst Rev Published Online First: August 2016. doi:10.1002/14651858.CD004131.pub3
6 National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333:1581–7. doi:10.1056/NEJM199512143332401
7 Mahoney FI, Barthel DW. FUNCTIONAL EVALUATION: THE BARTHEL INDEX. Md State Med J 1965;14:61–5.
8 Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther 1987;67:206–7. doi:10.1093/ptj/67.2.206