Stroke is the second most common cause of death and results in the disability of a large number of people worldwide. Strokes are either ischemic or hemorrhagic, but more than 80% of stroke cases are caused by cerebral ischemia. Many ischemic stroke patients experience a poor prognosis with neurological and motor function impairment, such as spastic paralysis, which greatly lowers the quality of life of stroke survivors. Various therapies have been used to conquer the sequela of stroke, including medication, rehabilitation and surgery but the effectiveness of these treatments remains unsatisfactory.
Acupuncture has been used to treat stroke patients in China for a very long time. Evidence shows that acupuncture not only reduces the myocardial injury but also significantly promotes recovery of neurological function in stroke patients and thus improves their quality of life. In recent years, many studies have shown that acupuncture has improved the symptoms of strokes in different stages of conditions. Here the potential mechanism and effects of acupuncture therapy on strokes reported in recent years are summarised.
1. Basic research
1.1 How did acupuncture help recovery in experimental ischemic stroke model?
A literature review study found that acupuncture stimulation significantly enhanced neurogenesis in the brain of experimental ischemic stroke model, according to a report published in journal of Scientific Reports.
Neurogenesis naturally occurs only in very a few small regions of the adult brain. However, neurogenesis is considered too weak to produce any significant compensation in response to brain injury. Promoting endogenous neurogenesis such as neural stem/progenitor cells appears to offer a promising therapeutic strategy for treating stroke. Recent studies showed that acupuncture treatment played a neuroprotective role in treating patients with stroke. Other studies reported acupuncture enhanced neurogenesis in the brain of experimental ischemic stroke.
A group of scientists (Lu et al., 2016) in China undertook a preclinical systematic review and meta-analysis to assess the current evidence for effect of acupuncture on neurogenesis in treating ischaemic stroke. Thirty-four studies represented a total of 1617 experimental subjects were included in the review study. The data showed that acupuncture improved neurological deficits and reduced brain edema in experimental ischemic models, and that the mechanisms mostly involved in enhancing endogenous neurogenesis including proliferation, migration and differentiation of neural stem/progenitor cells. Acupuncture was found to be effective in promoting neurogenesis, particularly from day 7 to day 14 after ischemia; neurocyte proliferation peaked at day 7 while differentiation peaked at day 14. These results suggested an optimum time window in stroke for acupuncture therapy. Authors suggested that the study may help the planning and improve the likelihood of success of future clinical trials, provide empirical evidence to improve the rigor of the conducting and reporting of preclinical research.
1.2. Mechanism underlying the effect of acupuncture on stroke
Acupuncture stimulation at acupoints one day after cerebral ischemia significantly reduced the cerebral infarct area and neurological deficit scores accompanied by increasing release of neurotrophic factors and activating anti-apoptosis process in the brain of stroke model according to a study (Cheng et al., 2014) recently reported in the journal BMC Complementary and Alternative Medicine.
Recently Dr. Cheng and colleagues in Taiwan investigated the effect of early acupuncture stimulation on stroke model and the mechanism of action of acupuncture. Electroacupuncture stimulation at GV20 and GV14 was applied on mild cerebral ischemia injury rat, a mild stroke model, one day after ischemia formation for 2 days. Neurological functions such as motor, sensory, balance and reflex were assessed before and after acupuncture.
It was found that acupuncture stimulation significantly improved neurological functions and reduced cerebral infarct area compared with baseline and non-acupoint treated group. Biochemical studies showed that acupuncture markedly increased the release of neurotrophic factors and initiated anti-apoptotic process compared with controls. Blockers of neurotrophic factors stopped the neuroprotective effect of acupuncture in the stroke model. The study suggests that early acupuncture use may act as neuroprotective therapy in the treatment of stroke.
- Clinical studies
2.1. Acupuncture as an adjunct improves symptoms of patients with early stage stroke
Acupuncture in combination with route treatments for early stage stroke significantly reduced the blood pressure, hematoma volume in the brain and improved neurological deficits of haemorrhagic stroke patients. The early stage stroke is a critical period for any better recovery. Immediate access to high quality stroke specialist care is paramount importance. Early multidisciplinary therapies that would help earlier recovery should be considered in stroke treatment.
Tao et al., (2014) conducted a clinical study to assess the impact of acupuncture as an adjunct on patients with early stage stroke. Fifty-four patients with small amount of cerebral haemorrhage were randomly divided into conventional treatment group and conventional plus acupuncture group. Patients in conventional group were treated with stroke special care, oxygen therapy, never nutrition and symptomatic support, antihypertension and other treatments when necessary. Patients in conventional plus acupuncture group were given additional acupuncture treatment at 4h, 6h and 12h after disease onset respectively. Blood pressure including systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP), hematoma volume and neurological deficits were assessed at different time points.
It was found that blood pressure including SBP, DBP and MAP were significantly increased 12h after stroke onset in conventional treatment group. Additional acupuncture significantly decreased blood pressure at 12h compared conventional treatment alone. This improvement in blood pressure by acupuncture lasted to 24h. Acupuncture significantly decreased hematoma volume at 6h after stroke onset compared with conventional treatment and this improvement maintained up to 24h. Evaluation of neurological deficits revealed that acupuncture markedly reduced neurological deficit scores compared with conventional treatment alone group. The study suggests that acupuncture as an adjunct therapy in early stage stroke treatment should significantly improve the symptoms within 24h and has potential for a better recovery.
2.2. Acupuncture improved MCI in patients with post-cerebral infarction
Acupuncture in combination with nimodipine showed a sustainable improvement of cognitive function in patients with post-cerebral infarction (Wang et al., 2016). It was reported in journal of BMC Complementary and Alternative Medicine.
Patients with cerebral vascular disease such as stroke often develop cognitive dysfunction ranging from mild cognitive impairment (MCI) to dementia. It was reported that nearly 50% of patients developed MCI within four years after stroke. Clinical studies showed that cholinesterase inhibitors donepezil, galantamine, and rivastigmine produced some beneficial effect in patients with MCI. However none of them was approved for the treatment of vascular cognitive impairment due to the uncertain effect of drugs. Acupuncture has been used to treat cognitive impairment in China for a long time.
Dr. Wang and colleagues conducted a randomized clinical study to assess the efficacy and safety of acupuncture alone or in combination with nimodipine, a calcium channel blocker, to treat cerebral infarction-induced MCI. A total of 126 patients with post-cerebral infarction MCI were recruited and randomly divided into 3 groups, nimodipine alone group (30 mg/time and 3 times daily), acupuncture alone group and acupuncture combined nimodipine group. Patients were assessed with Montreal Cognitive Assessment (MoCA) scale before treatment, at the end of 3-month treatment and post-treat 3-month follow-up. Acupuncture stimulation was manually applied at following acupoints: DU20, EX-HN1, ST2, GB20, GB12, BL10, DU26, HT7, PC6, ST40, SP6 and LR3, 30 min each time, 6 times a week for 3 months.
At the end of study, all three treatment groups showed a significant improvement judged by MoCA scale compared with respective baseline; however, the significant improvement was markedly higher in combination group compared nimodipine alone and acupuncture alone group. Further, at the 3-month follow-up the sustained improvement was more significant in combination group compared other two groups. No adverse effect was reported with three groups at the end of study. The study suggested that acupuncture could be used as an adjunct therapy to drug treatment to further improve cognitive function in patients with post-infarction.
2.3. Acupuncture lowered the risk of acute myocardial infarction in stroke patients
A retrospective cohort study showed that stroke patients receiving acupuncture treatment had a decreased risk of developing acute myocardial infarction compared with the stroke patients without acupuncture (Chuang et al., 2015). The report was published in journal of BMC Complementary and Alternative Medicine.
It has been reported that patients with stroke have a high risk of developing heart conditions such as acute myocardial infarction which is a fatal attack. How to reduce the risk of acute myocardial infarction in stroke patients remains a big concern in primary care.
Recently, a group of scientists led by Dr. Chuang conducted a retrospective cohort study to evaluate whether acupuncture could reduce the risk of acute myocardial infarction. They evaluated the data from 23475 stroke patients aged between 40-79 year-old, receiving acupuncture and compared with 46950 propensity score-matched stroke patients without acupuncture treatment. The study found that acupuncture treatment reduced the risk of developing acute myocardial infarction in stroke patients.
2.4. How does acupuncture stimulation at GB34 help improve motor function in post-stroke hemiplegic patients?
Acupoint GB34 has been used to treat patients with stroke to help motor function recovery and is accompanied with the increased neuronal activities in motor-related brain regions according to a neuroimaging study (Chen et al., 2015) published in journal of Brain Research.
Acupoint GB34 is one of the most common acupoints used in treating motor-related conditions in China for a very long time. However its underlying mechanism is not clear. Recently scientists (Chen et al., 2015) explored the central mechanism of immediate effect of acupuncture stimulation at GB34 on the motor-related network of stroke patients with hemiplegic.
Functional magnetic resonance image (fMRI) was used to assess the changes in neuronal activities of different brain regions before and after acupuncture stimulation at GB34 and compare the changes between GB34 and sham acupoint. Function MRI data analysis showed that acupuncture at GB34 may increase motor-cognition connectivity, including visual-memory, motor task learning, and motor intention, meanwhile decrease compensation of unaffected motor cortex and ipsilateral synkinesis, which can definitely promote the rehabilitation of hemiplegia and spasm. This study demonstrated the underlying mechanism of GB34 central action in post-stroke patient with hemiplegia.
2.5. Acupuncture is an effective post-stroke rehabilitation tool
Acupuncture therapy increased quality of life, improved mobility and activities of daily living of poststroke patients. The finding (Farmer et al., 2015) in which a review article recently reported in the Journal of Evidence-Based Complementary and Alternative Medicine.
It has been reported that approximately half of stroke survivors suffers from hemiparesis, cognitive deficits including difficulty in solving problems, dementia, memory impairment, depression and difficulty in communication. These significantly degraded their independence, quality of life and sense of emotional well-being. Although conventional post-stroke rehabilitation helps many stroke patients restore some of their physical or emotional function the outcome is not always satisfactory.
Recently Ms. C Farmer and colleagues studied some clinical trials which assessed the effect of acupuncture on the post-stroke patients suffering from chronic stroke symptoms. It was found that overall those clinical studies consist of a set of strengths and weakness that suggest the acupuncture as a worthy addition to the post-stroke patient rehabilitation. Acupuncture in particular is effective in improving quality of life, enhancing mobility and cognitive function. There were no adverse effects. Author stated that among the reviewed study there was a common consensus, based on the data that acupuncture is a safe and effective treatment for post-stroke rehabilitation.
2.6. Acupuncture improved symptoms of ataxia after stroke
Acupuncture techniques such as “3 acupoints regulating balance”, “3 acupoints regulating tremor” and “3 acupoints regulating movement” significantly improved symptoms of ataxia. A case report (Zhang et al., 2014) was published in the journal of Chinese Acupuncture and Moxibustion.
Ataxia is a term used to describe a group of neurological disorders. It usually results from damage to the cerebellum which plays an essential role of body’s co-ordination, and/or other parts of nervous system. The symptoms of ataxia include difficulties with walking, balance, speaking, vision and many more. Treatment is complicated and difficult depending on types of ataxia, such as hereditary ataxia, acquired ataxia etc.
Recently Dr. Zhange et al., treated a 68-year old, male patient with 2-year history of ataxia after stroke. The patient had extreme difficulty in walking and needed two people to support him while standing or walking. He was treated by specific acupuncture techniques called “3 acupoints regulating balance” – 1.5 cun below the lower edge of occipital protuberance, “3 acupoints regulating tremor” – chorea-tremor control area and “3 acupoints regulating movement” – motor area; plus acupoints GB12, GB20, GV16, BL10 and C3-C6 Jiaji acupoints. Acupuncture stimulation on above acupoints for 30 min, once daily, 5 days a week. One month after acupuncture, the patient’s conditions such as walking and balace were improved. He could walk steadily up to 50 to 100 meters, supported by only person. Two-month following acupuncture treatment, the patient could walk alone without any help and lived independently. One-year follow-up found the improvement was still well maintained.
2.7. Acupuncture is more effective than conventional therapy in improving functional activities in subacute stroke patients
Patients with ischemic stroke of subacute stage recovered better following combination of body acupuncture and scalp acupuncture treatment compared to conventional therapy, according to a report (Chen et al., 2014) recently published in journal Zhongguo Zhen Jiu.
Subacute stage of stroke occurs between 1-6 months after onset of stroke. Better recovery in the subacute stage of stroke is crucial for patient’s long-term revival. Chen et al., (2014) carried out a randomized controlled clinical trial to assess the efficacy of combination of body acupuncture and scalp acupuncture in patients of subacute stroke. One hundred twenty-six patients were divided into acupuncture treatment group (n=61) and conventional treatment group (n=65). Acupuncture was given 5 times a week for total 8 weeks. The Fugl-Meyer scale and NIHSS scale and Barthel index were used to evaluate the motor functioning, balance, sensation, joint functioning and activity of daily living before and during and after acupuncture treatment and follow-up.
Assessment after 4-week acupuncture showed a very good improvement compared to baseline judged by all parameters but did not show significant difference from conventional treatment group. At the end of 8-week acupuncture patients demonstrated markedly improvement in all assessments compared to baseline. Acupuncture showed a significant functional improvement compared to conventional group at the end of 8-week treatment and 3-month follow-up assessment. Authors conclude that combination of body acupuncture and scalp acupuncture achieved better clinical efficacy in stroke recovery compared to conventional treatment.
- Chen LF et al., [Motor dysfunction in stroke of subacute stage treated with acupuncture: multi-central randomized controlled study]. Zhongguo Zhen Jiu. 2014 Apr;34(4):313-8. http://www.ncbi.nlm.nih.gov/pubmed/24946625
- Chen X et al., A functional magnetic resonance imaging study on the effect of acupuncture at GB34 (Yanglingquan) on motor-related network in hemiplegic patients. Brain Res. 2015 Mar 19;1601:64-72. http://www.ncbi.nlm.nih.gov/pubmed/25601007
- Cheng CY et al., Electroacupuncture-like stimulation at Baihui and Dazhui acupoints exerts neuroprotective effects through activation of the brain-derived neurotrophic factor-mediated MEK1/2/ERK1/2/ p90RSK/bad signaling pathway in mild transient focal cerebral ischemia in rats. BMC Complementary and Alternative Medicine2014,14:92 http://www.biomedcentral.com/1472-6882/14/92
- Chuang SF et al., Decreased risk of acute myocardial infarction in stroke patients receiving acupuncture treatment: a nationwide matched retrospective cohort study. BMC Complementary and Alternative Medicine (2015) 15:318. http://www.ncbi.nlm.nih.gov/pubmed/26353964
- Farmer C, Bringing holistic treatments to the attention of medicine: acupuncture as an effective poststroke rehabilitation tool. Journal of Evidence-Based Complementary & Alternative Medicine, 2015 Apr;20(2):120-5. http://www.ncbi.nlm.nih.gov/pubmed/25552471
- Lu L et al., Acupuncture for neurogenesis in experimental ischemic stroke: a systematic review and meta-analysis. Sci Rep. 2016 Jan 20;6:19521. http://www.ncbi.nlm.nih.gov/pubmed/26786869
- Tao WQ et al., Impacts of acupuncture on blood pressure and hematoma in patients of cerebral hemorrhage at the early stage. Zhongguo Zhen Jiu. 2014 May;34(5):426-30. http://www.ncbi.nlm.nih.gov/pubmed/25022108
- Wang S et al., Efficacy and safety assessment of acupuncture and nimodipine to treat mild cognitive impairment after cerebral infarction: a randomized controlled trial. BMC Complementary and Alternative Medicine (2016) 16:361. http://www.ncbi.nlm.nih.gov/pubmed/27623621
- Zhang SL. [Professor ZHANG Yu-Lian’s experiences in treatment of post-stroke ataxia by regulating marrow sea acupuncture]. Zhongguo Zhen Jiu. 2014 Aug;34(8):807-9. http://www.ncbi.nlm.nih.gov/pubmed/25335266
- Grateful acknowledgements are due to Drs Chen LF, Chen X, Cheng CY, Chuang SF, Farmer C, Lu L, Tao WQ, Wang S, Zhang SL and colleagues (This paper was based on their articles cited in above Reference section), as well as to Bai-Yun Zeng for his work in preparing this briefing paper.