THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 20, Number 8, 2014, pp. 618–622 ª Mary Ann Liebert, Inc. DOI: 10.1089/acm.2014.0003
The Balance Effect of Acupuncture Therapy Among Stroke Patients Shih-Wei Huang, MD,1 Wei-Te Wang, MD,2 Tsung-Hsien Yang, MD,3 Tsan-Hon Liou, MD, PhD,1,4 Guan-Yu Chen, MSc,1 and Li-Fong Lin, MSc, PT1
Abstract
Objective: To analyze how acupuncture therapy affects balance in patients experiencing their first stroke and to identify the stroke group with greatest improvement in balance after acupuncture intervention. Design: Retrospective case–control study. Setting: Ward of a medical university hospital. Participants: A total of 629 stroke patients were enrolled initially; 345 patients met the study criteria and 132 were analyzed (66 each in the study and control groups). Interventions: The study group received physiotherapy combined with acupuncture and the control group received only physiotherapy. Main outcome measures: The Postural Assessment Scale for Stroke patients (PASS) was used to evaluate balance. This balance scale system can be subdivided into static balance (PASS-MP, maintain posture) and dynamic balance (PASS-CP, change posture). Results: This study revealed no statistically significant improvement of balance in the study group (t test). When patients with high Brunnstrom stage (Br stage) and low Br stage were analyzed separately, once again no statistical difference was detected between the study and control groups of those with high Br stage. However, among low–Br stage patients, the study group showed significant improvement in static balance (mean PASSMP score – standard deviation: 4.7 – 3.7) compared with the control group (PASS-MP score: 2.8 – 2.7) ( p < 0.05). Conclusions: In first-ever stroke patients with a low Br stage, acupuncture therapy can improve static balance during rehabilitation. However, the effect on balance was limited among high–Br stage patients. This study provides information valuable to patients with hemiplegic stroke because it suggests that acupuncture can be used to improve balance. A prospective double-blind, randomized, controlled study design is recommended for future studies in patients with hemiplegic stroke.
Introduction
S
troke is a major cause of disability, and it increases the economic burden on health care systems. Stroke accounts for 2% to 4% of total health care costs worldwide and for more than 4% of direct health care costs in industrialized countries.1 Stroke victims often experience neurologic impairment, and one third to half of all stroke patients have disabilities and depend on others to carry out their daily activities.2 A major and constant concern of stroke victims is related to attending effective rehabilitation programs to regain their strength and enhance their ability to undertake routine activities.
In addition to the conventional rehabilitation programs offered to stroke patients by physiotherapists, acupuncture is widely used in Taiwan. Acupuncture is a component of Traditional Chinese Medicine that has been applied for 3000 years, and acupuncture is provided as a complementary treatment in stroke rehabilitation.3 However, the effects of acupuncture on poststroke rehabilitation patients remain controversial. According to a meta-analysis preformed by Sze et al., acupuncture has a small positive effect on disability and no additional effect on motor recovery.4 A more recent systemic review and meta-analysis of a randomized controlled trial reported that acupuncture may be effective for poststroke
1
Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan. Department of Physical Medicine and Rehabilitation, Changhua Christian Hospital, Changhua, Taiwan. Department of Chinese Acupuncture and Traumatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan. 4 Graduate Institute of Injury Prevention, Taipei Medical University, Taipei, Taiwan. 2 3
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rehabilitation.5 However, the effects of acupuncture that have been described in these studies are not convincing because several of the studies are not sufficiently rigorous and because distinct outcome measurement methods have been used to study patients affected by stroke for varying periods. Muscle weakness, spasticity, loss of mobility, and impaired balance contribute to the disabilities caused by stroke.6 Balance, the ability to preserve body mass equilibrium, critically affects quality of life. In the case of stroke patients, muscle weakness on the affected side results in motor-control deficits and movement initiations.7 A lack of balance can lead to an unsteady gait and reduced walking speed.8 Thus, balance strongly affects a patient’s ability to achieve independence in mobility and performing routine activities.9,10 Balance was previously reported to be one of the most powerful predictors of functional independence after stroke.11 Therefore, balance training is a key aspect of stroke rehabilitation programs. To date, only one study has examined the effect of acupuncture on balance in stroke rehabilitation patients.12 However, this study focused on scalp acupuncture only, enrolled a limited number of participants, and included patients with a wide variation in stroke onset period. No research has focused on the effect of acupuncture on balance in patients experiencing their first stroke. Therefore, the current study sought to investigate the use of acupuncture therapy in improving balance in patients who had sustained a stroke within the preceding 6 months. Materials and Methods Patients
Patient data were obtained from the ward of a medical university hospital from January 1 to December 31, 2012. The inclusion criteria were (1) first incidence of stroke with an onset of less than 6 months, (2) unilateral stroke lesion confirmed by using brain computed tomography or magnetic resonance imaging, (3) age older than 40 years, and (4) motor function impairment and the inability to walk with or without aid devices at the start of the acupuncture and rehabilitation intervention. The exclusion criteria were (1) sequelae of limb weakness caused by previous neurologic or orthopedic problems, (2) unstable vital signs and vital organ decompensate status, (3) bilateral limb weakness, (4) ability to ambulate independently, and (5) admission period of less than 14 days. The following demographic data were obtained: age, sex, body weight, height, Brunnstrom recovery stage (Br stage), history of diabetes mellitus, hypertension, coronary artery disease, nasogastric tube, Foley tube, stroke onset days, urinary tract infection, pneumonia, and rolling ability (a motor skill in a coordinated manner to move from prone to supine and supine to prone on a bed) at admission. Study design
The study was an assessor-blinded retrospective case– control study involving two groups: The study group received standard physiotherapy and traditional acupuncture, and the control group received only the standard physiotherapy program. The demographic data and functional status of the patients were recorded by a physiotherapist during the first session of physiotherapy, and acupuncture was performed only during times when the physiotherapist was not at work. Therefore, the physiotherapist was unaware
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of whether the patients were receiving acupuncture intervention in addition to the daily routine work. The data were analyzed anonymously and the need for informed consent was waived approved by institution of review board. Conventional rehabilitation
The course of the conventional rehabilitation program included physical therapy that lasted for 60 min/d, 5 consecutive days a week. The physiotherapy program was performed according to the strength and the Br stage of the affected limbs. The Br stages of the lower limbs were defined as follows: stage I, flaccid stage without voluntary movement; stage II, spasticity with weak basic flexor and extensor synergies; stage III, voluntary movement of the limbs but with muscle activation within synergy patterns; stage IV, selective activation of muscles outside the extensor and flexor synergies; stage V, reduced spasticity and predominantly selective muscle activation that is independent of limb synergies; and stage VI, proper coordination of isolated movements. No stage VI patients were enrolled because most patients at this stage can walk. Stages I and II were defined as low Br stage and stages III–V were defined as high Br stage. In the case of low–Br stage participants, the physical therapy program focused on facilitation technique, safe transferring, passive movement, contracture prevention, posture, and transferring training. In the case of high-Br-stage patients, the physiotherapy program focused on balance training, trunk control improvement, sit-to-stand exercise, proper weight shifting, and gait training. The physical therapy program of both groups was performed by the same physiotherapists, who had more than 3 years of clinical experience in our hospital. Acupuncture therapy
Acupuncture was performed by two Traditional Chinese Medicine specialists with more than 5 years of clinical experience. The essential acupoints that were selected focused on the affected lower limb: Yanglingquan (GB34) and Zusanli (ST36). Other alternative acupoints were chosen on the basis of personal experience of clinical practice and on the theory of Traditional Chinese Medicine. The acupuncture needles (sterile, single-use, 0.3 · 40 mm, manufactured in Taiwan) were inserted to a depth of 13–25 mm and manipulated until the patient experienced a feeling of numbness, tingling, or heaviness (de qi). The needles were placed for at least 20 minutes. Acupuncture was performed 2 times per week, and the course lasted 3–4 weeks. Outcome measurement
The Postural Assessment Scale for Stroke patients (PASS) was used to assess the primary outcome of balance measurement. PASS, which was designed specifically for patients who have sustained a stroke,13 contains 12 items used for evaluating balance: 5 items to assess the maintenance of posture (PASS-MP) and 7 items to evaluate changes in posture (PASS-CP) subscores based on assessing the patient in rolling, sitting, and standing positions. Functional equilibrium, which requires both static (MP) and dynamic (CP) balance, can be represented by PASS, a useful stroke balance scale scan that can be applied to people affected by a broad
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range of impairments, including those with extremely poor balance and those with adequate balance. Each item is rated on an ordinal scale from 0 to 3 for a maximal score of 36; in this scale, the higher the score, the better the balance function of the stroke patients. The PASS score is highly correlated with the Functional Independence Measure and has high intrarater validity (0.95) and high interrater validity (0.88).13 This study evaluated the PASS-MP, PASS-CP, and PASS scores of both groups. Activities of daily living (ADLs) were measured as secondary outcome by the Barthel Index. This index is widely adopted for measuring ADL disabilities, which include feeding, bathing, grooming, dressing, bowel control, bladder control, toilet use, transfers (e.g., from chair to bed), walking, and stair climbing. The Barthel Index ranges from 0 (totally dependent) to 100 (independent). Statistical analysis
To eliminate the data selection bias of a retrospective study, the parameters of baseline data, such as age, sex, stroke onset days, comorbidity status, and PASS scores, were controlled between the control and study groups by using SAS software (SAS Institute, Inc., Cary, NC). Continuous variables were analyzed by using independent t tests, and categorical variables were compared by using chi-square tests. To analyze the effect of acupuncture on high–Br stage and low– Br stage patients, separate t tests were used. All data analyses were performed by using SAS software, version 9.1.3), and SPSS software, version 20.0 (IBM, Chicago, IL). A p-value < 0.05 was considered to represent a statistically significant difference. Results
A total of 629 stroke patients were eligible for this retrospective, case–control study; 284 of these patients were excluded on the basis of the exclusion criteria listed in the Methods section. Among the remaining patients, 242 were first-ever stroke patients who had received only conventional physiotherapy, and 103 patients had received both acupuncture and physiotherapy. After adjustment for the baseline confounding factors (using SAS software), 66 patients were selected for the study group and 66 for the control group, thereby achieving a 1:1 ratio. The demographic data of the patients in the study and control groups are presented in Table 1. No statistical differences were detected in the baseline variables or in the balance outcome measurements (PASS) between the groups (Table 1). When the low–Br stage patients with and without acupuncture were analyzed, no statistical difference was detected in the baseline demographic data between the two groups. However, static balance function in the physiotherapy plus acupuncture group (mean score – standard deviation, 4.7 – 3.7) was higher than that in the physiotherapy-only group (2.8 – 2.7), and the difference was statistically significant ( p = 0.037) (Table 2). In contrast, no statistical difference was seen between the two high–Br stage groups (Table 3). Discussion
Acupuncture is a viable alternative treatment for poststroke rehabilitation. However, the types of stroke patient
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Table 1. Demographic Characteristics, Comorbid Medical Disorders, and Balance Parameters of All Participants
Variable
Acupuncture plus physiotherapy Physiotherapy (n = 66) (n = 66) p-Value
Baseline Age (y) 63.4 – 14.4 Men (n) 42 Weight (kg) 68.1 – 11.8 Height (cm) 163.4 – 10.5 Onset duration (d) 36.9 – 37.9 Pneumonia (n) 14 Urinary tract 12 infection (n) Nasogastric 14 tube (n) Foley catheter (n) 13 Rolling (n) 18 Aphasia (n) 28 Diabetes 31 mellitus (n) Hypertension (n) 57 PASS-MP score 3.6 – 3.3 PASS-CP score 7.2 – 5.5 PASS-total score 10.8 – 8.6 Barthel Index 57.1 – 9.0 Intervention 20.7 – 8.2 period (d) After intervention PASS-MP score 6.2 – 4.6 PASS-CP score 10.7 – 6.6 PASS-total score 16.9 – 10.8 Barthel Index 76.8 – 10.1
65.3 – 13.3 47 68.0 – 13.7 163.4 – 8.2 32.5 – 39.4 13 18
0.433 0.458 0.976 0.982 0.509 1.000 0.218
16
0.836
18 27 19 28
0.412 0.141 0.144 0.600
54 3.1 – 2.8 6.7 – 5.0 9.8 – 7.6 56.8 – 11.9 18.1 – 9.0
0.635 0.381 0.555 0.472 0.902 0.084
5.2 – 4.1 5.6 – 6.6 14.5 – 10.6 75.4 – 11.4
0.203 0.315 0.193 0.444
Values expressed with a plus/minus sign are the mean – standard deviation. The p-values were calculated using independent t tests for the continuous variables and with a chi-square test for the categorical variables. PASS-MP, Postural Assessment Scale for Stroke patients–maintain posture; PASS-CP, PASS-change posture.
who might benefit the most from acupuncture and the effect of acupuncture on balance remain undetermined. These results revealed no measureable effect of acupuncture on balance in first-ever stroke patients who received treatment within 6 months after stroke. However, acupuncture therapy improved PASS-MP scores of patients with low Br stage compared with those of patients with high Br stage. Acupoint selection typically depends on the experience of the physician. The essential Yanglingquan (GB34) and Zusanli (ST36) acupoints were selected for this study on the basis of the meridian concept of the differential syndrome classification used in Traditional Chinese Medicine. The results indicated that acupuncture therapy improved the PASS-MP scores of patients with low Br stage. According to acupuncture theory in Traditional Chinese Medicine, this observation indicated that the flaccid limbs of stroke patients with low Br stage have less qi and blood than do those of high–Br stage stroke patients. Acupuncture can direct qi along a meridian pathway to a site that is weak in or lacking qi. The presence of sufficient qi can enhance the energy supply, thus improving the muscle strength.
BALANCE EFFECT OF ACUPUNCTURE FOR STROKE PATIENTS
Table 2. Demographic Characteristics, Comorbid Medical Disorders, and Balance Parameters of Patients with Low Brunnstrom Stage
Variable
Acupuncture plus physiotherapy Physiotherapy (n = 31) (n = 25) p-Value
Baseline Age (y) 62.3 – 15.5 Men (n) 19 Weight (kg) 67.0 – 10.9 Height (cm) 164.6 – 10.7 Onset duration (d) 36.9 – 40.6 Pneumonia (n) 8 Urinary tract 5 infection (n) Nasogastric 9 tube (n) Foley catheter (n) 5 Rolling (n) 7 Aphasia (n) 12 Diabetes 13 mellitus (n) Hypertension (n) 27 PASS-MP score 2.8 – 2.7 PASS-CP score 6.0 – 4.8 PASS-total score 8.8 – 7.1 Barthel Index 50.0 – 4.5 Intervention 20.4 – 7.9 period (d) After intervention PASS-MP score 4.7 – 3.7 PASS-CP score 8.9 – 5.9 PASS-total score 13.7 – 9.2 Barthel Index 70.3 – 9.7
66.0 – 14.2 18 67.1 – 13.0 165.2 – 8.5 43.2 – 46.7 5 6
0.364 0.571 0.966 0.836 0.590 0.754 0.505
7
1.000
9 6 12 11
0.123 1.000 0.590 1.000
20 2.0 – 2.0 4.7 – 4.4 6.7 – 6.2 47.0 – 10.1 18.8 – 7.7
0.493 0.198 0.293 0.237 0.143 0.454
2.8 – 2.7 6.3 – 5.5 9.2 – 7.9 65.6 – 7.7
0.037* 0.095 0.057 0.052
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Table 3. Demographic Characteristics, Comorbid Medical Disorders, and Balance Parameters of Patients with High Brunnstrom Stage
Variable
Acupuncture plus physiotherapy Physiotherapy (n = 35) (n = 41) p-Value
Baseline Age (y) 67.2 – 14.8 Men (n) 13 Weight (kg) 67.8 – 11.8 Height (cm) 160.2 – 10.5 Onset duration (d) 35.5 – 36.5 Pneumonia (n) 5 Urinary tract 7 infection (n) Nasogastric 5 tube (n) Foley catheter (n) 7 Rolling (n) 12 Aphasia (n) 8 Diabetes 14 mellitus (n) Hypertension (n) 25 PASS-MP score 4.3 – 3.5 PASS-CP score 9.3 – 6.0 PASS-total score 13.6 – 9.2 Barthel Index 63.3 – 7.3 Intervention 20.4 – 9.0 period (d) After intervention PASS-MP score 7.4 – 4.9 PASS-CP score 13.0 – 6.4 PASS-total score 19.7 – 11.6 Barthel Index 82.6 – 6.2
63.3 – 11.9 39 69.4 – 14.3 163.5 – 7.9 28.5 – 33.7 9 12
0.220 0.009 0.629 0.127 0.404 1.000 1.000
9
1.000
10 20 15 21
0.580 0.811 1.000 0.467
39 3.9 – 3.2 7.5 – 5.2 11.3 – 8.1 62.8 – 8.4 18.6 – 9.5
0.194 0.585 0.171 0.274 0.792 0.425
6.8 – 4.4 11.3 – 6.6 18.1 – 10.8 81.3 – 9.0
0.530 0.279 0.545 0.499
Values expressed with a plus/minus sign are the mean – standard deviation. The p-values were calculated using independent t tests for the continuous variables and with a chi-square test for the categorical variables. *p < 0.05.
Values expressed with a plus/minus sign are the mean – standard deviation. The p-values were calculated using independent t tests for the continuous variables and with a chi-square test for the categorical variables.
A recent study reported that performing acupuncture at GB34 enhances stroke recovery by strengthening the causal influence between the motor cortices of the ipsilesional and contralesional areas14 and improves coordination by reorganizing the network of motor functions. Acupuncture therapy also activates the motor and sensory cortex areas of the cerebellum.15 The sensation created by the acupuncture needle produces sensory input by stimulating muscle spindles and mechanoreceptors,16 thereby leading to motor cortex activation.17,18 These findings suggest that acupuncture can improve both balance and the strength of limbs affected by stroke. Therefore, acupoints located along various nerve fibers in the lower limbs were selected to evaluate the effect of acupuncture on balance in stroke patients. Balance plays a key role in the ADL independence of stroke patients, and balance deficits detrimentally affect transfers, ambulation, and ADL.19,20 Improved standing balance plays a more critical role than increased muscle strength does in stroke patients with gait dysfunction. Another study reported that sitting balance strongly influences independence in ADLs, including toileting, dressing, and transfer, following the completion of
inpatient rehabilitation.21 Therefore, the effect of balance improvement following stroke warrants further investigation. In the current study, acupuncture combined with conventional physiotherapy exerted a stronger effect on static balance in stroke patients with flaccid muscles or low muscle tone (low Br stage) than did physiotherapy alone. However, the acupuncture therapy exerted no significant effect on balance in mildly impaired and hemiparetic (high Br stage) stroke patients. It is believed that in high–Br stage patients, increased muscle tone, and partial recovery of strength might limit improvement in balance following acupuncture. The mechanism of acupuncture therapy is similar to that of mechanical sensory stimulation. This route of stimulation is considered to be a neuromuscular facilitation technique that is primarily active in hemiplegic (low Br stage) stroke patients and is consistent with Rood’s cutaneous sensory stimulation theory.22 Facilitation therapy is primarily used to induce muscle strength and tone in flaccid-condition patients. By contrast, facilitation therapy is used less often for patients who exhibit improved voluntary motion because the main rehabilitation goals of these patients are to improve
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muscle strength, weight shifting, motion control, and gait. Thus, acupuncture therapy may offer limited benefits for patients with high Br stage. These findings have certain limitations. First, selection bias is inherent to the retrospective design of the study. However, strict inclusion and exclusion criteria were used for patient selection. In addition, the study effectively controlled for all of the major confounding factors in the statistical comparisons of the study and control groups. Second, the placebo effect was not determined because of the difficulties associated with blinding in acupuncture studies. However, the effects of acupuncture can be influenced by a patient’s previous acupuncture experience, regardless of the study design used. Third, the study included only first-ever stroke patients who were initially unable to ambulate independently. Nonetheless, variability in the clinical functional status of patients as a result of having lesions in different areas of the brain might have influenced their acupuncture outcomes. However, the study controlled for bias related to functional status based on the Br stage of each patient. Fourth, no rating system exists for evaluating the expertise of physiotherapists or acupuncturists, which is another factor that might have influenced the effects of the various treatments used in our study. Finally, the study did not evaluate the long-term effect of acupuncture. Limited information is available regarding the long-term effect of acupuncture in stroke patients. Future longitudinal studies are warranted to extend these findings. In conclusion, this study provides key information on selecting stroke patients for examining how balance is improved with use of manual acupuncture therapy. Acupuncture is recommended for low–Br stage first-ever stroke patients with an onset period of less than 6 months, in whom combining acupuncture with physiotherapy can improve static balance to a greater extent than conventional physiotherapy alone can. Prospective double-blind, randomized, controlled trials featuring large sample sizes and long follow-up periods are recommended for future studies. Author Disclosure Statement
No competing financial interests exist. References
1. Donnan GA, Fisher M, Macleod M, Davis SM. Stroke. Lancet. 2008;371:1612–1623. 2. Ra G-S, Yoo J-C, Kang C, Kim Y-S. Microfabricated inchannel structured polydimethylsiloxane microfluidic system for a lab-on-a-chip. J Nanosci Nanotech 2008;8:4588–4592. 3. Rabinstein AA, Shulman LM. Acupuncture in clinical neurology. Neurologist 2003;9:137–148. 4. Sze FK-h, Wong E, Or KK, et al. Does acupuncture improve motor recovery after stroke? A meta-analysis of randomized controlled trials. Stroke 2002;33:2604–2619. 5. Wu P, Mills E, Moher D, Seely D. Acupuncture in poststroke rehabilitation: a systematic review and meta-analysis of randomized trials. Stroke 2010;41:e171–e179. 6. Bohannon RW. Muscle strength and muscle training after stroke. J Rehab Med 2007;39:14–20. 7. Arene N, Hidler J. Understanding motor impairment in the paretic lower limb after a stroke: a review of the literature. Topics Stroke Rehabil 2009;16:346–356.
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8. Cunha IT, Lim PA, Henson H, et al. Performance-based gait tests for acute stroke patients. Am J Phys Med Rehabil 2002;81:848–856. 9. Lin JH, Hsieh CL, Hsio SF, Huang MH. Predicting longterm care institution utilization among post-rehabilitation stroke patients in Taiwan: a medical centre-based study. Disabil Rehabil 2001;23:722–730. 10. Sandin KJ, Smith BS. The measure of balance in sitting in stroke rehabilitation prognosis. Stroke 1990;21:82–86. 11. Di Monaco M, Trucco M, Di Monaco R, et al. The relationship between initial trunk control or postural balance and inpatient rehabilitation outcome after stroke: a prospective comparative study. Clin Rehabil 2010;24:543–554. 12. Liu SY, Hsieh CL, Wei TS, et al. Acupuncture stimulation improves balance function in stroke patients: a singleblinded controlled, randomized study. AM J Chin Med 2009;37:483–494. 13. Benaim C, Pe´rennou DA, Villy J, et al. Validation of a standardized assessment of postural control in stroke patients the Postural Assessment Scale for Stroke Patients (PASS). Stroke 1999;30:1862–1868. 14. Bai L, Cui F, Zou Y, Lao L. Acupuncture de qi in stable somatosensory stroke patients: relations with effective brain network for motor recovery. Evid Based Complement Alternat Med 2013;2013:197238. 15. Li G, Jack CR, Yang ES. An fMRI study of somatosensory? Implicated acupuncture points in stable somatosensory stroke patients. J of Magn —Reson Imaging. 2006;24: 1018–1024. 16. Wang K, Liu J. Needling sensation receptor of an acupoint supplied by the median nerve—studies of their electrophysiological characteristics. Am J Chin Med 1989;17: 145–155. 17. Lo YL, Cui S, Fook-Chong S. The effect of acupuncture on motor cortex excitability and plasticity. Neurosci Lett 2005;384:145–149. 18. Kaelin-Lang A, Luft AR, Sawaki L, et al. Modulation of human corticomotor excitability by somatosensory input. J Physiol 2002;540:623–633. 19. Hsieh CL, Sheu CF, Hsueh IP, Wang CH. Trunk control as an early predictor of comprehensive activities of daily living function in stroke patients. Stroke 2002;33:2626– 2630. 20. Kollen B, van de Port I, Lindeman E, et al. Predicting improvement in gait after stroke a longitudinal prospective study. Stroke 2005;36:2676–2680. 21. Hama S, Yamashita H, Shigenobu M, et al. Sitting balance as an early predictor of functional improvement in association with depressive symptoms in stroke patients. Psychiatry Clin Neurosci 2007;61:543–551. 22. Rood MS. Neurophysiological reactions as a basis for physical therapy. Phys Ther Rev 1954;34:444.
Address correspondence to: Li-Fong Lin, MSc, PT Department of Physical Medicine and Rehabilitation Shuang Ho Hospital Taipei Medical University 291 Jhongjheng Road Jhonghe, New Taipei City 235 Taiwan E-mail: [email protected]
The Balance Effect of Acupuncture Therapy Among Stroke Patients Shih-Wei Huang, MD,1 Wei-Te Wang, MD,2 Tsung-Hsien Yang, MD,3 Tsan-Hon Liou, MD, PhD,1,4 Guan-Yu Chen, MSc,1 and Li-Fong Lin, MSc, PT1
Abstract
Objective: To analyze how acupuncture therapy affects balance in patients experiencing their first stroke and to identify the stroke group with greatest improvement in balance after acupuncture intervention. Design: Retrospective case–control study. Setting: Ward of a medical university hospital. Participants: A total of 629 stroke patients were enrolled initially; 345 patients met the study criteria and 132 were analyzed (66 each in the study and control groups). Interventions: The study group received physiotherapy combined with acupuncture and the control group received only physiotherapy. Main outcome measures: The Postural Assessment Scale for Stroke patients (PASS) was used to evaluate balance. This balance scale system can be subdivided into static balance (PASS-MP, maintain posture) and dynamic balance (PASS-CP, change posture). Results: This study revealed no statistically significant improvement of balance in the study group (t test). When patients with high Brunnstrom stage (Br stage) and low Br stage were analyzed separately, once again no statistical difference was detected between the study and control groups of those with high Br stage. However, among low–Br stage patients, the study group showed significant improvement in static balance (mean PASSMP score – standard deviation: 4.7 – 3.7) compared with the control group (PASS-MP score: 2.8 – 2.7) ( p < 0.05). Conclusions: In first-ever stroke patients with a low Br stage, acupuncture therapy can improve static balance during rehabilitation. However, the effect on balance was limited among high–Br stage patients. This study provides information valuable to patients with hemiplegic stroke because it suggests that acupuncture can be used to improve balance. A prospective double-blind, randomized, controlled study design is recommended for future studies in patients with hemiplegic stroke.
Introduction
S
troke is a major cause of disability, and it increases the economic burden on health care systems. Stroke accounts for 2% to 4% of total health care costs worldwide and for more than 4% of direct health care costs in industrialized countries.1 Stroke victims often experience neurologic impairment, and one third to half of all stroke patients have disabilities and depend on others to carry out their daily activities.2 A major and constant concern of stroke victims is related to attending effective rehabilitation programs to regain their strength and enhance their ability to undertake routine activities.
In addition to the conventional rehabilitation programs offered to stroke patients by physiotherapists, acupuncture is widely used in Taiwan. Acupuncture is a component of Traditional Chinese Medicine that has been applied for 3000 years, and acupuncture is provided as a complementary treatment in stroke rehabilitation.3 However, the effects of acupuncture on poststroke rehabilitation patients remain controversial. According to a meta-analysis preformed by Sze et al., acupuncture has a small positive effect on disability and no additional effect on motor recovery.4 A more recent systemic review and meta-analysis of a randomized controlled trial reported that acupuncture may be effective for poststroke
1
Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan. Department of Physical Medicine and Rehabilitation, Changhua Christian Hospital, Changhua, Taiwan. Department of Chinese Acupuncture and Traumatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan. 4 Graduate Institute of Injury Prevention, Taipei Medical University, Taipei, Taiwan. 2 3
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rehabilitation.5 However, the effects of acupuncture that have been described in these studies are not convincing because several of the studies are not sufficiently rigorous and because distinct outcome measurement methods have been used to study patients affected by stroke for varying periods. Muscle weakness, spasticity, loss of mobility, and impaired balance contribute to the disabilities caused by stroke.6 Balance, the ability to preserve body mass equilibrium, critically affects quality of life. In the case of stroke patients, muscle weakness on the affected side results in motor-control deficits and movement initiations.7 A lack of balance can lead to an unsteady gait and reduced walking speed.8 Thus, balance strongly affects a patient’s ability to achieve independence in mobility and performing routine activities.9,10 Balance was previously reported to be one of the most powerful predictors of functional independence after stroke.11 Therefore, balance training is a key aspect of stroke rehabilitation programs. To date, only one study has examined the effect of acupuncture on balance in stroke rehabilitation patients.12 However, this study focused on scalp acupuncture only, enrolled a limited number of participants, and included patients with a wide variation in stroke onset period. No research has focused on the effect of acupuncture on balance in patients experiencing their first stroke. Therefore, the current study sought to investigate the use of acupuncture therapy in improving balance in patients who had sustained a stroke within the preceding 6 months. Materials and Methods Patients
Patient data were obtained from the ward of a medical university hospital from January 1 to December 31, 2012. The inclusion criteria were (1) first incidence of stroke with an onset of less than 6 months, (2) unilateral stroke lesion confirmed by using brain computed tomography or magnetic resonance imaging, (3) age older than 40 years, and (4) motor function impairment and the inability to walk with or without aid devices at the start of the acupuncture and rehabilitation intervention. The exclusion criteria were (1) sequelae of limb weakness caused by previous neurologic or orthopedic problems, (2) unstable vital signs and vital organ decompensate status, (3) bilateral limb weakness, (4) ability to ambulate independently, and (5) admission period of less than 14 days. The following demographic data were obtained: age, sex, body weight, height, Brunnstrom recovery stage (Br stage), history of diabetes mellitus, hypertension, coronary artery disease, nasogastric tube, Foley tube, stroke onset days, urinary tract infection, pneumonia, and rolling ability (a motor skill in a coordinated manner to move from prone to supine and supine to prone on a bed) at admission. Study design
The study was an assessor-blinded retrospective case– control study involving two groups: The study group received standard physiotherapy and traditional acupuncture, and the control group received only the standard physiotherapy program. The demographic data and functional status of the patients were recorded by a physiotherapist during the first session of physiotherapy, and acupuncture was performed only during times when the physiotherapist was not at work. Therefore, the physiotherapist was unaware
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of whether the patients were receiving acupuncture intervention in addition to the daily routine work. The data were analyzed anonymously and the need for informed consent was waived approved by institution of review board. Conventional rehabilitation
The course of the conventional rehabilitation program included physical therapy that lasted for 60 min/d, 5 consecutive days a week. The physiotherapy program was performed according to the strength and the Br stage of the affected limbs. The Br stages of the lower limbs were defined as follows: stage I, flaccid stage without voluntary movement; stage II, spasticity with weak basic flexor and extensor synergies; stage III, voluntary movement of the limbs but with muscle activation within synergy patterns; stage IV, selective activation of muscles outside the extensor and flexor synergies; stage V, reduced spasticity and predominantly selective muscle activation that is independent of limb synergies; and stage VI, proper coordination of isolated movements. No stage VI patients were enrolled because most patients at this stage can walk. Stages I and II were defined as low Br stage and stages III–V were defined as high Br stage. In the case of low–Br stage participants, the physical therapy program focused on facilitation technique, safe transferring, passive movement, contracture prevention, posture, and transferring training. In the case of high-Br-stage patients, the physiotherapy program focused on balance training, trunk control improvement, sit-to-stand exercise, proper weight shifting, and gait training. The physical therapy program of both groups was performed by the same physiotherapists, who had more than 3 years of clinical experience in our hospital. Acupuncture therapy
Acupuncture was performed by two Traditional Chinese Medicine specialists with more than 5 years of clinical experience. The essential acupoints that were selected focused on the affected lower limb: Yanglingquan (GB34) and Zusanli (ST36). Other alternative acupoints were chosen on the basis of personal experience of clinical practice and on the theory of Traditional Chinese Medicine. The acupuncture needles (sterile, single-use, 0.3 · 40 mm, manufactured in Taiwan) were inserted to a depth of 13–25 mm and manipulated until the patient experienced a feeling of numbness, tingling, or heaviness (de qi). The needles were placed for at least 20 minutes. Acupuncture was performed 2 times per week, and the course lasted 3–4 weeks. Outcome measurement
The Postural Assessment Scale for Stroke patients (PASS) was used to assess the primary outcome of balance measurement. PASS, which was designed specifically for patients who have sustained a stroke,13 contains 12 items used for evaluating balance: 5 items to assess the maintenance of posture (PASS-MP) and 7 items to evaluate changes in posture (PASS-CP) subscores based on assessing the patient in rolling, sitting, and standing positions. Functional equilibrium, which requires both static (MP) and dynamic (CP) balance, can be represented by PASS, a useful stroke balance scale scan that can be applied to people affected by a broad
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range of impairments, including those with extremely poor balance and those with adequate balance. Each item is rated on an ordinal scale from 0 to 3 for a maximal score of 36; in this scale, the higher the score, the better the balance function of the stroke patients. The PASS score is highly correlated with the Functional Independence Measure and has high intrarater validity (0.95) and high interrater validity (0.88).13 This study evaluated the PASS-MP, PASS-CP, and PASS scores of both groups. Activities of daily living (ADLs) were measured as secondary outcome by the Barthel Index. This index is widely adopted for measuring ADL disabilities, which include feeding, bathing, grooming, dressing, bowel control, bladder control, toilet use, transfers (e.g., from chair to bed), walking, and stair climbing. The Barthel Index ranges from 0 (totally dependent) to 100 (independent). Statistical analysis
To eliminate the data selection bias of a retrospective study, the parameters of baseline data, such as age, sex, stroke onset days, comorbidity status, and PASS scores, were controlled between the control and study groups by using SAS software (SAS Institute, Inc., Cary, NC). Continuous variables were analyzed by using independent t tests, and categorical variables were compared by using chi-square tests. To analyze the effect of acupuncture on high–Br stage and low– Br stage patients, separate t tests were used. All data analyses were performed by using SAS software, version 9.1.3), and SPSS software, version 20.0 (IBM, Chicago, IL). A p-value < 0.05 was considered to represent a statistically significant difference. Results
A total of 629 stroke patients were eligible for this retrospective, case–control study; 284 of these patients were excluded on the basis of the exclusion criteria listed in the Methods section. Among the remaining patients, 242 were first-ever stroke patients who had received only conventional physiotherapy, and 103 patients had received both acupuncture and physiotherapy. After adjustment for the baseline confounding factors (using SAS software), 66 patients were selected for the study group and 66 for the control group, thereby achieving a 1:1 ratio. The demographic data of the patients in the study and control groups are presented in Table 1. No statistical differences were detected in the baseline variables or in the balance outcome measurements (PASS) between the groups (Table 1). When the low–Br stage patients with and without acupuncture were analyzed, no statistical difference was detected in the baseline demographic data between the two groups. However, static balance function in the physiotherapy plus acupuncture group (mean score – standard deviation, 4.7 – 3.7) was higher than that in the physiotherapy-only group (2.8 – 2.7), and the difference was statistically significant ( p = 0.037) (Table 2). In contrast, no statistical difference was seen between the two high–Br stage groups (Table 3). Discussion
Acupuncture is a viable alternative treatment for poststroke rehabilitation. However, the types of stroke patient
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Table 1. Demographic Characteristics, Comorbid Medical Disorders, and Balance Parameters of All Participants
Variable
Acupuncture plus physiotherapy Physiotherapy (n = 66) (n = 66) p-Value
Baseline Age (y) 63.4 – 14.4 Men (n) 42 Weight (kg) 68.1 – 11.8 Height (cm) 163.4 – 10.5 Onset duration (d) 36.9 – 37.9 Pneumonia (n) 14 Urinary tract 12 infection (n) Nasogastric 14 tube (n) Foley catheter (n) 13 Rolling (n) 18 Aphasia (n) 28 Diabetes 31 mellitus (n) Hypertension (n) 57 PASS-MP score 3.6 – 3.3 PASS-CP score 7.2 – 5.5 PASS-total score 10.8 – 8.6 Barthel Index 57.1 – 9.0 Intervention 20.7 – 8.2 period (d) After intervention PASS-MP score 6.2 – 4.6 PASS-CP score 10.7 – 6.6 PASS-total score 16.9 – 10.8 Barthel Index 76.8 – 10.1
65.3 – 13.3 47 68.0 – 13.7 163.4 – 8.2 32.5 – 39.4 13 18
0.433 0.458 0.976 0.982 0.509 1.000 0.218
16
0.836
18 27 19 28
0.412 0.141 0.144 0.600
54 3.1 – 2.8 6.7 – 5.0 9.8 – 7.6 56.8 – 11.9 18.1 – 9.0
0.635 0.381 0.555 0.472 0.902 0.084
5.2 – 4.1 5.6 – 6.6 14.5 – 10.6 75.4 – 11.4
0.203 0.315 0.193 0.444
Values expressed with a plus/minus sign are the mean – standard deviation. The p-values were calculated using independent t tests for the continuous variables and with a chi-square test for the categorical variables. PASS-MP, Postural Assessment Scale for Stroke patients–maintain posture; PASS-CP, PASS-change posture.
who might benefit the most from acupuncture and the effect of acupuncture on balance remain undetermined. These results revealed no measureable effect of acupuncture on balance in first-ever stroke patients who received treatment within 6 months after stroke. However, acupuncture therapy improved PASS-MP scores of patients with low Br stage compared with those of patients with high Br stage. Acupoint selection typically depends on the experience of the physician. The essential Yanglingquan (GB34) and Zusanli (ST36) acupoints were selected for this study on the basis of the meridian concept of the differential syndrome classification used in Traditional Chinese Medicine. The results indicated that acupuncture therapy improved the PASS-MP scores of patients with low Br stage. According to acupuncture theory in Traditional Chinese Medicine, this observation indicated that the flaccid limbs of stroke patients with low Br stage have less qi and blood than do those of high–Br stage stroke patients. Acupuncture can direct qi along a meridian pathway to a site that is weak in or lacking qi. The presence of sufficient qi can enhance the energy supply, thus improving the muscle strength.
BALANCE EFFECT OF ACUPUNCTURE FOR STROKE PATIENTS
Table 2. Demographic Characteristics, Comorbid Medical Disorders, and Balance Parameters of Patients with Low Brunnstrom Stage
Variable
Acupuncture plus physiotherapy Physiotherapy (n = 31) (n = 25) p-Value
Baseline Age (y) 62.3 – 15.5 Men (n) 19 Weight (kg) 67.0 – 10.9 Height (cm) 164.6 – 10.7 Onset duration (d) 36.9 – 40.6 Pneumonia (n) 8 Urinary tract 5 infection (n) Nasogastric 9 tube (n) Foley catheter (n) 5 Rolling (n) 7 Aphasia (n) 12 Diabetes 13 mellitus (n) Hypertension (n) 27 PASS-MP score 2.8 – 2.7 PASS-CP score 6.0 – 4.8 PASS-total score 8.8 – 7.1 Barthel Index 50.0 – 4.5 Intervention 20.4 – 7.9 period (d) After intervention PASS-MP score 4.7 – 3.7 PASS-CP score 8.9 – 5.9 PASS-total score 13.7 – 9.2 Barthel Index 70.3 – 9.7
66.0 – 14.2 18 67.1 – 13.0 165.2 – 8.5 43.2 – 46.7 5 6
0.364 0.571 0.966 0.836 0.590 0.754 0.505
7
1.000
9 6 12 11
0.123 1.000 0.590 1.000
20 2.0 – 2.0 4.7 – 4.4 6.7 – 6.2 47.0 – 10.1 18.8 – 7.7
0.493 0.198 0.293 0.237 0.143 0.454
2.8 – 2.7 6.3 – 5.5 9.2 – 7.9 65.6 – 7.7
0.037* 0.095 0.057 0.052
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Table 3. Demographic Characteristics, Comorbid Medical Disorders, and Balance Parameters of Patients with High Brunnstrom Stage
Variable
Acupuncture plus physiotherapy Physiotherapy (n = 35) (n = 41) p-Value
Baseline Age (y) 67.2 – 14.8 Men (n) 13 Weight (kg) 67.8 – 11.8 Height (cm) 160.2 – 10.5 Onset duration (d) 35.5 – 36.5 Pneumonia (n) 5 Urinary tract 7 infection (n) Nasogastric 5 tube (n) Foley catheter (n) 7 Rolling (n) 12 Aphasia (n) 8 Diabetes 14 mellitus (n) Hypertension (n) 25 PASS-MP score 4.3 – 3.5 PASS-CP score 9.3 – 6.0 PASS-total score 13.6 – 9.2 Barthel Index 63.3 – 7.3 Intervention 20.4 – 9.0 period (d) After intervention PASS-MP score 7.4 – 4.9 PASS-CP score 13.0 – 6.4 PASS-total score 19.7 – 11.6 Barthel Index 82.6 – 6.2
63.3 – 11.9 39 69.4 – 14.3 163.5 – 7.9 28.5 – 33.7 9 12
0.220 0.009 0.629 0.127 0.404 1.000 1.000
9
1.000
10 20 15 21
0.580 0.811 1.000 0.467
39 3.9 – 3.2 7.5 – 5.2 11.3 – 8.1 62.8 – 8.4 18.6 – 9.5
0.194 0.585 0.171 0.274 0.792 0.425
6.8 – 4.4 11.3 – 6.6 18.1 – 10.8 81.3 – 9.0
0.530 0.279 0.545 0.499
Values expressed with a plus/minus sign are the mean – standard deviation. The p-values were calculated using independent t tests for the continuous variables and with a chi-square test for the categorical variables. *p < 0.05.
Values expressed with a plus/minus sign are the mean – standard deviation. The p-values were calculated using independent t tests for the continuous variables and with a chi-square test for the categorical variables.
A recent study reported that performing acupuncture at GB34 enhances stroke recovery by strengthening the causal influence between the motor cortices of the ipsilesional and contralesional areas14 and improves coordination by reorganizing the network of motor functions. Acupuncture therapy also activates the motor and sensory cortex areas of the cerebellum.15 The sensation created by the acupuncture needle produces sensory input by stimulating muscle spindles and mechanoreceptors,16 thereby leading to motor cortex activation.17,18 These findings suggest that acupuncture can improve both balance and the strength of limbs affected by stroke. Therefore, acupoints located along various nerve fibers in the lower limbs were selected to evaluate the effect of acupuncture on balance in stroke patients. Balance plays a key role in the ADL independence of stroke patients, and balance deficits detrimentally affect transfers, ambulation, and ADL.19,20 Improved standing balance plays a more critical role than increased muscle strength does in stroke patients with gait dysfunction. Another study reported that sitting balance strongly influences independence in ADLs, including toileting, dressing, and transfer, following the completion of
inpatient rehabilitation.21 Therefore, the effect of balance improvement following stroke warrants further investigation. In the current study, acupuncture combined with conventional physiotherapy exerted a stronger effect on static balance in stroke patients with flaccid muscles or low muscle tone (low Br stage) than did physiotherapy alone. However, the acupuncture therapy exerted no significant effect on balance in mildly impaired and hemiparetic (high Br stage) stroke patients. It is believed that in high–Br stage patients, increased muscle tone, and partial recovery of strength might limit improvement in balance following acupuncture. The mechanism of acupuncture therapy is similar to that of mechanical sensory stimulation. This route of stimulation is considered to be a neuromuscular facilitation technique that is primarily active in hemiplegic (low Br stage) stroke patients and is consistent with Rood’s cutaneous sensory stimulation theory.22 Facilitation therapy is primarily used to induce muscle strength and tone in flaccid-condition patients. By contrast, facilitation therapy is used less often for patients who exhibit improved voluntary motion because the main rehabilitation goals of these patients are to improve
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muscle strength, weight shifting, motion control, and gait. Thus, acupuncture therapy may offer limited benefits for patients with high Br stage. These findings have certain limitations. First, selection bias is inherent to the retrospective design of the study. However, strict inclusion and exclusion criteria were used for patient selection. In addition, the study effectively controlled for all of the major confounding factors in the statistical comparisons of the study and control groups. Second, the placebo effect was not determined because of the difficulties associated with blinding in acupuncture studies. However, the effects of acupuncture can be influenced by a patient’s previous acupuncture experience, regardless of the study design used. Third, the study included only first-ever stroke patients who were initially unable to ambulate independently. Nonetheless, variability in the clinical functional status of patients as a result of having lesions in different areas of the brain might have influenced their acupuncture outcomes. However, the study controlled for bias related to functional status based on the Br stage of each patient. Fourth, no rating system exists for evaluating the expertise of physiotherapists or acupuncturists, which is another factor that might have influenced the effects of the various treatments used in our study. Finally, the study did not evaluate the long-term effect of acupuncture. Limited information is available regarding the long-term effect of acupuncture in stroke patients. Future longitudinal studies are warranted to extend these findings. In conclusion, this study provides key information on selecting stroke patients for examining how balance is improved with use of manual acupuncture therapy. Acupuncture is recommended for low–Br stage first-ever stroke patients with an onset period of less than 6 months, in whom combining acupuncture with physiotherapy can improve static balance to a greater extent than conventional physiotherapy alone can. Prospective double-blind, randomized, controlled trials featuring large sample sizes and long follow-up periods are recommended for future studies. Author Disclosure Statement
No competing financial interests exist. References
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Address correspondence to: Li-Fong Lin, MSc, PT Department of Physical Medicine and Rehabilitation Shuang Ho Hospital Taipei Medical University 291 Jhongjheng Road Jhonghe, New Taipei City 235 Taiwan E-mail: [email protected]
