Clinical observation on acupoint pressure plus longsnake moxibustion for upper-limb spastic hemiplegia after cerebral infarction

Wang Yu-chun (王玉春), Sun Hai-yan (孫海燕)

Traditional Chinese Medical Hospital of Taihe County, Anhui Province, Fuyang 236601, China

Abstract Objective: To observe the clinical efficacy of acupoint pressure plus long-snake moxibustion for upper-limb spastic hemiplegia after cerebral infarction.

Keywords: Acupuncture-moxibustion Therapy; Acupoint Pressure Therapy; Moxibustion Therapy; Governor Vessel;Cerebral Infarction; Poststroke Syndrome; Hemiplegia; Muscle Spasticity

Spastic hemiplegia is a common limb dysfunction characterized by increased muscle tone and tendon hyperreflexia after cerebral infarction. The upper limb manifests flexion spasticity and the lower limb manifests tonic spasm[1]. Among them, the lower limb function has a certain ability of self-recovery, and the walking function can be regained as long as there is just a little improvement in the function[2]. For patients with upperlimb spasm, the lesion area is mostly in the middle cerebral artery. The projection site of cerebral cortex is large, which makes flexor spasm very difficult to recover,seriously affecting patient's activities of daily living (ADL)and quality of life (QOL)[3]. Moxibustion and acupoint pressure therapy are important methods in traditional Chinese medicine (TCM) external therapies, with good safety and economic rating, and widely used in rehabilitation for patients with cerebral infarction. Study showed that moxibustion had good therapeutic effects on poststroke syndromes such as aphasia, dysphagia,cognitive disorder, urinary or defecation disorder and depression[4]. Acupoint pressure therapy can directly and effectively mitigate the muscular spasticity in patients with stroke or cerebral palsy[5-6]. In this study, we observed the clinical efficacy of acupoint pressure plus long-snake moxibustion for upper-limb spastic hemiplegia after cerebral infarction.

1 Clinical Materials

1.1 Diagnostic criteria

This study referred the diagnostic criteria of cerebral infarction inChina Guideline for Cerebrovascular Diseases Prevention and Treatment[7]. The onset was related to cerebral atherosclerosis, hypertension and arteriosclerosis; the clinical manifestations were not quite severe, but might present with temporary conscious disturbance; clear infarction site could be found by CT or MRI examination, and lumbar puncture showed no bloody cerebrospinal fluid.

1.2 Inclusion criteria

Those who met the above diagnostic criteria for cerebral infarction, and were the first attack; with clear consciousness; had unilateral upper-limb spastic paralysis and increased muscle tone; with disease duration no more than 6 months; with stable vital signs;aged 30-85 years; agreed to participate in this trial and signed informed consent.

1.3 Exclusion criteria

Those with increased muscle tone caused by brain tumors or other reasons; who had severe disease of cardiovascular system, lung or kidney; women during pregnancy or lactation; patients with flaccid paralysis;who had recently taken muscular relaxants.

1.4 Elimination and dropout criteria

Those who did not receive the treatment in this study on time; got worse in the disease condition or presenting with severe adverse reactions; or with incomplete data.

1.5 Statistical methods

All data were statistically analyzed by the SPSS version 22.0 statistical software. Counting data were processed by Chi-square test. The rank-sum test was used for the comparisons of ranked data. Measurement data in normal distribution and with homogeneous variance were expressed as mean ± standard deviation (±s).The intra-group comparison was analyzed by pairedttest, and the comparison between the groups was analyzed by groupt-test. If data did not meet the normal distribution or homogeneous variance, non-parametric test was applied.P＜0.05 was considered to indicate a statistically significant difference.

1.6 General data

A total of 100 patients with upper-limb spastic hemiplegia after cerebral infraction were enrolled between January 2019 and December 2019. SPSS version 22.0 statistical software was used to generate a random number table, and then random numbers were assigned to each patient according to the visiting sequence. The random numbers were sequenced from small to large, and patients corresponding to the first 50 random numbers were included in the control group,and patients corresponding to the last 50 random numbers were included in the observation group. During the trial, there was no dropout case in either groups.There were no significant differences in gender, age,duration of disease and the side of paralysis (allP＞0.05),indicating that the two groups were comparable(Table 1).

Table 1. Comparison of general data between the two groups

2 Treatment Methods

Patients in both groups were treated with the conventional internal medicine and rehabilitation training. The conventional internal medicine included stabilizing plaque, lowering blood lipids, improving brain microcirculation, anti-platelet aggregation, nourishing nerves, and treating primary diseases such as diabetes,hypertension and coronary heart disease. The rehabilitation training mainly included exercise therapy,occupational therapy, and orthosis.

2.1 Control group

The control group was treated with additional acupoint pressure therapy on the basis of the above conventional treatments.

Acupoints: Hegu (LI 4), Neiguan (PC 6), Chize (LU 5),Quchi (LI 11) and Jiquan (HT 1) on the affected side.

Methods: The patient took a supine position and relaxed. The physician stood by the affected side of the patient. Firstly, Na-grasping was applied to relax the muscles of the affected limb. Then Dian-digital pressing,An-pressing and Rou-kneading manipulations were applied to the corresponding acupoints with thumb or middle finger. Jiquan (HT 1), Quchi (LI 11), Chize (LU 5),Neiguan (PC 6) and Hegu (LI 4) of the affected upper limb treated with Dian-digital pressing and An-pressing in sequence. The strength of manipulation gradually increased, producing sensations such as soreness,numbness, distension and heaviness. The force then gradually decreased before the manipulation ended. The treatment was performed once a day, 20-30 min per time, and lasted for one month.

2.2 Observation group

The observation group was treated with long-snake moxibustion on the basis of the treatments in the control group.

Treatment area: Alone the Governor Vessel, from Dazhui (GV 14) to Yaoshu (GV 2).

Methods: The patient took a prone position, with skin of the back exposed. After routine disinfection with 75%alcohol cotton balls, the physician dipped the cotton ball in ginger juice and smeared it on the disinfected skin area,then evenly spread the Governor Vessel moxibustion powder on the skin, and then spread the mashed ginger on the moxibustion powder to form a ladder-like structure with a narrow top and a wide bottom (the upper width was about 4 cm, the lower width was about 5 cm, and the height was about 2 cm). Finally, the moxa floss was spread on the mashed ginger, and made into a long snake-like moxa stick with a sharp top and a wide bottom and an isosceles triangle cross-section. The physician ignited the moxa stick by the head, middle and tail, and waited till it burned out, which was considered as one moxa-cone. After burnt out, moxa floss was spread to continue moxibustion. Three cones were used for each time of moxibustion, and the moxibustion was applied once a week, for 1 month in total. On the day of long-sake moxibustion, the acupoint pressure therapy should be performed after moxibustion.

3 Observation of Curative Efficacy

3.1 Observation items

3.1.1 Ashworth grade

With the elbow joint as the observation site, the degree of spasticity of the affected elbow flexor muscle group was evaluated with six grades of 0, 1, 1+, 2, 3 and 4. The higher the grade, the higher the muscle tone and the severe the spasticity[8].

3.1.2 Fugl-Meyer assessment upper limb scale(FMA-UL)

The FMA-UL was scored before and after treatment.The total score of FMA-UL was 66 points. The higher the score, the better the mobility of the affected limb[9].

3.1.3 Barthel index (BI)

The BI was scored before and after treatment. The total score of BI was 100 points. The higher the score, the better the ADL[10].

3.1.4 Surface electromyography (sEMG) signal

The sEMG signals of biceps brachii and flexor carpi radialis on the affected side were measured before and after treatment. And the root mean square (RMS) values were recorded.

3.2 Criteria of curative efficacy

The efficacy was assessed according to Ashworth grade[11].

Markedly effective: Ashworth grade was reduced by more than 2 levels.

Effective: Ashworth grade decreased, but less than 2 levels.

Invalid: No improvement in the Ashworth grade.

3.3 Results

3.3.1 Comparison of clinical efficacy

The total effective rate in the observation group was 96.0%, which was significantly higher than 80.0% in the control group (χ2=6.060,P=0.014), (Table 2).

Table 2. Comparison of clinical efficacy between the two groups (case)

3.3.2 Comparison of Ashworth grade

Before treatment, there was no significant difference in the Ashworth grade between the two groups(Z=-0.363,P=0.717). After treatment, the Ashworth grades in both groups improved significantly (in the control group,Z=-3.596,P=0.000; in the observation group,Z=-6.032,P=0.000), and the Ashworth grade in the observation group was superior to that in the control group (Z=-2.675,P=0.007), (Table 3).

3.3.3 Comparison of FMA-UL and BI scores

Before treatment, there were no significant differences in the FMA-UL and BI scores between the two groups (bothP＞0.05). After treatment, the FMA-UL and BI scores in both groups increased compared with those before treatment (allP＜0.05), and the FMA-UL and BI scores in the observation group were higher than those in the control group (bothP＜0.05), (Table 4).

3.3.4 Comparison of RMS values of biceps brachii and flexor carpi radialis on the affected side

Before treatment, there were no significant differences in the RMS values of biceps brachii and flexor carpi radialis of the affected limb between the two groups (bothP＞0.05). After treatment, the RMS values of biceps brachii and flexor carpi radialis in both groups decreased compared with those before treatment (allP＜0.05), and the RMS values of biceps brachii and flexor carpi radialis in the observation group were lower than those in the control group (bothP＜0.05), (Table 5).

Table 3. Comparison of Ashworth grade between the two groups (case)

Table 4. Comparison of FMA-UL and BI scores between the two groups (±s, point)

Note: Compared with the same group before treatment, 1) P＜0.05; compared with the control group after treatment, 2) P＜0.05

Group n FMA-UL BI Before treatment After treatment Before treatment After treatment Observation 50 40.20±4.83 47.64±3.841)2) 60.80±10.51 79.50±6.721)2)Control 50 40.02±4.80 43.60±4.251) 60.20±9.89 73.00±9.091)

Table 5. Comparison of RMS values of biceps brachii and flexor carpi radialis on the affected side (±s, μV)

Table 5. Comparison of RMS values of biceps brachii and flexor carpi radialis on the affected side (±s, μV)

Note: Compared with the same group before treatment, 1) P＜0.05; compared with the control group after treatment, 2) P＜0.05

Group n Biceps brachii Flexor carpi radialis Before treatment After treatment Before treatment After treatment Observation 50 19.53±4.79 14.74±3.371)2) 18.88±3.74 14.69±2.611)2)Control 50 19.36±4.07 17.42±3.581) 17.85±3.72 16.09±2.981)

4 Discussion

After cerebral infarction, the advanced motor center is injured, and the inhibition of spinal cord reflex arc is lower than normal, breaking the balance of spinal cord segmental neurons, and making the mutual restriction and interaction of α and γ motor neurons unbalanced. γ motor neurons occupy a dominant position, and the excitability of the stretch reflex is enhanced, leading to increased muscle tone and tendon hyperreflexia[12-14].

Upper-limb spastic hemiplegia after cerebral infraction belongs to Jing-spasm syndrome and sinew disease in TCM, mainly caused by disorders of Yin Heel Vessel and Yang Heel Vessel. The syndrome is mainly blood stasis due to qi deficiency, resulting in insufficient nourishment of tendons and meridians. It can be seen that the imbalance of yin and yang and the disharmony of qi and blood are the basic pathogenesis of the disease[15], and the treatment should be based on the principles of balancing yin and yang and harmonizing qi and blood.

Long-snake moxibustion is a unique therapy of TCM.The Governor Vessel is the sea of yang meridians,connecting with all the yang meridians, where gathers yang qi of the whole body, and connects with the Conception Vessel. Therefore, regulating the Governor Vessel can balance yin and yang, and unblock qi and blood flow of the whole body. The Governor Vessel enters and connects the brain, which is the sea of marrow. Therefore, regulating the Governor Vessel can refresh the brain and supplement marrow. From the perspective of meridian circulation, the three yang meridians of upper limbs are directly or indirectly connected with the Governor Vessel through their divergent meridians. Hence, regulating the Governor Vessel can promote qi movement and blood circulation.Long-snake moxibustion has the characteristics of sufficient moxibustion fire, heat and strong warmunblocking power, which can balance yin and yang,harmonize qi and blood, refresh the brain and improve spasticity, and nourish tendons and meridians[16].

Acupoint pressure therapy is characterized by small point of force application and intense stimulation, which can open the blockage, and promote qi movement and activate blood flow, so as to achieve the effects of unblocking meridians and activating collaterals,balancing yin and yang, and eliminating pathogen and strengthening the healthy qi, thus helping to relieve muscle spasm[17]. Modern medicine believes that Diandigital pressing and An-pressing the important acupoints can stimulate peripheral nerves and send feedback to the brain center, thereby promoting the recovery of brain functions, so as to enhance the two-way regulation of the central nervous system, keeping the nervous system in a relatively balanced state of excitement and inhibition. Meanwhile, the acupoint pressure therapy also can directly improve the blood and lymph circulation of the paralyzed limbs, nourish the local muscles, and strengthen the elasticity of the muscles and ligaments,thereby relieving the contracture and deformity of the limbs[18]. In this study, Neiguan (PC 6) and Hegu (LI 4)were chosen because they are close to the wrist and can promote qi movement and activate blood flow, thus relieving the joint spasm and recovering the activity function of the wrist joint. Quchi (LI 11) and Chize (LU 5)are located at the elbow joint, mainly treating the spasm and pain of the elbow and arm, and unfavorable elbow flexion and extension. Jiquan (HT 1) is under the armpit,mainly for shoulder and arm contracture pain, and disability in raising the arm. Therefore, applying acupoint pressure to the above points could relax tendons and relieve pain, promote qi movement and activate blood flow, smooth the joints, and reduce swelling and remove stasis, so as to relieve limb spasm and recover functions and activities.

The results in this study suggested that the total effective rate in the observation group was significantly higher than that in the control group. After treatment,the Ashworth grade in the observation group was superior to that in the control group. The FMA-UL and BI scores in both groups increased significantly compared with those before treatment, and the FMA-UL and BI scores in the observation group were higher than those in the control group. These results indicated that on the basis of conventional treatments, acupoint pressure therapy plus long-snake moxibustion had a great therapeutic efficacy for upper-limb spastic hemiplegia after cerebral infarction, improving the spasticity degree of the affected limb, and enhancing the mobility of the affected limb and the ADL.

The sEMG signal detection is a non-invasive, objective and quantitative method to assess neuromuscular function, and is widely used in rehabilitation and sports medicine. Among them, RMS represents the effective value of muscle fiber discharge, reflecting the level of muscle activity[19]. The larger the RMS value, the greater the muscle strength. The RMS value mainly reflects the muscle tone while the limbs are relaxed and passively stretched[20]. After treatment, the RMS values of biceps brachii and flexor carpi radialis on affected side in both groups decreased, and the RMS values of biceps brachii and flexor carpi radialis in the observation group were lower than those in the control group. These results indicated that on the basis of conventional treatments,acupoint pressure therapy plus long-snake moxibustion could reduce the muscle tone of biceps brachii and flexor carpi radialis, and relieve spasticity in patients with upper-limb spastic hemiplegia after cerebral infraction.

In summary, on the basis of conventional treatments,acupoint pressure therapy plus long-snake moxibustion has a great therapeutic efficacy for upper-limb spastic hemiplegia after cerebral infarction. It can reduce the muscle tone of biceps brachii and flexor carpi radialis of the affected limb, improve the spasticity degree of the affected limb, and enhance the mobility of the affected limb and the ADL. Thus, is worthy of clinical promotion.

Conflict of Interest

The authors declare that there is no potential conflict of interest in this article.

Acknowledgments

There was no project-fund supporting for this study.

Statement of Informed Consent

Informed consent was obtained from all individual participants.

Received: 15 April 2020/Accepted: 11 May 2020