Original Article

Bringing Holistic Treatments to the Attention of Medicine: Acupuncture as an Effective Poststroke Rehabilitation Tool

Journal of Evidence-Based Complementary & Alternative Medicine 2015, Vol. 20(2) 120-125 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2156587214565459 cam.sagepub.com

Cecilia Farmer, BSN, RN1

Abstract This article reviews 3 studies that explore the effects of acupuncture on poststroke patients suffering from chronic stroke symptoms. The 3 studies selected strive to show how acupuncture can be a safe, noninvasive, and cost-effect rehabilitation tool useful in adjunct with traditional rehabilitation. Chou et al (2009), Hopwood et al (2008), and Wayne et al (2005) all studied acupuncture’s effects on quality of life. Additionally, both Hopwood et al and Wayne et al studied acupuncture’s effects on mobility and activities of daily living. While the frequency, duration, and length of the entire treatment varied by study, overall, the results of all 3 studies suggest that acupuncture increases quality of life and improves mobility and activities of daily living. Keywords stroke, acupuncture, rehabilitation Received November 12, 2014. Accepted for publication December 1, 2014.

Introduction Nine thousand, one hundred and fifty-seven. That is the number of needles inserted into poststroke patient Devon Dearth’s body over the course of 3 months of extensive acupuncture therapy.1 Dearth, a 40-year-old, body-building champion, business owner, and family man, suffered a traumatic stroke to his brain stem, leaving him with right-sided paralysis and enormous verbal and visual deficits. Unfortunately, his insurance company disappointed him and his family by covering a set number of visits, leaving him with the only option of paying between $100 000 and $200 000 per month for his extensive rehabilitation. His loss of independence resulted in depression for himself and his wife, who suffered caregiver burnout as a result of bearing the complete weight of supporting her entire family as well as assisting her husband with all of his activities of daily living. It was only after his brother, Doug Dearth, performed his own research of other reasonable options for poststroke rehabilitative care that he discovered a short-term, intensive acupuncture treatment held in Tianjian, China, at a price they could afford. There were remarkable improvements in his speech, movement, and mood. By the end of the film, Devon walks with assistance, exercises in the gym, and is able to have conversations with friends and family. Devon’s inspiring story, while standing as a single example, is a testament to the effectiveness of acupuncture as a poststroke rehabilitation tool. Moreover, it is especially relevant in US health care system,

which is dominated by insurance company policies often preventing patients from receiving all available options of care. Stroke is the number one cause for serious, life-long disability in the United States, with approximately 3 million permanently disabled stroke survivors.2,3 Stroke, a condition where brain tissue dies due to lack of blood supply, creates numerous physical limitations that take months to years of rehabilitation in attempts to correct the residual effects. Approximately half of stroke survivors suffer from hemiparesis and 46% suffer cognitive deficits, including difficulty solving problems, dementia, memory impairment, depression, and difficulty communicating.2 Living with these limitations robs their independence, quality of life, and sense of emotional well-being, taking a toll on psychological and physiological health. One third of poststroke patients experience depression as a result of their loss of abilities, not to mention their caregivers suffer as well.2 Furthermore, poststroke rehabilitation creates an enormous financial burden as well with an estimated 57.9 billion dollars in cost of treatment, a number expected to grow more

1

University of California, Irvine, CA, USA

Corresponding Author: Cecilia Farmer, BSN, RN, 22446 Porreras, Mission Viejo, CA 92692, USA. Email: [email protected]

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over the next 2 decades due to the increasing age of the population and rising number of stroke survivors.3 The implication of acupuncture for nurses is that they should help facilitate recovery from stroke by becoming more knowledgeable of the most up-to-date information on community resources in order to offer better assistance in obtaining needed poststroke rehabilitation services. Only 30.7% of stroke survivors received rehabilitation due to lack of accordance with clinical practice guideline recommendations.2 Rehabilitation services should be delivered through a variety of disciplines, decided on by the collaborative care team, family, and patient if they are cognitive.4 Traditional outpatient rehabilitation for poststroke patients includes time with a physical, occupational, and/or speech therapist developing self-care skills (feeding, bathing), mobility, communication, and social skills. As effective as traditional rehabilitation methods can be, only 14% of survivors will reach a full recovery, while 25% to 50% still require some assistance with their activities of daily living.5 It should be noted during this ongoing collaborative conversation that additional therapies are available to patients. Nurses should consider exploring these options as an adjunct to conventional treatment, one of which is acupuncture. Acupuncture is an ancient form of Chinese therapy that intends to balance the flow of internal energy in the body (qi) by inserting fine needles into points on the body, which regulate the energy channels that affect internal organ systems. Although acupuncture as a medical treatment began in China more than 2000 years ago, it was not until 1971 when a high-profile reporter wrote in the New York Times how well acupuncture eased his own pain that acupuncture became well-known and adapted as a part of the complementary and alternative therapy movement in the West.6 The effectiveness of acupuncture lies in the release of endogenous opioids in the body. Numerous other studies have shown acupuncture improves activities of daily living and quality of life, which this article will strive to highlight.7 Acupuncture is an affordable option that treats the root of disease, supports the body without being overtly invasive, easy and relaxing to receive, and has low potential for negative side effects. The purpose of this article is to review the most recent scholarly literature regarding acupuncture’s efficacy as a poststroke rehabilitation tool and proposes that acupuncture treatments has significant potential to increase the quality of life through restoration of cognitive and motor abilities. Nurses can help meet Healthy People 2020’s goal of increasing the amount of stroke survivors referred to a rehabilitation program on discharge.8 This can be accomplished by tailoring programs to meet their patient’s needs with knowledge of other complementary therapies and advocating the patient’s right to such treatment.

Studies Reviewed The databases Cumulative Index to Nursing and Allied Health Literature, PubMed, and Cochrane were used to find a combination of randomized controlled trials and systematic reviews regarding acupuncture as a poststroke rehabilitation tool. For

Cumulative Index to Nursing and Allied Health Literature, the terms ‘‘Stroke OR Hypertension’’ AND ‘‘acupuncture’’ were used, and were filtered by those published in the past 5 years, peer-reviewed, in the alternative and complementary category, and limiting patients older than 40 years old living in the United States, resulting in a final number of 17 articles. On PubMed, 12 articles resulted from (stroke OR hypertension OR ischemic) AND (acupuncture) AND (rehabilitation) and filtered to the most recent of the past 5 years and systematic reviews. In the Cochrane database, 12 resulted when the terms ‘‘stroke,’’ ‘‘rehabilitation,’’ and ‘‘acupuncture’’ were searched and narrowed down by publication in the past 5 years and reviews only.

Methods Study 1: Wayne et al (2005) Wayne and colleagues9 performed a prospective, sham-controlled, randomized controlled trial that assessed the benefits of acupuncture for chronic poststroke symptoms: upper extremity range of motion, spasticity, motor function, and consequently the quality of life, activities of daily living, and mood. The study consisted of an individualized, traditional Chinese medicine–based protocol along with a sham protocol in which sham acupuncture needles were used. Both patients and assessors were blinded, but not the acupuncturists. Inclusion criteria selected people who had moderate upper extremity disability from a first stroke at least 6 months prior and who were capable of rising from a chair and walking without assistance. Any patients who had prior experience with acupuncture, had contraindications to electroacupuncture (eg, pacemaker), comorbidities that could prevent patients from participating (eg, cancer), involvement with other physical therapy, participation in other studies, or any cognitive impairment that would affect one’s ability to give informed consent were excluded. Up to 140 stroke patients were recruited initially with 93 screened out due to meeting one or more of the exclusion criteria. Eleven left because of disinterest and 14 could not participate due to lack of transportation. At the end of selection, 33 patients were enrolled in the study and randomized into either the acupuncture (16 patients) or the sham control group (17 patients). Those allocated to active treatment had a total of 3 dropouts due to scheduling issues and a sick child. The sham treatment group had 6 dropouts due to non–stroke related health issues and travel. This resulted in completion of 13 subjects in treatment and 11 in control. Treatments were administered to patients twice every week for a length of 10 weeks by 2 licensed acupuncturists. The active acupuncture intervention involved inserting needles on the body surface and on the scalp, alternating weekly, for a period of 20 to 30 minutes. Each visit began with an evaluation of interrogation, looking, smelling, listening, and palpation that determined where the acupuncture points would be placed. Stimulation was applied manually until ‘‘de qi,’’ a heavy ache felt in the tissue, was reached. In addition, each of the points was electrically stimulated (exact electrical value not provided). As for the sham acupuncture intervention, the device used appeared as a needle, which the patient can see and feel, but retracts and slides up the needle shaft, never penetrating the skin. The upper extremity function, activities of daily living, quality of life, and mood were assessed at baseline and again at 12-week and 6-month follow-ups. The Fugl-Meyer Assessment assessed motor function and the Modified Ashworth Scale assessed wrists and elbows. 121

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The Barthel Index assessed each patient’s activities of daily living (highest score ¼ 20), the Center for Epidemiological Surveys Depression scale assessed mood (>16 indicated depression), and, finally, the Nottingham Health Profile measured quality of life based on several dimensions: emotional relations, sleep, lack of energy, pain, physical mobility, and social isolation (highest score ¼ 100). A Student t test and Fisher’s exact test were used to compare the characteristics of both groups. Multiple linear regression models were used to compare effects of acupuncture based on spasticity, grip strength, range of motion, activities of daily living, quality of life, and mood. This study takes a new approach to past randomized controlled trials of acupuncture by using individualized treatments meant to treat the unique diagnostic classes of stroke for each survivor as opposed to a standard treatment protocol. The acupuncturists were trained in China and had an average of 20 years of clinical experience each. This study also used a validated sham acupuncture device to prevent any additional, unwanted medical effects that could compromise the findings. Masking of treatment assignment is shown to be effective through the results of their blinding assessments with only 28% correctly guessing their assignment at the start and only 35% guessed correctly at the termination of the study. The most notable weaknesses are convenience sampling and small sample size. Patients were recruited mostly from the Spaulding Rehabilitation Hospital’s Stroke service as well as from the city of Boston, thus potentially causing risk for further bias with a convenience sample damaging the external validity of the results. Furthermore, some patients had their strokes nearly 6 months prior to the experiment, potentially weakening the treatment effect. More weakness is apparent in the small sampling sizes of 13 and 11 in treatment and control groups and wide confidence intervals. With a small, convenient sampling including patients with longer history of chronic stroke symptoms, it is difficult to make bigger claims about the positive effects of acupuncture in general.

Study 2: Hopwood et al (2008) Hopwood et al10 conducted a single-blinded, randomized, clinical trial investigating the efficacy of acupuncture on stroke recovery. Patients were required to have had an acute stroke 4 to 10 days before randomization with at least a 25% cognitive deficit. Exclusion criteria included previous stroke, inability to give informed consent, comorbidities, pacemaker, participation in other studies, and any bleeding in the brain. Up to 644 patients were originally collected but 539 were excluded mostly due to having a previous stroke. With that, 105 patients entered the study from the beginning but 67 completing the trial in entirety. A total of 23 patients in the experimental group and 15 in the control group could not complete assessments or treatment for reasons including transferring out of the area, illness, a protocol violation, withdrawal, or death. Severity of stroke was balanced between both groups by using Barthel Index score to stratify the randomization. Treatment began 4 to 10 days after each patient’s stroke. Each session lasted 30 minutes for 3 times per week for 4 weeks with 12 treatments in total. All patients received ‘‘traditional care’’ in addition, involving drug therapy, physical therapy, and occupational therapy. The control group received a placebo intervention with body and scalp points attached to a deactivated transcutaneous electrical nerve stimulation machine. The experimental group received acupuncture according to best practice guidelines. De qi was obtained during the needling with 2 Hz of electricity. The primary outcome measure was the 10-question Barthel Index (20 points ¼ perfect score) measuring activities of daily living. Motor recovery was measured with the

Motricity Index. The Nottingham Health Profile, a self-assessment tool, measured quality of life, pain, and mood. The Barthel Index, Motricity Index, and Nottingham Health Profile were recorded at baseline, 3, 6, 12, 24, and 52 weeks. A w2 test and t test were used to compare the demographic characteristics and validity of the results. A t test evaluated the results of the 3 tests as well as a longitudinal analysis of outcomes. The study collected more substantial results by starting their intervention shortly after the time of stroke while there is better potential for healing. Homogeneity was ensured with stratification on randomization with regard to Barthel Index score. Assessment nurses were blinded to treatments administered and were instructed not to discuss treatments with the patients. The outcome measurement tool, Barthel Index, is widely used and validated based on previous acupuncture studies. This study stated that with 100 patients they could detect with 80% power how significant the findings would be able to replicate in the population. They successfully collected 105 subjects from a pool of 539, so the criteria for sufficient power were met. Baseline characteristics were equally distributed across both groups. No adverse events occurred and the only patient who was on anticoagulants was dropped before treatment began. Like many acupunctures studies, patients were blinded but the acupuncturists were not. Also, the overall program only lasted 4 weeks while a longer length of treatment could have led to better results. The physiotherapists in this study had limited experience with acupuncture, trained just before the program, with the subjects being their first acupuncture patients. The protocol followed was standardized across all the patients with no regard to specific symptoms or class of stroke, so effects could have been limited. Convenience sampling was a weakness in this study with 68% of patients recruited from the same hospital. The size of the sample was affected by a high mortality rate of the subjects due to their very recent strokes, very rigorous exclusion criteria, especially excluding those with previous stroke and transient ischemic attacks, and from a hiatus in the trial due to reorganization of stroke care in the hospitals involved. The hiatus, which is not clearly explained in the article and left vague, severely limited recruitment and led to premature termination of the trial. The issue of whether the pressure of the sticker attached to the transcutaneous electrical nerve stimulation machine used on placebo patients remains uncertain. Finally, risk of self-report bias could be apparent in those patients that have better insight into their condition when completing their assessment surveys.

Study 3: Chou et al (2009) Chou and colleagues11 performed a prospective, randomized, singleblind design to prove the effect of electroacupuncture on cognitive function and quality of life in poststroke patients. A total of 38 Taiwanese poststroke patients with cognitive impairment were included in the study that demonstrated the following traits: ages between 50 and 90 years, history of past stroke at least a year prior, and some cognitive impairment (a score 16 indicates depression). Hopwood et al’s Nottingham Health Profile scores showed significant improvement only in the area of energy levels (P ¼ .043). Wayne et al’s study showed positive treatment effect with the

Center for Epidemiological Surveys Depression (1.53, P ¼ .28) but with not enough statistical significance. Chou et al measured quality of life with 2 different tools: Lowenstein Occupational Therapy Cognitive Assessment for geriatric population, 36-item short-form health survey, and a stroke-specific quality of life scale with an emphasis on language and personality. The Lowenstein Occupational Therapy Cognitive Assessment scores of the treatment group showed statistically significant differences in the scores between 8 weeks of treatment and before in 4 areas: orientation, perception, praxis, and memory (P < .05). Short-form health survey scores in the treatment group showed significant difference (P < .05) in areas of role limitation due to physical problems, vitality, social functioning, role limitation due to emotional problems, and mental health. The quality of life scores of the treatment group between baseline and 8 weeks showed significant difference (P < .001) in the area of language. The results of Hopwood et al and Chou et al agree that acupuncture achieves improvement in quality of life.

Mobility Two of the studies, Hopwood et al10 and Wayne et al,9 examined acupuncture’s benefits for physical rehabilitation poststroke. Hopwood et al demonstrated this by measuring the treatment and control groups at baseline, 3, 6, 12, 24, and 52 weeks using the Motricity Index. The Motricity Index scores were averaged from total scores of the upper and lower extremities, with a higher score indicating better muscle strength. Both treatment and control groups improved; however, the differences became insignificant after 3 weeks. Wayne et al, using the Fugl-Meyer Assessment at baseline and 12 weeks, demonstrated better results (P < .01) in upper extremity function: Ashworth wrist scores, shoulder rangeof-motion through the frontal plane, and wrist range-ofmotion in the sagittal and frontal planes. Only Wayne et al was able to conclusively show positive effects of acupuncture on mobility.

Activities of Daily Living Barthel Index was used to measure activities of daily living in both studies of Hopwood et al10 and Wayne et al.9 Hopwood et al’s study showed activities of daily living improvement in both treatment and control groups. Hopwood and colleagues observed that the results of their study were similar to what was expected from traditional stroke rehabilitation alone, thus suggesting that acupuncture does not provide additional effects even as a placebo. As for Wayne et al, activities of daily living, measured by the Barthel Index, also did not show a statistically significant difference between 2 groups. The treatment effect showed to be 0.72 (least-squares mean of the active treatment group minus the least-squares mean of the shame treatment group) at a P value of .70, while showing an overall positive trend, is not enough to attribute to acupuncture alone and cannot make recommendations based on these results. 123

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Discussion Strengths These studies are well validated through effective randomization and stratification of subjects using certain characteristics, such as Barthel Index score, to ensure homogeneity. If any one group had more severe subjects than the other, the treatment could potentially be seen to be more or less effective than if the groups had equal severity. All 3 studies, Chou et al,11 Wayne et al,9 and Hopwood et al,10 performed randomization of all their subjects. At least 2 of the studies mentioned that they also used stratification to ensure homogeneity. Hopwood et al clearly delineated the entire process: randomization was computer generated by independent administrative staff in blocks of 6, followed by stratification into 2 subgroups using the Barthel Index score on entry to control for severity. Wayne et al stratified groups based on severity of the patients’ hand motor impairment by assessing how well the subject could tap their index finger (of impaired hand) 3 or more times on a tabletop within 15 seconds. Their randomization was explained thoroughly as well: randomization was computer-generated using permuted blocks of 4; results were sealed in opaque envelopes for each group. Furthermore, at least 2 studies had rigorous exclusion criteria to ensure none of their patients had comorbidities that could interfere with the results of the study or lead to dropouts. For example, in Chou et al’s study, any patient that had a preexisting condition (psychiatric diagnosis, history of drug abuse) that could mask any cognitive benefits of acupuncture were excluded. Wayne et al also excluded comorbidities that would prohibit participation such as active renal dialysis, metastatic cancer, or extremity fracture within past 6 months. As a result, no dropouts occurred due to of patient health-related concerns. Hopwood et al excluded a quarter of their original pool of subject due to comorbidities as well.

Weaknesses Unfortunately, due to rigorous exclusion criteria, samples sizes were too small for applying findings to the general public. Chou et al11 had a total of 38 participants, 17 in the treatment group and 16 in the control group. Wayne et al9 had even less, a total of 33 participants and of those that finished per protocol, 11 in acupuncture and 8 in control. Hopwood et al10 came closest to overcoming this limitation with the largest group of the 3 studies, a finishing group total of 67 participants, 34 in acupuncture and 33 in placebo. The researchers of this study postulated that if they had at least 100 subjects in the study, they could detect a difference of 4 units in mean Barthel Index score with 80% power and 5% significance level using the ANCOVA statistical analysis methodology. Although they initially collected 105 participants to meet these criteria, 67 is the number that finished, so they also utilized longitudinal analysis to make up the difference. Finally, the results are based on patient self-report tools with a risk of attrition bias. Both Hopwood et al and Wayne et al

used the Nottingham Health Profile survey to measure quality of life. This patient-answered survey tool measures subjective health status in the form of perceived quality of life. Hopwood et al acknowledged that brain-injured patients are more realistic in their self-assessments and less subject to ‘‘wishful thinking,’’ which may lower Nottingham Health Profile scores. Chou et al incorporated 2 different quality of life measuring tools: Short Form survey-36 and the Stroke Specific Quality of Life Scale, both of which are also patient-reported outcomes. Attrition bias is a possibility whenever patients report their own findings, as some will report higher because they believe the treatment is working. Others may even use recall bias, that is, some may not have the best insight into their own conditions or may remember their history incorrectly. Therefore, the results of these surveys should be taken under consideration with caution, at best. The best outcomes would be measured by an objective assessor who is trained and licensed.

Implications for Nursing Practice and Future Research Overall, these studies comprised a collage of strengths and weaknesses that suggest that acupuncture is a worthy clinical tool for poststroke, rehabilitation patients that requires further research. All 3 studies noted in their conclusions that there were not nearly enough patients for them to make general recommendations. However, even where there was not enough data to show significant difference, overall positive trends were found to exist in areas such as quality of life, mobility, and cognitive function. Conclusively, there is evidence to show that acupuncture does improve quality of life. This improvement in quality of life can be arguably attributed to the improvements made in mobility and the cognitive functions. Acupuncture showed in the studies by Hopwood et al and Wayne et al that it increases blood flow to the areas needles, thus leading to better rehabilitation of these parts of the body. One of the most important strengths is that there were no adverse effects from the treatment. Among the 3 studies there was consensus that acupuncture is a safe and effective treatment based on findings. While this treatment is shown to be safe, the scientific community requires evidence that acupuncture improves quality of life, mobility, activities of daily living, and so on, so that it can be incorporated into the standard of care and no longer viewed skeptically by the larger medical community. Patients like Devon Dearth need options like acupuncture available when no other options are viable.1 As his documentary demonstrated, acupuncture alone was able to make remarkable difference in a short amount of time. Having these additional options provides hope for poststroke patients, especially for those for whom price is an issue or when traditional treatment with physical therapy is not enough. Until acupuncture has been scientifically refuted as not effective, there currently exists enough literature that point patients in this direction as an option. Education begins at the bedside with the nurse. Patients and their families cannot make the best choices in terms of treatment

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postdischarge if they do not have all the resources and information available. Patients trust their nurses more than any other profession and look for and heed the advice and information given by them. Nurses themselves need to be further educated in this rehabilitation option and action should be implemented in creating a framework where nurses who work in stroke units are required to educate themselves of available complementary and alternative medicine such as acupuncture. Society as whole—patients, their families, hospitals, nurses—would benefit from incorporating more complementary and alternative medicine therapies into practice, based on evidence such as these 3 studies. Perhaps future studies will succeed where these 3 past studies failed. Further research is necessary to determine what the effects of electricity versus acupuncture are in the electroacupuncture treatments. Electricity, in itself, causes a contraction and affects circulation, thus potentially leading to the mobility improvements. Second, more research is necessary for showing how well certain acupuncture placebo treatments work. A standard, evidence-based placebo treatment that has no significant effects, whether by acupressure or acupuncture, that would discredit the placebo effect. Finally, more studies need to be done to physically and biochemically assess and understand how acupuncture affects the modification of neurotransmitters and the treatment of pain in stroke patients. Studies in this area would further assist in adding credibility to acupuncture and convincing skeptics and offering hope to patients like Devon Dearth.1

Conclusion The major setbacks caused by stroke—depression, dementia, memory impairment, speech impediment, and physical handicap—create an enormous burden for the victims and their caregivers. Not nearly enough of all nurses are doing their part to ensure that patients receive the additional aid they need to reach full recovery. Not only are patients not being referred to enough rehabilitation clinics, but of those that do, do not fully recover the same quality of life, mobility, and activities of daily living they had prior to stroke with traditional rehabilitation alone. The studies reviewed show that acupuncture is an effective rehabilitation tool for improving quality of life and mobility in the older adult population suffering a recent stroke. While there are apparent flaws in all 3 studies, the strongest study, Wayne et al,9 showed that, while acupuncture requires larger, more definitive randomized controlled trials, Chinese acupuncture may help patients with chronic stroke symptoms. Nurses can use this affordable and often underrated therapeutic tool to treat and even cure chronic stroke symptoms among poststroke patients. Acknowledgments Credit is due to the faculty, Dr Jung-Ah Lee and Anne Rendeiro, whose instruction and encouragement made this article possible.

Declaration of Conflicting Interests The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article:

Dr Jung-Ah Lee is the professor of a Scholarly Concentration course and also focuses her research on stroke; this article is an assignment of this class and the topic is influenced by her knowledge of stroke research.

Funding The authors received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval This study is exempt from oversight by human subjects research protection as there were no human subjects involved.

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Bringing holistic treatments to the attention of medicine: acupuncture as an effective poststroke rehabilitation tool.

This article reviews 3 studies that explore the effects of acupuncture on poststroke patients suffering from chronic stroke symptoms. The 3 studies se...
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