Stimulated by Ma et al and Zhang et al 2024.[1,2]
CV23 has recently been introduced on the BMAS Foundation Course…
PSD – post stroke dysphagia
key to acronyms
IF – impact factor
FMA – Fugl-Meyer assessment (motor function assessment after stroke)
BI – Barthel index (assessment of activities of daily living)
DOSS – dysphagia outcome severity scale
SWAL-QOL – swallowing quality of life (outcome score)
APC – article processing charge
CAM – complementary and alternative medicine
MBA – masters in business administration
TENS – transcutaneous electrical never stimulation
I was struggling to find a paper to get my teeth into this week and finally settled on 2 similar papers on PSD. They both come from China, and from regions on roughly the same longitude but 1300km apart – Hebei to the northeast of Beijing and Hubei, which is considerably further south and better known for its principal city, Wuhan. The first paper comes from a hospital in the city Zhangjiakou, Hebei province. Zhangjiakou literally translates as the Zhang family pass. The first author of the second paper is also a Zhang, but since this is one of the most common surnames in the world, I doubt there is any relevant link.
The first paper is a retrospective study of stroke patients with PSD at a single centre published in the Sage journal Clinical Rehabilitation (IF 3.0). Two cohorts (n=60 each) were identified based on similar disease parameters and whether or not they had received acupuncture alongside standard rehabilitation. Outcomes were FMA, BI, DOSS, and the rather onomatopoeic SWAL-QOL.
The acupuncture was labelled as ‘quick’ and described as ‘pulling needles immediately after applying a certain intensity of stimulation’. From this I assume that no needles were retained, but each point was treated individually, and the needle removed. Treatment was performed once a day for 6 days a week over 4 weeks, and the points included: GV20, CV23, GB20, LI11, LI10, TE5, LI4, LI15, ST36, SP6, LR3, ST32, GB34. Often in stroke studies only points in the midline and on the side affected by hemiplegia are used, but this is not explicitly stated in the paper.
All outcomes improved significantly from baseline and most showed a significantly greater improvement in the acupuncture cohort compared with the control (standard rehabilitation only). The mean DOSS score was numerically higher than control, but the difference did not reach statistical significance. This may well be related to the nature of the score (only 7 possible scale points) and a ceiling effect. The SWAL-QOL score improved to a significantly greater degree in the acupuncture cohort, but this is not a surprise since we know that sham acupuncture as well as verum has a large effect on quality-of-life scores.[3]
The second paper is a prospective trial of the same size (n=120) as the previous study. Whilst the methodology is better (prospective and randomised), the reporting is somewhat problematic from my perspective. I generally avoid this particular open access journal (Medicine), although it has been going for over 100 years. I am unsure when it switched to open access, but I guess it was around 10 years ago when the number of issues per volume jumped from 6 to over 50 in the space of a couple of years. The APC is just under $2k, the acceptance rate is just under 50%, and the IF is 1.6 according to Google. I have just checked the profiles of section editors and see that for CAM they have a chiropractor with an MBA (see my facial expression at the top of the blog).
Well, I have started now, so I better carry on. Acupuncture was added to standard rehabilitation for swallowing function as well as presumably standard rehabilitation of other stroke related neurological deficits. The points used included: GB20, GV26, CV23, PC6, SP6, TE17, and the points that are bled under each side of the tongue. I have mentioned the latter previously: Acupuncture for PSA 2022. Whilst they used a standard needle size (0.25x40mm) the paper describes penetration depths of millimetres, with the deepest being less than 5mm at SP6. This seems very odd for treatment of stroke patients in China. Needle retention time was 30 minutes and sessions were daily for 4 weeks. EA was applied to GB20 at 2Hz, presumably from one side to the other. The tongue points were bled every other day, and PC6 and GV26 were treated every 3 days.
The results show an effective rate of over 90% in the acupuncture group and just over 80% in the standard rehabilitation control. I am not at all keen on outcomes expressed as effectiveness rates. They also describe a standardised swallowing assessment, but it is not reported whether this is carried out by clinicians who are blind to the group allocation.
Objective measures are also reported, and these favour the acupuncture group (auditory evoked potentials and cerebral blood flow), although again there is no mention of masking the relevant observers.
A third relevant paper I spotted on my searches this week is a review of neurostimulation after stroke published in Physical Medicine and Rehabilitation Clinics of North America (IF 1.7).[4] The paper describes a variety of devices from transcranial direct current stimulation to TENS, but absolutely no mention of acupuncture or even EA (see my facial expression at the top of the blog again).
References
1 Ma Y, Guo H, Geng L, et al. Effect of quick acupuncture combined with rehabilitation therapy on improving motor and swallowing function in patients with stroke. Clin Rehabil. 2024;2692155241228694.
2 Zhang W, Jin H-T, Wang F, et al. A randomized controlled study investigating the efficacy of electro-acupuncture and exercise-based swallowing rehabilitation for post-stroke dysphagia: Impacts on brainstem auditory evoked potentials and cerebral blood flow. Medicine (Baltimore). 2024;103:e37464.
3 Saramago P, Woods B, Weatherly H, et al. Methods for network meta-analysis of continuous outcomes using individual patient data: a case study in acupuncture for chronic pain. BMC Med Res Methodol. 2016;16:131.
4 Osman H, Siu R, Makowski NS, et al. Neurostimulation After Stroke. Phys Med Rehabil Clin N Am. 2024;35:369–82.
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