Acupuncture in ICH 2023

Stimulated by Li et al 2023.[1]

ICH – intracerebral haemorrhage
RCT – randomised controlled trial
EA – electroacupuncture
SAH – subarachnoid haemorrhage
mRS – modified Rankin Scale (a 0 to 6 scale measuring disability)
GCS – Glasgow coma scale (measures conscious level up to a maximum of 15)
BDNF – brain derived neurotrophic factor

key to acronyms

I have been interested in the potential of adjuvant acupuncture in serious neurological conditions since I first came across an RCT of EA in acute SAH – see SAH headache 2019. Serious outcomes were reduced 10-fold in the group receiving additional EA.[2] I should note that the acute SAH was treated conventionally with regard to the actual bleeding – usually by endovascular coiling.

In the current paper, a rather vigorous form of MA was tested in a non-penetrating sham controlled trial with an additional non-randomised control group. It took me a while to work out what was going on with the additional control group who did not have ICH, but it turned out to be a useful addition, if only to illustrate the strength of the MA applied. All 20 in the control group complained of pain and 7 went on to drop out due to pain. For comparison, only 2 out of 40 with acute ICH allocated to MA complained of pain. Many of the patients were unconscious due to the condition.

The MA protocol is a semi-standardised technique developed in Tianjin, China. It is known as Xingnao Kaiqiao (XNYQ) acupuncture and it uses GV26, PC6, and SP6. Additional points listed are HT1, LU5, and BL40. These are used only on the affected side, which presumably refers to the paralysed side in the case of hemiplegia.

The description of needling starts with PC6. Lifting and trusting is applied vertically to a depth that would be likely to reach the median nerve. GV26 is needled with ‘heavy bird pecking’ until tear formation is observed in the patient’s eyes. Needling of SP6 is expected to generate 3 twitches of the lower limbs. Similar twitching appears to be desirable when treating the additional points as well. The needles used were 0.30mm in diameter. So, you probably get the idea that this was a set of techniques developed on unfortunate patients that could not vote with their feet and leave the building!

Anyway, as well as measuring outcomes with mRS and GCS, they also measured serum BDNF. 84 patients with ICH were enrolled over a roughly 6-month period and randomly allocated to either XNYQ acupuncture or non-penetrating sham acupuncture. Patients without ICH who happened to attend the same hospital for some form of physical assessment were recruited to the additional control group and had the XNYQ acupuncture method applied.

XNYQ was applied daily to the patients who remained alive and could not escape. 14 treatments were applied over a 3-week period. Outcomes were measured at baseline, 3 weeks, and 12 weeks.

Good outcomes in terms of disability (2 or less on mRS) were seen in 18 of 35 in the XNYQ group and 9 of 37 in the sham group at 12 weeks. The GCS total improved more in the XNYQ group. At 12 weeks the only significant difference in improvement was in the motor subscale of the GCS.

I am less convinced by the measurement of serum BDNF; however, there was a difference between groups. The baseline figures look a little unbalanced and they only change in the group with ICH who received XNYQ acupuncture and not the healthier control group that received the same intervention.

The results are consistent with what we have seen in the past, although I am not convinced that we need to use such vigorous needling techniques, and the use of sham controls seems unnecessary where many of the patients have a reduced level of consciousness.

References

1          Li L, Wang X, Guo J, et al. Effect of acupuncture in the acute phase of intracerebral hemorrhage on the prognosis and serum BDNF: a randomized controlled trial. Front Neurosci 2023;17:1167620. doi:10.3389/fnins.2023.1167620

2          Sun J, Liu Y, Zhang J, et al. Electroacupuncture Improves Cerebral Vasospasm and Functional Outcome of Patients With Aneurysmal Subarachnoid Hemorrhage. Front Neurosci 2018;12:724. doi:10.3389/fnins.2018.00724

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Declaration of interests MC