J. Acupunct. Tuina. Sci. (2008) 6: 222-226 DOI: 10.

1007/s11726-008-0222-x

Clinical Study

Clinical Study on Early Acupuncture for Acute Ischemic Stroke

ZHANG Ling ( )1, GE Lin-bao ()2, CHEN Lian-fang ()3, WU Yao-chi ()1 1 Sixth Peoples Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200233, P. R. China 2 Yueyang Hospital of Integrative Chinese & Western Medicines Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 200437, P. R. China 3 Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 200021, P. R. China

90 45 Bathel ADL P0.01, P0.01 AbstractObjective: To observe the clinical efficacy and safety of early acupuncture in the treatment of acute ischemic stroke. Methods: In clinical randomized controlled trial, 90 subjects were divided into drug group and acupuncture group, 45 cases in each group. The neurological deficit score, Bathel index and some blood laboratory indexes were detected before and after treatment in both groups. Results: In acute stage, there were striking differences in the neurological deficit score and activities of daily living (ADL) between before and after treatments in acupuncture group (P0.01), and between acupuncture group and drug group (P0.01); but there was no difference in blood lipid and rheology between two groups. Conclusion: Acupuncture is rather safe in the early treatment of acute ischemic stroke, and improvement of disability and the patients quality of life. Key WordsAcupuncture Therapy; Stroke; Activities of Daily Living; Hemorheology CLC NumberR246.1 Document CodeA Stroke is a disease of high mortality, disability and recurrence rate. The disabilities rate is 80%, and severe disability rate is 40%. It seriously affects patients quality of life and brings heavy loads to the society and families[1]. The authors performed acupuncture to treat ischemic stroke in the early stage and further tried to optimize the treatment modality. It was reported as follows.

1 Clinical Data
1.1 Inclusive criteria Stroke on Chinese medical diagnosis, ischemic cerebrovascular disease on Western medicine, ischemic stroke confirmed by CT scan or MRI within two weeks; neurological deficit score below 30 points but over 8 points. 1. 2 Exclusive criteria Those absent with ischemic stroke; transient cerebral ischemic attack; mild stroke just with some subjective symptoms; those with severe primary diseases in the heart, liver, kidney, hematopoietic system and endocrine system, unconsciousness; hypertension: systolic pressure over 24.0 kPa or

Funding Item: State Administration of Traditional Chinese Medicine of P. R. China2003zl26 Author: ZHANG Ling (1978- ), female, resident physician. Email: flyzhangl@hotmail.com

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J. Acupunct. Tuina. Sci. (2008) 6: 222-226

diastolic pressure over 14.7 kPa; severe joint deformity leading to difficult recovery of its function; those incompliant to the whole experiment. 1.3 General data All patients were the inpatients of the departments of acupuncture, neurology and emergency of Yueyang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine from November 2004 to February 2006. In acupuncture group, 15 cases were men and 30 cases were women; the youngest was 42 years old and the oldest was 75 years old; the longest duration was 14 days and the shortest was 4 days. In drug group, 19 cases were men and 26 cases were women; the youngest was 45 years old and the oldest was 80 years old; the longest duration was 14 days and the shortest was 3 days. The general data, past history and accompanying disease scores determined by National Fourth Cerebrovascular Disease Conference[1] were of no significance between treatment group and control group (P0.05), indicating comparability between the two groups. Clinical randomized controlled method was used. The 90 cases of acute ischemic stroke were allocated into control group and treatment group, 45 cases in each group. Comparison between two groups and between pre-treatment and post-treatment in one group were made.

3 Results
3.1 Criteria for therapeutic effects The clinical efficacy was scored in the light of modified scandinavian stroke scale (SSS) and activity of daily living scale (ADL). The scoring doctor was specifically trained. Basic cure: The neurological deficit score reduced by 91%-100%; Marked effectiveness: The neurological deficit score reduced by 46%-90%; Effectiveness: The neurological deficit score reduced by 18%-45%; Failure: The neurological deficit score reduced by less than 17% or even increased. 3.2 Neurological deficit score The neurological deficit scores in the two groups were determined according to the modified SSS[1] between the two groups and between before and after treatment in one group (Table 1 and 2). There were striking differences in the neurological deficit score between before and after treatments in acupuncture group and drug group (P0.01), but with better effects in acupuncture group than in drug group (P0.01).
Table 1. Comparison of neurological deficit score between before and after treatment ( x s) Groups Drug N 45 Before treatment 16.666.456 15.826.203 After treatment 8.593.7701) 2) 13.915.7691)

2 Treatment Methods
2.1 Acupuncture group Acupoints: scalp motor area (MS 6), sensory area (MS 7), speech area, Baihui (GV 20), Fengchi (GB 20), Quchi (LI 11), Hegu (LI 4), Zusanli (ST 36) and Taichong (LR 3). Operation: The needle was retained in every acupoint for 20 min in each treatment, once a day and 10-treatment made up one course. There was a one-day interval between any two courses. After 2-course treatments, the neurological deficit score, Bathel index and some blood laboratory indexes were detected before and after treatment in both groups. 2.2 Drug group Drug group was given routine therapy: intravenous drip of Piracetam Injection 250 mL, Danshen Injection 20 mL and physiological saline 250 mL, once a day, with the same course as acupuncture group.

Acupuncture 45

Notes: Compared with before treatment, 1)P0.001; compared with drug group, 2)P0.001 Table 2. Comparison of clinical efficacy between two groups (Cases) Groups N Marked effect 33 3 Effect 9 20 Failure 3 22 Total effective rate (%) 93.3 41.1

Acupuncture 45 Drug 45

Table 3. Comparison of Bathel Index Groups Acupuncture Drug N 45 45 Before treatment 39.3329.12 31.6710.93 After treatment 67.0018.081) 2) 46.1714.721)

Notes: Compared with before treatment, 1)P0.001; compared with drug group, 2)P0.001

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J. Acupunct. Tuina. Sci. (2008) 6: 222-226 Table 4. Comparison of TG, TC and LDL before and after treatment ( x s) Groups Acupuncture Drug N TG Before treatment After treatment 2.100.920 1.800.832 4.571.041 4.940.876 TC Before treatment After treatment 4.310.940
1)

LDL Before treatment 3.070.781 3.360.819 After treatment 2.900.722 3.070.793

45 1.920.996 45 1.820.748

4.540.9511)

Note: Compared with before treatment, 1) P0.05 Table 5. Comparison of fibrinogen, whole high-shear reduced viscosity, whole low-shear reduced viscosity and HCT Fibrinogen Groups N Before treatment After treatment Whole high-shear reduced viscosity Before treatment After treatment Before treatment 35.584.761 35.885.060 Whole low-shear reduced viscosity After treatment 34.765.264 35.125.491 Before treatment 0.4490.045 0.4680.054 HCT After treatment 0.4570.050 0.4800.058

Acupuncture 45 2.490.317 2.420.274 Drug 45 2.360.371 2.560.4551)

5.901.270 5.681.566 5.491.053 5.351.204

Note: Compared with before treatment, 1) P0.05

3.3 ADL scale The Bathel Index before and after treatment between the two groups was compared by activity of daily living scale (Table 3). There were striking differences in ADL between before and after treatments in both groups (P0.01), but with better effects in acupuncture group than in drug group (P0.01). 3.4 Blood lipid The laboratory indexes concerning blood lipid were detected before and after treatment in both groups (Table 4). There were no differences in triglyceride between before treatment and after treatment in both groups and between acupuncture and drug groups (P 0.05). There were differences in cholesterol between before treatment and after treatment in both groups (P 0.05), but no difference between acupuncture and drug groups (P0.05). There was a difference in low density lipoprotein between before treatment and after treatment in both groups (P0.05). 3.5 Blood rheology The blood rheology was detected before and after treatment in both groups (Table 5). There were no differences in whole high-shear reduced viscosity, whole low-shear reduced viscosity, hematocrit (HCT) between before treatment and after treatment in both groups and between acupuncture and drug groups after treatment (P0.05). There was a difference in fibrinogen between before and after treatment in drug group (P0.05), indicating that drugs have better

effect than acupuncture in increasing fibrinogen (P0.05).

4 Analysis and Discussion

According to the epidemiological survey made by WHO, the established risk factors of stroke primarily consist of hypertension, heart diseases and diabetes mellitus, and other risk factors include high blood lipid, obesity, smoking and alcohol[2]. Cerebral atherosclerosis is the pathological basis of cerebral stroke, while lipid metabolism disorder and normal blood rheology is the cardinal pathological changes of atherosclerosis[3]. Compared with healthy people, stroke patients had high blood lipid, it leads to poor blood flow, hemangioendothelial injury, decreasing erythrocyte deformation, platelet rupture, vascular collagen exposure and coagulation factors activation, which promote the production of embolism and hemorrhage[4]. Blood rheology reflects the fluxion, viscosity, coagulability, yield strength and its influential factors; it is one part of many pathological processes or bridge[5]. Therefore, blood rheology abnormality is one of the causes of cerebral ischemia[6]. Research results at home and abroad also demonstrated that blood rheology abnormality usually came before atherosclerosis, which played a vital role on vascular injury, microcirculation disturbance and thromogenesis[7,8]. Blood lipid and blood rheology may affect each other; specifically, elevated contents of

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J. Acupunct. Tuina. Sci. (2008) 6: 222-226

lipoprotein and cholesterol can slow down blood velocity and hence cause thrombosis. It is reported that the patients with the acute stage of transient ischemic attack had serum lipid and lipoprotein abnormality, higher contents of whole blood viscosity, plasma blood viscosity and fibrinogen than healthy people, revealing that abnormality of blood lipid and blood rheology is an important factor of the attack of cerebral stroke[9]. Acupuncture has rich experience in the treatment of stroke. Early in Nei Jing (Inner Classic, ), acupuncture was considered as a primary means to treat stroke. From the Qin and Han Dynasties down, a great many physicians applied acupuncture and moxibustion to treat stroke and achieved excellent results. In modern times, a large number of experiments have shown that, in the treatment of cerebral stroke, acupuncture could dilate blood vessels, accelerate blood flow, improve microcirculation, increase blood flow to the brain, relieve cerebral ischemia and anoxia, promote the establishment of cerebral collateral circulation, and abate the harm to cerebral tissues[10]. Researches at home and abroad concluded similar results[11-14]. In the past 20 years, the quality of life received more and more attention, and became a hot spot in the world; the researches concerning cerebral stroke increased day by day[15]. With the gradually increasing life span, the quality of life of the old people has been believed to be an important subject in geratology. It is argued that building a reasonable lifestyle and strengthening mental health education are the key measures to the the prevention and treatment of heart and cerebrovascular diseases in the old people[16]. Based upon other peoples clinical researches, the author optimized the treatment methods and hence adopted scalp acupuncture and body acupuncture to treat acute ischemic stroke; in this method, only manual techniques were used and such auxiliary methods as electric acupuncture was not used. It is concluded that early acupuncture treatment for stroke is rather safe and does not give rise to needling syncope, blood pressure fluctuation, dizziness and headache, and cardiac discomforts. In comparison with drug group, the neurological deficit score was obviously improved in acupuncture group, indicating that acupuncture can significantly improve the functions of the affected limbs. There were striking

differences in ADL between before and after treatments in both groups, but the acupuncture group had better effects than drug group, revealing that this acupuncture therapy has positive effects on acute stroke by improving the patients disability, increasing patients quality of life. Therefore, it is of definite feasibility and great social significance of acupuncture in the early treatment of stroke. Acupuncture works similarly as drugs on hyperlipidemia and high viscosity in this research, but acupuncture works differently from drugs on fibrinogen; in other words, acupuncture tends to increase fibrinogen more significantly than drugs. The reasons may be as follows: the first reason is the treatment course. Acupuncture serves to regulate the bodys immunity and its acting time depends on the individual constitution and needling techniques, which requires further researches. The second reason is the administration of other medicines. Hyperlipidemia patients often take hypolipidemics and stroke suffers take antiplatelet aggregation agents and anticoagulants. In this research, the effects of these medicines cannot be ruled out. The third reason is the detection methods and apparatuses. All these factors should be studied to optimize the acupuncture therapy for the treatment of acute ischemic stroke and further enhance the clinical efficacy.

References
[1] HU Zhi-wei. New Advance in Diagnosis and Treatment of Stroke. Zhejiang Journal of Integrated Traditional Chinese and Western Medicine, 2004, 4(14): 263-265. [2] ZHOU Yu-mei, GAO An-li. Relationship Between Cerebral Stroke and Related Etiology and Its Preventive Measures. Chinese Journal of Clinical Rehabilitation, 2003, 7 (31): 4232. [3] LIU Wei-hong, SHAO Nian-fang. Study of Relationships Between the Different Syndromes and the Blood Pressure, Blood-Liqid, Blood Rheological in Patients with Premonition Symptoms of Apoplexy. Chinese Journal of Integrative Medicine on Cardio-Cerebrovascular Disease, 2003, 1 (3): 146-147. [4] WANG Li-wen, GE Ya-dong, GU Hong-zhang. The Application of Index Related to Hemorheology and Blood Lipid in Stroke Diagnosis. Journal of Chinese Microcirculation, 2002, 6(6): 359-360. [5] CHEN Xiao-hong, WANG Yin-hua, YUAN Jia-ying. Analysis of Hemorheology for Predicting Occurrence of Arteriosclerosis and Cerebral Infarction. Chinese Journal of Geriatric Cardiovascular and Cerebrovascular Disease, 2002, 4 (6): 394-396. [6] Koenig W, Ernst E. The Possible Role of Hemorheology in

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J. Acupunct. Tuina. Sci. (2008) 6: 222-226 Atherothrombogensis. Atheroselerosis, 1992, 94(2): 93-107. [7] WANG Tian-you. Blood Rheology. Urumqi: Xinjiang [8] Ajmani RS, Rifkind JM. Hemorheological Changes during Human Aging. Gerontology, 1998, 44(2): 111-120. [9] YANG Xiu-min, MA Gui-rong, LIU Shu-xian, et al. Study [10] RAO Ping, ZHOU Li, MAO Min, et al. A Randomized Controlled Trial of Acupuncture Treatment of Acute Ischemic Stroke. Chinese Acupuncture & Moxibustion, 2006, 26(10): 694-696. [11] Sze FK, Wong E, Yi X, et al. Does Acupuncture Have Additional Value to Standard Poststroke Motor Rehabilitation. Stroke, 2002, 33(1): 186-194. [12] Johansson BB, Haker E, Arbin MV, et al. Acupuncture and Transcutaneous Nerve Stimulation in Stroke Rehabilitation: A Randomized Controlled Trial. Stroke, 2001, 32(3): 707-713. [13]Shiflett S C. Acupuncture and Stroke Rehabilitation. Stroke, 2001, 32(8): 1934-1936.

Scientific and Technical Health Press, 1992. of TC, TG, HDL-C, LDL-C in TIA Patients. Journal of Tianjin Medical University, 1995, 1(3): 26-28. [14] Moon SK, Whang YK, Park SU, et al. Antispastic Effect of Electroacupuncture and Moxibustion in Stroke Patients. Am J Chin Med, 2003, 31(3): 467-474. [15] LI Hui, LIANG Wei-xiong, GUO Xin-feng. Application of Quality of Life Assessment to Cerebral Stroke. Chinese Journal of Clinical rehabilitation, 2004, 8(1): 136-137. [16] LIU Ping-an, ZENG Jian-song, ZHAO Song-wei. An Analysis on Cardio Cerebrovascular Diseases and Their Influence on Survival Quality of Elderly Patients in Changsha. Practical Geriatrics, 1997, 11(5): 215-216. Translator: XIAO Yuan-chun () Received Date: April 2, 2008

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One of the largest research orgnizations of acupuncture and meridian in China, founded in 1958; Possesses a group of specialists capable of clinical and experimental research, and teaching; Studying in depth acupuncture treatment for diseases of immune, nerve, endocrine, digestive, urinary and genital systems; Undertakes responsibility of WHO research projects and is bed-side teaching unit for domestic and foreign students, visiting scholars, as well as the students for mastership and doctoral; Completed with clinic and research department; Accept acupuncturists and students aboard majoring in acupuncture for bed-side study and training;Send senior doctors abroad have cooperated with public and private medical organizations in Hong Kong, Macao, Taiwan, and so on. Address: No.650, south Wanping road, Shanghai 200030, P. R. China Phn: 0086-021-64382190 Email: zjtnyx@126.com; shzjzz@periodicals.net.cn

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