Inspired by Li et al 2024.[1]
My point is that you cannot do mechanistic laboratory studies on PSA in rodents.
Photo by Kanashi on Unsplash.
PSA – post-stroke aphasia
key to acronyms
PSA – prostatic specific antigen (not the subject of this blog)
EA – electroacupuncture
PSD – post-stroke dysphagia (the subject of a previous blog)
RCT – randomised controlled trial
MA – manual acupuncture
SR – systematic review
AQ – aphasia quotient
WAB – Western aphasia battery
CFCP – Chinese functional communication profile
It has been nearly 2 years since I mentioned PSA on the blog (Acupuncture for PSA),[2] but only a year since we discussed a very impressive laboratory paper on the mechanism of EA in PSD (EA for PSD).[3] They are of course quite different in terms of the brain areas affected; however, the treatment with acupuncture overlaps to some degree (use of CV23 for example), and I wonder whether there could be some similarity in the mechanisms involved.
To my surprise, PSA had come top of the list, in the 2022 BMJ series of papers on acupuncture research, of conditions where there was ‘good’ evidence of effectiveness, but no recommendations in guidelines.[4,5]
This paper is the largest RCT of acupuncture (MA) in PSA to date, and it comes from the same group in Tianjin that published the SR I reviewed in the only previous blog on the subject.
Tianjin is a large port city just southeast of Beijing. The name literally means heavenly ford, but the origin of the name is disputed. Rather like modern day Shanghai, Tianjin is built to a great extent on the silt deposited over centuries by one of the 2 great rivers in China – the yellow river, which at one time entered the open sea in the area. Now the yellow river enters the sea somewhat farther to the south. Shanghai is built on the silt from the Yangtse in case you were wondering about the other famous river in China.
The paper is just out in JAMA Network Open, so not really one to overlook, and it is the first large clinical trial (n=252) of acupuncture in PSA. All prior trials had fewer than 50 per arm. The MA used in this trial was fairly robust and intense – daily treatment on weekdays for 6 weeks, and vigorous manual manipulation of the needle in points such as HT1, LU5, SP6, and BL40 requiring the relevant limb to twitch 3 times. SP6 was used bilaterally, but the others only on the side of the body affected by the stroke (presumably this is usually the right side if the patient has PSA).
As mentioned above, my favourite point in the tongue (CV23 – Lianquan) was used, but also a pair of points either side of it (Panglianquan). I haven’t seen these mentioned before and they don’t appear in any of my point resources, whereas the points in the mouth on the underside of the tongue do appear, as have be discussed previously (see Acupuncture for PSA). I am not particularly keen on these ones, and I suspect they derive from a time when very swollen tongues were a cause of difficulty speaking rather than stroke.
A superficial off point sham was used in the control arm of the trial with points typically 1 cun (~2cm) away from the classical points. No manual stimulation of the needles was performed in this group.
The primary outcomes were the aphasia quotient (AQ) of the Western Aphasia Battery (WAB) and the CFCP. The AQ is measured from 0 to 100 with lower scores indicating greater impairment of language function and the CFCP is from 0 to 250 with higher scores representing better functional communication ability in Mandarin – I wonder how well I would score on that one ;-). Probably not so well, despite me not currently suffering from PSA.
The strong MA group did significantly better achieving a between group difference of 7.99 on the AQ, which compares well with the significant change on this measure quoted by Gilmore et al at 5.05.[6] Similarly the MA group did significantly better on the CFCP with a change from baseline getting well into the range considered clinically important.
I have to say I have been relatively convinced by this data, particularly in combination with the mechanistic data from animal models in a related condition (PSD). Of course, it would be hard to measure improvements in PSA in rodents :D!
References
1 Li B, Deng S, Zhuo B, et al. Effect of Acupuncture vs Sham Acupuncture on Patients With Poststroke Motor Aphasia: A Randomized Clinical Trial. JAMA Netw Open. 2024;7:e2352580.
2 Li B, Deng S, Sang B, et al. Revealing the Neuroimaging Mechanism of Acupuncture for Poststroke Aphasia: A Systematic Review. Neural Plast. 2022;2022:5635596.
3 Yao L, Ye Q, Liu Y, et al. Electroacupuncture improves swallowing function in a post-stroke dysphagia mouse model by activating the motor cortex inputs to the nucleus tractus solitarii through the parabrachial nuclei. Nat Commun. 2023;14:810.
4 Lu L, Zhang Y, Tang X, et al. Evidence on acupuncture therapies is underused in clinical practice and health policy. BMJ. 2022;376:e067475.
5 Zhang B, Han Y, Huang X, et al. Acupuncture is effective in improving functional communication in post-stroke aphasia : A systematic review and meta-analysis of randomized controlled trials. Wien Klin Wochenschr. 2019;131:221–32.
6 Gilmore N, Dwyer M, Kiran S. Benchmarks of Significant Change After Aphasia Rehabilitation. Arch Phys Med Rehabil. 2019;100:1131-1139.e87.
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