Effect of Needle-retaining Time on Therapeutic Efficacy for Post-stroke Hemiplegia

Li Hai-zhou, Xie Kai, Zhou Li-feng, Fu Qing-lan, Zheng Pei-hong

1 Rehabilitative Care Technique Teaching and Research Room, Ningbo Tianyi Polytechnic, Zhejiang 315104, China

2 Lianhua Hospital, Zhenhai District, Ningbo, Zhejiang 315207, China

Effect of Needle-retaining Time on Therapeutic Efficacy for Post-stroke Hemiplegia

Li Hai-zhou1, Xie Kai2, Zhou Li-feng1, Fu Qing-lan1, Zheng Pei-hong2

1 Rehabilitative Care Technique Teaching and Research Room, Ningbo Tianyi Polytechnic, Zhejiang 315104, China

2 Lianhua Hospital, Zhenhai District, Ningbo, Zhejiang 315207, China

Objective: To observe the effect of needle-retaining time in scalp acupuncture on therapeutic efficacy for post-stroke hemiplegia.

Methods: A total of 82 cases who met the inclusion criteria were randomly allocated into a control group (22 cases), a short-time needleretaining group (30 cases) and a long-time needle-retaining group (30 cases). Conventional Bobath therapy was employed in the control group while the scalp acupuncture was combined in the short-time (0.5 h) needle-retaining group and long-time (24 h) needle-retaining group. Then functional assessments were made 1 month and 3 months after treatment using Fugl-Meyer motor scale (FMMS), Fugl-Meyer assessment of balance (FMA-B) and modified Barthel index (MBI) score.

Results: Cases in the long-time needle-retaining group obtained better effects in motor function of the limbs and activities of daily living (ADL) than the other two groups (P＜0.05). In addition, there was no statistical significance between the short-time needle-retaining group and the control group (P＞0.05).

Conclusion: The needle-retaining time in scalp acupuncture is substantially associated with the effect for post-stroke hemiplegia and long-time needle-retaining is more advisable.

Acupuncture Therapy; Scalp acupuncture; Stroke; Complications; Hemiplegia; Rehabilitation

As a common medical emergency, stroke affects 5-6 million people in China and its incidence rate is approximately 200/100 000[1]. Despite the remarkable advance in medical diagnosis and treatment, most stroke survivors left hemiplegic and need rehabilitation care. Today, integrative acupuncture (traditional method) and movement training (modern rehabilitation medicine) have been extensively used in the management of post-stroke hemiplegia[2]. However, the treatment effects vary greatly due to non-standardized method. This study aims to observe the effect of needle-retaining time of scalp acupuncture on post-stroke hemiplegia and thus provide evidence for standardized scalp acupuncture.

1 Clinical Materials

1.1 Inclusion criteria

This is based on the diagnostic criteria stipulated in the 4th National Academic Conference on Cerebrovascular Diseases[3]. Initial cerebral ischemia or hemorrhage confirmed by CT or MRI scan; aged below 80 with stable vital signs and can cooperate in examination and training, and in absence of apparent cognitive disorder.

1.2 Exclusion criteria

Hemiplegia due to brain trauma, brain tumor or non-cerebrovascular diseases following brain surgery; cerebral infarction with concurrent hemorrhage; complications of organ failures involving heart, lung, liver and kidney; severe aphasia and cannot communicate due to severe cognitive disorder; and having a history of stroke and/or limb disturbance.

1.3 General data

A total of 82 outpatients treated in the Department of Acupuncture & Rehabilitation of our hospital were randomized into a control group, a short-time needle-retaining group and a long-time needle-retaining group. Of 22 cases in the control group, 13 cases were ischemic and 9 cases were hemorrhagic; 12 cases were male and 10 cases were female; the average age was (63±9) years; and the mean duration was (54.5±17.6) d. Of 30 cases in the short-time needle-retaining group, 16 cases were ischemic and 14 cases were hemorrhagic; 18 cases were male and 12 cases were female; the average age was (63±7) years; and the mean duration was (56.5±18.7) d. Of 30 cases in the long-time needleretaining group, 14 cases were ischemic and 16 cases were hemorrhagic; 15 cases were male and 15 cases were female; the average age was (63±8) years; and the mean duration was (55.7±16.5) d. There were no statistical differences in general data among the three groups (P＞0.05).

2 Treatment Methods

Patients in all groups took routine Western medications to control blood pressure, blood sugar, blood fat and improve cerebral blood circulation.

2.1 Short-time needle-retaining group

2.1.1 Scalp acupuncture

Points: The Motor Area (MS 6), Foot Motor-sensory Area (MS 8), Sensory Area (MS 7) and Chorea Trembling Control Area (parallel with and 1.5 cm anterior to MS 6) according to the Jiao’s scalp acupuncture.

Method: After routine disinfection using iodophors, puncture the above points 25 mm subcutaneously using filiform needles of 40 mm in length, conduct fast twisting and retain the needles for 30 min. The treatment was done once a day by the same acupuncturist.

2.1.2 Rehabilitation training

Physical therapy (PT) and occupational therapy (OT) in Bobath concept were adopted for stroke patients. In order to inhibit abnormal motor pattern and obtain normal motor pattern, the PT mainly targets spasm-control training of the torso and four limbs, motor-control training of the passive movementassistant movement-active movement, functional exercise of turning the body over-sitting up-standingwalking and balanced training. The OT mainly targets the performance in activities of daily living, including dressing/undressing, using eating utensils, feeding, personal hygiene and toilet use, etc. The treatment was done once a day by the same therapist, 45 min for each treatment.

2.2 Long-time needle-retaining group

Except for retaining the needles for 24 h, the same method was employed as the short-time needleretaining group.

2.3 Control group

3 Treatment Results Observation

3.1 Evaluation methods

The following evaluations were made in each group before, 1 month and 3 months after treatment. All evaluations were done by one same physician.

3.1.1 Assessment of motor function

The motor function was assessed using Fugl-Meyer motor scale (FMMS) and Fugl-Meyer assessment of balance (FMA-B).

3.1.2 Assessment of activities of daily living (ADL)

The activities of daily living were assessed using modified Barthel index (MBI).

3.2 Statistical method

The SPSS 10.0 version software was used for statistical management, () and repeated measuringF-test for measurement data expression, independent samplet-test and Chi-square test for patients’ general material.α=0.05 indicates a statistical significance.

3.3 Treatment results

After 1 and 3 months of treatment, the FMMS, FMA-B and MBI scores were significantly improved in all groups (P＜0.01). Before and after 1 month of treatment, there were no statistical differences in FMA-B and MBI scores among the three groups (P＞0.05); however, the FMMS score in the long-term needle-retaining group was higher than that in the other two groups (bothP＜0.05). After 3-month treatment, there were no statistical differences in FMMS, FMA-B and MBI scores between the short-time needleretaining group and control group (P＞0.05); however, the FMMS and MBI scores in the long-time needleretaining group were higher than those in the other two groups (P＜0.05). Although the FMA-B score in the long-time needle-retaining group showed no statistical difference with the other two groups, and it did show a better tendency (see table 1, 2, and 3).

Table 1. Comparison of FMMS scores among three groups before and after treatment (, point)

Table 1. Comparison of FMMS scores among three groups before and after treatment (, point)

Note: Compared with intra-group results before treatment, 1)P<0.01; compared with the control group, 2)P<0.05; compared with the short-time needle-retaining group, 3)P<0.05

Control 22 29.83±22.24 57.33±23.161)65.23±19.751)Short-time needle-retaining 30 28.35±22.40 56.45±23.651)66.58±20.231)Long-time needle-retaining 30 26.46±21.02 63.85±24.561)2)74.16±21.101)2)3)

Table 2. Comparison of FMA-B scores among three groups before and after treatment (, point)

Table 2. Comparison of FMA-B scores among three groups before and after treatment (, point)

Note: Compared with the intra-group results before treatment, 1)P＜0.01

Control 22 5.23±2.10 7.21±2.111)8.23±2.131)Short-time needle-retaining 30 5.20±2.05 7.14±2.151)8.20±2.091)Long-time needle-retaining 30 5.13±2.10 7.39±2.111)8.66±2.401)

Table 3. Comparison of MBI scores among three groups before and after treatment (, point)

Table 3. Comparison of MBI scores among three groups before and after treatment (, point)

Note: Compared with intra-group results before treatment, 1)P<0.01; compared with the control group, 2)P<0.05; compared with the short-time needle-retaining group, 3)P<0.05

GroupsnBefore treatment1 month after treatment 3 months after treatment Control group 22 38.23±15.17 53.21±14.231)72.23±18.551)Short-time needle-retaining 30 40.20±16.23 51.14±14.051)70.20±17.151)Long-time needle-retaining 30 39.13±15.54 55.09±14.641)75.16±20.141)2)3)

4 Discussion

Acupuncture has always been a popular traditional method for post-stroke rehabilitation because of its low cost and good effect. Today, it remains to be the main therapy for stroke sequelae in regions with little access to rehabilitation medicine. Modern studies have suggested that acupuncture could systematically regulate different layers or phases of post-stroke pathophysiology, electrophysiology, biochemistry and gene expression, and thus improve functional reconstruction of the brain. Numerous clinical trials have confirmed its positive effect on functional rehabilitation and inducing voluntary movements of the affected limbs. However, this cannot guarantee normal movements for stroke patients. Depending on input of correct movement pattern, i.e., unceasing input of facilitation signal via neurophysiological technology, normal movement patterns are important for an early functional reorganization and remodeling of the nervous system[4]. Consequently, it is necessary to combine with modern rehabilitation training. Body and scalp acupuncture can both be used for stroke. Since scalp acupuncture does not limit the limb movement or directly stimulate the spastic muscle, it is more convenient to be used with modern rehabilitation training. However, there is still no consensus regarding the needle-retaining time.

According to this study, compared with rehabilitation training alone for post-stroke hemiplegia, scalp acupuncture of 30-min needle-retaining could not further improve the effect; whereas scalp acupuncture of 24-hour needle-retaining could improve the patients’motor function and performance in ADL and showed a better synergistic action with rehabilitation training. This indicates that unlike acupuncture for other conditions, scalp acupuncture with short-time needle-retaining may not work well for stroke; 24 h of needle-retaining has been proved to be a better option. Further study is needed to identify the optimal needle-retaining time for stroke patients.

Although there were no statistical differences in FMA-B scores between the long-time needle-retaining group and the other two groups after 3 months of treatment, a tendency of effectiveness did show in the numerical value. This might be explained by inadequate balance training in 45-minute rehabilitation exercise conducted by outpatients in this study.

According to modern rehabilitation medicine, the injured central nervous system (CNS) can reorganize or remodel both structure and function and some neurons can be regenerated under appropriate conditions[5]. Based on neurophysiology and neurodevelopment principle, the Bobath therapy modulates the excitability of neurons in neural transmission pathways, activates the weakened muscles, reduces muscle spasticity andthus promotes normal motor patterns. It is now one of the most extensive and effective approaches to enhance CNS remodeling. It’s generally believed that scalp acupuncture can enhance cerebral circulation, activate cerebral cortex or layers, coordinate the stimulation to cerebral cortex or layers, and thus improve the nerve function recovery rates. Some researchers think scalp acupuncture-induced voluntary movements or motor pattern coupled with rehabilitation training can consolidate and help with completion of ‘normal movement patterns’ in motor areas of cerebral cortex[6]. Some researchers believe the effect of scalp acupuncture on stimulating cerebral cortex via deep sensation afferent nerve pathways and enhancing reorganization of sensory and motor function areas might be related to the activation of ipsolateral compensatory functions of pyramidal tracts[7]. This is probably the theoretical foundation for integration of scalp acupuncture and modern rehabilitation training.

Chinese medicine considers that post-stroke sequelae are mainly attributed to stasis obstructing the brain. Acupuncture can dredge local meridians and improve the limb movement. Stimulating motor area and sensory area can improve the motor and sensory functions[8-14]. Stimulating chorea trembling control area can relieve post-stroke spasticity. Long-time needleretaining is necessary to circulate qi and resolve blood stagnation.

In summary, as a worthwhile comprehensive therapy, combined long-time needle-retaining and modern rehabilitation training can shorten the duration of patients with post-stroke hemiplegia. Further study is still needed regarding the needle-retaining time in order to standardize its application, relieve patient’s suffering and thus obtain better effects.

[1] Jia ZS, Lü PY, Yan YN. Rehabilitation of Cerebral Apoplexy. Shijiazhuang: Hebei Science and Technology Publishing House, 2006: 2.

[2] Yang D, Zhang CE, Xu L. Observation on therapeutic effect of acupuncture plus rehabilitation for hemiplegia following stroke. J Acupunct Tuina Sci, 2008, 6(4): 219-221.

[3] Chinese Neuroscience Society, Chinese Neurosurgical Society. Key diagnostic points for cerebrovascular diseases. Zhonghua Shenjingke Zazhi, 1996, 29(6): 379-380.

[4] Zheng WK, Qiao CH, Liu JS. Effect of combined acupuncture and rehabilitation training on daily living and mobility of patients with upper limb paralysis. Jilin Yixue, 2009, 30(21): 2678.

[5] Liao HS. Principles of functional recovery following central nervous system (CNS) injury (II). Zhongguo Kangfu Lilun Yu Shijian, 1996, 2(1): 1-5.

[6] Guo JW, Xie YX, Sun QL, Bai W, Yu JB, Gu SJ. Application of acupuncture in the early rehabilitation for stroke patients. Zhongguo Kangfu Yixue Zazhi, 2005, 20(1): 40-43.

[7] Ceballos-Baumann AO, Passingham RE, Marsden CD, Brooks DJ. Motor reorganization in acquired hemidystonia. Ann Neurol, 1995, 37(6): 746-757.

[8] Li L, Gong JQ, Ding GH, Cai DH, Cai Y. Effect of parallel scalp acupuncture therapy on hemodynamic function of cerebral circulation in post-stroke patients. J Acupunct Tuina Sci, 2008, 6(5): 309-311.

[9] Yu L. Clinical observations on the efficacy of scalp acupuncture as a main treatment for stroke sequela. Shanghai Zhenjiu Zazhi, 2010, 29(2): 88-90.

[10] Cai H, Li M. Observations on the efficacy of scalp acupuncture plus body acupuncture in treating post-stroke hemiplegia. Shanghai Zhenjiu Zazhi, 2009, 28(7): 383-385.

[11] Wang J, Sun KX, Wu XB. Effect of individualized needling on gross motor function in cerebral palsy infants. J Acupunct Tuina Sci, 2013, 11(1): 13-18.

[12] Bai J, Li BD, Wang QH. Therapeutic observation on cluster needling at scalp acupoints plus cognition training for post-stroke cognitive impairment. Shanghai Zhenjiu Zazhi, 2012, 31(10): 711-713.

[13] Sun YZ, Wang YJ, Wang W. Effect of acupuncture plus rehabilitation training on shoulder-hand syndrome due to ischemic stroke. J Acupunct Tuina Sci, 2012, 10(2): 109-113.

[14] Wu XB, Zhang HM, Sun KX. Assessment of effect of interactive scalp acupuncture on gross motor function in treating infantile spastic cerebral palsy. Shanghai Zhenjiu Zazhi, 2011, 30(3): 177-179.

Translator: Han Chou-ping

Received Date: June 6, 2013

R246.6

A

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simple PT and OT rehabilitation training without acupuncture.

Author: Li Hai-zhou, M.M., lecturer.

E-mail: zjtnyx@126.com