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 Table of Contents  
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 80-86

An overview of acupuncture in stroke recovery: A narrative review

1 MossRehab, Elkins Park, PA, USA
2 Wellspan Health, York, PA, USA
3 Physical Medicine and Rehabilitation Department, Kaiser Permanente, Sacramento, CA, USA
4 Physical Medicine and Rehabilitation Department, Temple University/MossRehab, Elkins Park, PA, USA
5 Physical Medicine and Rehabilitation Department, The University of Texas Health Science Center-Houston, TIRR, Houston, TX, USA

Date of Submission04-Jun-2020
Date of Decision26-May-2020
Date of Acceptance04-Jun-2020
Date of Web Publication01-Sep-2020

Correspondence Address:
Dr. Ning Cao
MossRehab, 60 Township Line Road, Elkins Park, PA 19027
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jisprm.jisprm_19_20

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Acupuncture has been used in stroke recovery in Eastern countries from ancient times. Increased interests and attention have been paid to understand how this oriental practice works for stroke patients in Western medicine. In particular, the effort has been made to study whether adjunct use of acupuncture to standard rehabilitation treatment could potentially further improve recovery after stroke. Therefore, in this comprehensive review of most recent literature, we are able to summarize some convincing evidence on beneficial effect of adjunct acupuncture treatment on poststroke recovery in the domains, including dysphagia, poststroke pain syndrome, and spasticity. Furthermore, some limited emerging evidence in the areas of motor recovery, insomnia, cognitive impairment, and depression is reviewed as well. This comprehensive review intends to provide insights about the potential clinical application of acupuncture for stroke rehabilitation and its future research direction.

Keywords: Acupuncture, rehabilitation, stroke

How to cite this article:
Cao N, Nguyen B, Li S, Lamba R, Hafner R, Li S. An overview of acupuncture in stroke recovery: A narrative review. J Int Soc Phys Rehabil Med 2020;3:80-6

How to cite this URL:
Cao N, Nguyen B, Li S, Lamba R, Hafner R, Li S. An overview of acupuncture in stroke recovery: A narrative review. J Int Soc Phys Rehabil Med [serial online] 2020 [cited 2023 May 28];3:80-6. Available from: https://www.jisprm.org/text.asp?2020/3/3/80/294129

  Introduction Top

Stroke is currently the fifth leading cause of death in the United States, with nearly 800,000 people experiencing a stroke each year. Between 2000 and 2010, the relative rate of stroke deaths dropped by 35.8% in the United States. Yet, stroke remains a major socioeconomic burden and accounts for 10%–12% of all deaths in industrialized countries. It is also a major cause of disability, affecting approximately 3 million stroke survivors. It subsequently brings heavy burden upon caregivers. More than two-thirds of stroke survivors receive rehabilitation services after hospitalization, with an estimated 34 billion dollars in the cost of treatment.[1] In May 2016, the American Heart Association and American Stroke Association (AHA/ASA) released the first ever guideline on rehabilitation after stroke, entitled Adult Stroke Rehabilitation and Recovery, reviewing the evidence for best clinical practices.[2] Included were the mention of acupuncture and the roles in which it may play, particularly in the areas of mobility and dysphagia. In this paper, we provide an overview of acupuncture and its uses in poststroke recovery. More recent evidence on poststroke mobility and dysphagia is reviewed. Furthermore, emerging evidence of acupuncture in poststroke pain syndrome, spasticity, insomnia, cognitive impairment, and depression are analyzed.

  Overview of Acupuncture in Poststroke Recovery Top

Acupuncture has been used in traditional Chinese medicine (TCM) for more than 3000 years for many diseases, including poststroke rehabilitation in China[3] and other Asian countries.[4] Conventionally, acupuncture is a component of standard therapy after a stroke with the goals for improvements in motor function, sensation, and speech.[5] Of 1095 physicians surveyed from 247 Chinese hospitals between 1993 and 1994, it was found that 66% of doctors routinely used acupuncture for stroke patients.[5] In 2007, among 202 Chinese acute stroke patients, 63% said that they would choose to have acupuncture as part of their medical intervention.[6] In Korea, 54% of stroke patients utilize complementary and alternative therapies such as acupuncture.[4] Despite the long history of acupuncture in the East, the treatment only became well known and adapted as part of the complementary and alternative therapy movement in the West after it was profiled in a New York Times article in 1971.[7] The 1997 National Institutes of Health (NIH) Consensus Development Panel on Acupuncture summarized the available evidence and supported the adjunctive use of acupuncture in nausea and vomiting related to chemotherapy, adult postoperative surgery pain, and postoperative dental pain.[8] In 2016, the role of acupuncture in rehabilitation of poststroke dysphagia and impaired mobility is recognized.

The theory of acupuncture lies in the thought that the very core of disease onset is disruption of Qi, the body's vital internal energies. Qi flows through a network of channels, called “meridians,” running along the surface of the human body. Inserting needles at certain acupoints along meridians restores qi flow and influences progression of the disease. With the needle insertion, a “de qi” reaction occurs in which the patient perceives an ache or heaviness in the area surrounding the needle, while the acupuncturist performs biomechanical movements to restore qi flow at that site and through its correct paths.[9],[10] Furthermore, different pathophysiological mechanisms for stroke were proposed as the basis for selection of acupoints, according to TCM theories.[11]

The physiological mechanism of acupuncture in Western Medicine is controversial, however. Acupuncture has shown to have physiological effects that theoretically could also influence brain plasticity. Chavez et al.[12] have reviewed 40 studies of Sprague–Dawley rats, Wistar rats, mice, or gerbils, with permanent or temporary occlusion of the unilateral or bilateral middle cerebral artery and/or common carotid artery stroke models. These studies suggested that acupuncture or electroacupuncture (EA) performed in the acute and subacute states after ischemic injury may have beneficial effects through five major mechanisms: (1) promotion of neurogenesis in the central nervous system, (2) regulation of cerebral blood flow, (3) inhibition of apoptotic process, (4) regulation of neurochemicals, and (5) modulation of long-term potentiation and memory improvement. However, it was pointed out that the preclinical data cannot be completely extrapolated to the human clinical study. The exact mechanism by the peripheral stimulation of acupoints to activate afferent fibers to the brain is not clear at this point.[12] Lee et al.[13] conducted a study in which a series of six patients with MCA occlusion received a single-photon emission computed tomography brain perfusion image before and after acupuncture treatment. Comparing the changes in regional cerebral blood flow (rCBF) to those of normal control, it was found that the all subjects in the experimental group had focally increased rCBF. This was especially noted in the hypoperfused zone surrounding the ischemic lesion, the ipsilateral or contralateral sensorimotor area, or both. In contrast, normal subjects showed increased rCBF mainly in the parahippocampal gyrus, premotor area, frontal and temporal areas bilaterally, and ipsilateral globus pallidus. It should be noted that these results were compared to normal individuals as opposed to a control group that did not receive acupuncture. Based on this study, it appears that acupuncture stimulation after stroke activates perilesional or use dependent reorganized sites, possibly facilitating neuronal plasticity.[13]

Although the usage of acupuncture in Western medicine has increased, its widespread acceptance remains limited due to conflicting reports as to its efficacy. Many previous acupuncture and stroke trials have been of poor quality, which includes poor study design, small sample size, lack of randomization, and lack of standard outcome measures.[6],[14] These concerns regarding study quality are illustrated in a systematic review by Wu et al., which looked at 56 randomized controlled trials between 1992 and 2009(Wu et al., 2010).[3] Overall, the studies included 5650 patients with 3156 in the treatment group and 2494 in the control group. The trials included both patients after ischemic and hemorrhagic strokes and tended to be relatively small with a median sample size of n = 86 (range 16–241). Outcome measures included motor impairment scales, generalized stroke scales, and disability assessments. Randomization and allocation concealment were poorly reported with only 25% of the studies giving detailed accounts of how patients were randomized. Patients were blinded in only 11% of the studies in which sham acupuncture was utilized. Further, assessor blinding was reported in 28.6% of studies. Forty-five of the studies showed positive results, six had positive benefits in subgroup analysis, and no difference was found in five studies. However, many trials were conducted in China and yielded important differences in treatment effects than studies conducted elsewhere. Due to variability of the endpoints, the authors were unable to meta-analyze all the trials. This systematic review found that acupuncture may have a role in poststroke rehabilitation, but the authors were unable to strongly endorse it due to concerns about study quality. They conclude that there needs to be further evaluation in a large, well-conducted transparent clinical trial (Wu et al., 2010). Similarly, a meta-analysis by Sze et al.[15] on most randomized controlled trials published from 1990 until 2002 concluded that there was no credible evidence for effectiveness of acupuncture in stroke rehabilitation.[15] However, when these data were reexamined by Shiflett,[16] there were a number of factors found to be involved in the finding of nonsignificance when there was indeed significant evidence for acupuncture in poststroke recovery.[16] From his reanalysis, he found that crude, low-powered statistics were being used and that there was failure to adequately account for stroke severity. The other flaw was the timing of posttreatment assessments that required a rapid effect to be evident. The disparity lies in the fact that stroke takes many weeks to months to recover based on severity. There is an unreasonable expectation for acupuncture to have rapid effects; the thought is likely related to the fact that it has an often-immediate effect on pain. Shiflett proposes that there should be stratification of acupuncture based on stroke severity and that assessment times should be done later as change should be more evident in 2–6 months. In the reexamination of a meta-analysis that initially showed no evidence for acupuncture, Shiflett was able to find statistical significance in favor of acupuncture for three of the four outcome categories used in the review, including functional independence and motor recovery.[16] Shiflett therefore provides a promising direction for future acupuncture studies to be conducted.

With the available data, the NIH Consensus Development Conference on Acupuncture concluded in 1997 that there was limited and encouraging evidence for the relationship between acupuncture and stroke recovery, although there was not enough evidence to recommend its use as medical procedure.[8] Despite some of the issues regarding the quality of research on the effectiveness of acupuncture in stroke, the latest guideline by the AHA/ASA(Weistein et al. 2016)[2] finds that there is good scientific evidence to consider including acupuncture as an adjunct to standard stroke rehabilitation to improve walking speed and dysphagia.[2] Acupuncture is advantageous due to its affordability, low potential for adverse effects, technical simplicity, and minimal invasiveness. In addition, it has been safely used in patients on blood thinners. For example, Johansson et al.[17] found that there were no bleeding complications observed in six patients treated with acupuncture while on warfarin during a total of 120 treatment sessions. Another study by Johansson et al.[17] reported minimal adverse events that included pain, dizziness, bleeding, aggravation, hematoma, infection, and discomfort.[17] Given emerging evidence of clinical efficacy and its advantages, acupuncture is a promising adjunct therapy for stroke rehabilitation programs to improve clinical outcomes.

  Acupuncture Use in Dysphagia Top

Dysphagia is a common condition that occurs in 42%–67% of patients within 3 days after a stroke. Of these patients, about half aspirate, and one-third of those patients develop pneumonia.[18] Stroke primarily affects the oral and pharyngeal phases of swallowing. Problems involve uncoordinated tongue movements, reduced propulsion of the tongue base, delayed swallowing reflex, and reduced lifting of laryngeal and contraction of posterior pharyngeal wall.[19] Unfortunately, there were insufficient data for swallowing therapy effects on functional outcome and death in dysphagic patients with either acute or subacute stroke, according to a Cochrane review in 2012. Intriguingly, it was found that behavioral interventions and acupuncture can improve dysphagia.[11],[20]

A meta-analysis of randomized controlled trials was conducted on 29 studies investigating the effects of acupuncture on dysphagia in stroke rehabilitation from the earliest record to 2016(Li et al., 2018).[9] The intervention groups received either acupuncture or EA. The included studies had a medium quality grade based on the Consolidated Standards of Reporting Trials and Standards for Reporting Interventions in Clinical Trials of Acupuncture checklist. There were issues in the heterogeneity of outcomes measures and intervention intensity in the studies; however, the subgroup and meta-regression analyses suggested that acupuncture therapy provided a higher effective rate compared with nonacupuncture treatments. For subgroup analysis, acupuncture treatment tended to be more effective in patients with ischemic stroke, in chronic phase if provided in higher intensity. It was pointed out that the effective rate in this study was determined primarily based on bedside evaluation which may not be accurate. Interpretation therefore becomes limited due to heterogeneity of the data. In addition, other sources of concern lie in the short-term follow-up after treatment. Whether acupuncture can be recommended to be used in daily routine dysphagia treatment after stroke remains inconclusive in this current review, due to concern of methodology of studies.

Chan et al.[19] looked at the effects of acupuncture versus sham acupuncture versus conventional care. N = 87 subjects with neurogenic dysphagia due to Parkinson's disease, stroke, or vascular dementia were randomized to groups receiving either 20 sessions of true acupuncture or sham acupuncture for 1.5 months. Data revealed that the average level of food and fluid consistencies displayed greater improvement in the experimental groups compared to control. The Royal Brisbane Hospital Outcome Measure for Swallowing (RBHOMS) increased in all groups studied. Interestingly, however, the percentage improvement in average RBHOMS scores and food/fluid consistencies was higher in acupuncture and control groups when compared to sham group. Unfortunately, the study could not reach statistical significance due to small sample size. As a result, the recommendation remains limited that acupuncture may have therapeutic effects and long-term efficacy for neurogenic dysphagia.[19]

However, there appears to be promise in acupuncture for dysphagia, and it may still be used by qualified practitioners without much negative effect. The mechanism of acupuncture for poststroke dysphagia remains uncertain. Although various acupoints were applied in the included studies in Wong's systematic review, two acupoints, Lianquan (CV23) and Fengchi (GB 20), were most commonly used.[21] These acupoints have been shown to dilate arteries and increase the blood flow to the brain and reduce ischemic damage. It is believed that this causes an “awakening” of neurons, resulting in reconstruction of swallowing reflex. Acupuncture has been previously found to modulate the subcortical gray structures. Through the alteration of regional brain activity, it is speculated that acupuncture thereby restores the swallowing reflex.[19]

A larger sample, multicenter, well-blinded randomized controlled trial with homogeneity in outcome measures needs to be carried out.[9]

  Acupuncture Use in Poststroke Pain Syndrome Top

Another major issue that affects function and quality of life after stroke is central poststroke pain (CPSP), also known as thalamic pain or Dejerine–Roussy syndrome. CPSP is a pain that results from a lesion in the somatosensory system rather than from a peripheral nociceptive or psychogenic cause.[22],[23] The prevalence of CPSP in patients with stroke is between 1% and 12%. As the underline mechanism of CPSP is still unclear, this condition has been a challenge to treat and multidisciplinary approach is essential.[24]

There are relatively fewer studies examining the use of acupuncture in CPSP as compared to dysphagia. However, the ones that are available do show promise that the use of acupuncture as a nonpharmacologic modality may be a viable option. In particularly, apipuncture, the subcutaneous injection of diluted bee venom in acupoints, has been used for pain control in inflammatory diseases such as rheumatoid arthritis and osteoarthritis. However, less is known about its use in CPSP. It is thought to increase brain activity in the regions closely associated with a wider pain matrix responsible for modulating both the sensation and affective pain perception.[25]

Apipuncture is an alternative treatment method that has been used since at least the second century BC in Eastern Asia. Apipuncture exerts simultaneous pharmacologic effects from the bioactive compounds from the bee venom and mechanical actions from acupuncture stimulation. This is thought to be more effective than other forms of acupuncture. In animal studies, apipuncture produces a very potent and long-lasting antinociceptive effect in both acute and chronic rodent pain. Its antinociceptive mechanism is hypothesized to be mediated by spinal cord alpha-2 adrenoceptors through the activation of alpha-2 adrenergic and serotonergic components of the descending pain inhibitory system.[26]

The descending pain inhibitory system involves two major components of the endogenous descending antinociceptive system. One is the intrinsic opioidergic system and the other is a descending monoaminergic (i.e., serotonin and adrenaline) system in the brainstem. It has been proposed that the antinociceptive effect is mediated by different neuronal mechanisms depending on the type of stimulation that is applied to an acupoint. For instance, low-frequency EA-induced analgesia appears to be mediated by the endogenous opioidergic system, while the analgesic effect of high-frequency EA is mediated by nonopioidergic system. Kim et al.[26] illustrated this differential effect by reversing the apipuncture's effect by intrathecal pretreatment with alpha-2 adrenoceptor antagonist (idazoxan) or the nonselective serotonin receptor antagonist (methysergide).[26],[27] In contrast, apipuncture-induced antinociception was not affected by intrathecal injection antagonists to other adrenoceptor subtypes or nonselective opioid receptor antagonist.[27]

This implies that antinociceptive effect of apipuncture is mediated by specific descending monoaminergic pathways, rather than intrinsic opioidergic system. Adrenergic and serotonergic components of the descending pain modulation system arise from the nucleus raphe magnus and locus coerulus. Activation of these nuclei by acupoint stimulation with dBV therefore produces an antinociceptive effect via the activation of spinal alpha-2 and/or serotonergic receptors. This is supported by the finding that BV acupoint stimulation increases neuronal activity in the brainstem catecholaminergic neurons.[27]

There are limited data on the usage of acupuncture in CPSP. A small preliminary study from 2013 investigated the use of apipuncture point injection using diluted bee venom for CPSP. N = 20 patients with CPSP and visual analog scale (VAS) >4 were divided into two groups and blinded. Two groups had diluted bee venom versus normal saline injected two times per week for 3 weeks. In addition, the patients maintained their medications and physical therapy. The outcome measure was the VAS score of pain severity. The median VAS score decreased by 36.50 points in the treatment group and 11.50 points in the control group, a significant improvement with P = 0.009. This suggests that apipuncture significantly improves CPSP. Again, this is a small preliminary study. Further studies of its mechanism and larger and longer-term follow-up double-blind trials are needed to determine the efficacy of apipuncture and elucidate its duration of effect.[27]

  Acupuncture Use in Poststroke Shoulder Pain Top

Poststroke shoulder pain is a very common complication after stroke with an estimation of 54%–75% of prevalence in stroke rehabilitation settings. Effective treatment options are limited, including electric stimulation (Price and Pandyan, 2001).[28] Recent evidence supports the promising role of acupuncture in managing poststroke shoulder pain.

The latest systemic review published in 2018 by Chau et al.[29] reviewed 29 randomized controlled trials involving 2250 participants published from 2009 to 2017.[29] Among the 29 trials, 21 of them explored the effect of conventional acupuncture, five examined the effect of EA, one examined the effect of fire acupuncture, and one analyzed warm acupuncture on the stroke patients with poststroke shoulder pain. The primary outcome measures were to assess pain and upper extremity function immediately after intervention, except one study followed the outcome after 1 month of intervention. Due to the heterogeneity of acupuncture regimen in various studies, meta-analysis and sensitivity analysis were not feasible in this study. However, by narratively analyzing the data, the review has found conventional acupuncture can be associated with potential benefit with pain and improving upper extremity function; the similar effect was found in EA treatment in terms of shoulder pain and upper extremity function. However, the limited number of trials would question the risk of bias of this conclusion. Another limitation is that the most trials included in the review did not define the component of usual care in control group.

The most recent randomized trial published in 2019 with effort to examine the effect of acupuncture in combination with routine rehabilitation therapy for early pain recovery of poststroke shoulder pain syndrome. In this article, the authors only included the patients 7 days to 3 months after stroke, with very defined rehabilitation intervention to both intervention and control groups on a daily basis for 1 month. The intervention group who received conventional acupuncture treatment in addition to the rehabilitation treatments demonstrated favorable effect in terms of early pain and upper extremity motor function.[30]

Worth to mention that despite the highly heterogeneous intervention regimens of the trials on EA, Jianyu (SI15), Quchi (LI 11), Hegu (LI 4), and Jianzhen (SI 9) were the most commonly selected acupoints, and reaching the status of “deqi” was suggested based on the recent literature and systematic reviews.[29],[30]

In conclusion, it seems patients with shoulder pain benefit more when acupuncture was applied early after stroke; mostly, immediate effect of pain relief has been observed based on the current studies' results.

  Acupuncture Use in Poststroke Spasticity Management Top

Spasticity is a common complication in stroke, occurring in about 20%–50% of stroke survivors.[31],[32] It has been commonly defined as abnormal velocity-dependent increase in muscle resistance, resulting from hyperexcitability of the stretch reflex. Spastic muscles resulting from stroke can be a significant burden on motor function, be a source of pain and skin damage, as well as interfere with activities of daily living.[31],[33],[34] Current established treatments including stretching, splinting, oral medications, botulinum injections, chemical neurolysis, and intrathecal baclofen all offer potential unwanted side effects. Moreover, despite these established treatments, many patients still exhibit a significant degree of spasticity. Acupuncture may offer a safe, cost-effective alternate way to improve spasticity in stroke patients.

One recent systematic review looked at recent trials that compared the effects of acupuncture or EA to routine care or placebo acupuncture (Lim et al., 2015).[35] The authors reviewed the current literature in English and also accredited journals in Chinese and Korean and found a total of five randomized controlled trials. The trials assessed spasticity primarily using the modified Ashworth scale (MAS), and taken as whole, the meta-analysis revealed that four out of five of these RCTs showed that acupuncture or EA significantly decreased poststroke spasticity, especially in the wrist, knee, and elbow. However, there was marked heterogeneity in acupoints, poststroke duration, and control populations.

For example, in one of the five randomized controlled trials cited in the systematic review, Zhao et al. 2009[36] studied 131 patients with spastic hemiplegia who underwent 30-day treatment regimens: standard therapy and traditional acupuncture treatment versus standard therapy alone.[35] This single-blinded study found that the average Ashworth score significantly decreased from 3.08 ± 0.77 before treatment to 1.82 ± 0.65 after acupuncture intervention in the wrist joint and from 2.72 ± 0.59 to 1.32 ± 0.71 in the elbow joint in the treatment group.

However, in another meta-analysis of randomized controlled trials, Park et al., 2014[35] concluded that “the effect of acupuncture for spasticity in patients with stroke remains uncertain, primarily because of the poor quality of the available studies.”[35] In this meta-analysis, randomized trials assessing the effects of acupuncture for the treatment of spasticity after stroke were identified by searching various databases including foreign ones. Overall, the study included eight trials and concluded that compared with controls, acupuncture had no significant effect on improving outcomes. However, none of these trials had adequate methodological quality.

Another recent meta-analysis[32] evaluated the effects of EA on stroke patients with spasticity. The analysis found that EA, as an add-on therapy to routine care, has the potential to further reduce spasticity in stroke patients.[32] However, it was found that there was only a significant effect if EA was done within 180 days poststroke. Spasticity was measured by the MAS. In this meta-analysis, a total of 22 trials involving 1425 participants were included. Taken together, these trials suggested that EA had potential to reduce upper limb as well as lower limb spasticity. EA also significantly improved lower limb motor function and activities of daily living. However, future randomized controlled trials with appropriate blinding are needed. Therefore, the protocol for a randomized controlled trial was proposed by Cai et al.[37] to evaluate the effects and safety of EA plus usual care for poststroke spasticity with high methodological and reporting quality. The selection of acupuncture points was suggested by the WHO[38] are LI4, TE5 (wrist), LI10, LI11 (elbow), LI15 (shoulder), GB34, ST36, ST40 (knee), SP36 (ankle), and LR3 (toe joint) as mandatory points. This trial will provide additional insights regarding the adverse side effects of EA, as well as the relative effect of spasticity on different joints when completed.

In conclusion, there is some evidence that EA could significantly improve spasticity after stroke, especially if the treatment is done relatively early poststroke. Given acupuncture's low reported rate, severity of adverse side effects, and the relatively low associated cost compared to other treatments for spasticity, the efficacy of acupuncture of spasticity should be further studied. Our current knowledge is limited by the small number of studies available; moreover, many studies are of poor methodological quality. Future research should aim to focus on larger, double-blind randomized controlled trials with sham control group, adequate follow-up to assess for adverse side effects, the optimal timing and frequency of acupuncture, and a standardized set of acupoints. It would also be beneficial to elucidate the exact mechanism by which acupuncture improves spasticity. Future direction should also aim to assess whether EA is more promising in improving spasticity than traditional acupuncture.

  Acupuncture Use in Insomnia After Stroke Top

Insomnia after stroke is a common complaint from patients with stroke. Although effective pharmacological treatments are available, treatment with acupuncture is believed to be safer and more acceptable to many patients who have concerns about side effects. The most recent systematic and meta-analysis[39] included 13 randomized controlled trials that reviewed the effectiveness of acupuncture treatment compared to medication treatment for poststroke insomnia. Results from the meta-analysis showed that acupuncture appears to be more effective than medications based on subjective grades from the evidence-based Pittsburgh sleep quality index, the efficacy standards of Chinese medicine, the insomnia severity index, and the Athens insomnia scale. The meta-analysis had significant limitations, mostly that the acupuncture methods were not standardized. For example, different combinations of conventional acupuncture, auricular acupuncture, and EA were used. These methods may produce different effects even though all acupoints were drawn from TCM theory. The results would otherwise need to be interpreted with caution, given that most of the analyzed studies had small samples, showed unclear risk of bias, and had poor overall methodology.[39] Further consistency between studies needs to be established in the future.

  Other Acupuncture Uses in Poststroke Recovery Top

Other uses of acupuncture have been studied with regard to other aspects of stroke recovery, such as cognition/depression, motor recovery, and aphasia. However, the number of published studies has been relatively small. The emerging evidence from the preclinical and clinical trials demonstrated that acupuncture may help treat the poststroke depression and cognitive impairment.[40],[41] Hung et al. reported from the four randomized control trials with validated outcome measures that acupuncture treatment in addition to conventional therapy could improve cognitive function when compared to cognitive rehabilitation alone. They also summarized from ten published trials that acupuncture is potentially effective and could possibly be a safe monotherapy for poststroke depression. However, the long-term benefit was not certain in most of the studies. Due to lack of methodology details, and not fully executed PRISMA for included systematic reviews, the strength of this recommendation is limited and further research needs to be done to support the implementation of changes to clinical practice.[42]

With regard to the motor recovery after stroke, the application of acupuncture has been examined in several studies, but current evidence is not convincing, in most part due to poorly designed trials. It is worthwhile to point out that Au-Yenng et al.[43] performed a well-designed double-blind placebo-controlled clinical trial to look at upper limb motor recovery when received electric stimulation to the acupoints, compared to conventional rehabilitation in acute phase after stroke.[42] Patients who received additional electric stimulation to acupoints had better improvement than control group in hand grip and pinch strength after 4 weeks treatment. However, Action Research Arm Test was not different between groups. The question of efficacy observed in this study may relate to the placebo effect, which warrants a larger randomized controlled trial to examine possible placebo influence of the electric stimulation treatment on motor recovery of the affected hand. Although there were interests in acupuncture usage in poststroke aphasia recovery, the few publications in China would be very hard to be generalized to other clinical practice, due to the nonstandardized speech therapy utilized with different language.

  Conclusion and Future Direction Top

Acupuncture, a TCM treatment in use for thousands of years, has found increased usage over the past 40 years in Western medicine. Indications for acupuncture have been varied, from nausea and vomiting in chemotherapy to postoperative pain and dental pain. During this time period, acupuncture has gained recognition through the NIH and most recently the stroke recovery guideline by the AHA/ASA, to have possible uses in poststroke recovery. However, its recommendation is largely within the roles for adjunctive therapy within alternative and complementary medicine. While studies have shown promise for its use, there is not enough evidence for strong recommendations to be routine treatment given at this time. A large part of this is due to conflicting reports of efficacy and investigations conducted by poor methodological studies.

In this paper, the most updated literature was reviewed in regard to acupuncture applications in the aspects of dysphagia, CPSP, spasticity, and insomnia and emerging evidence of its application in cognitive impairment and depression, motor recovery, and aphasia. These are conditions that have important implications on stroke patients' quality of lives and function, and acupuncture has gained adequate attention to be studied for these conditions. To better elucidate the role of acupuncture within these disorders, more robust studies need to be carried out. Overall, future studies need to involve large multicenter trials with adequate randomization and methodology. Heterogeneity of data and outcomes have been a weakness, which can be better controlled for through the standardization outcome measures. In addition, a standardization of acupuncture type and acupoints used would be critical as well. Shiflett's reanalysis of a systemic review helped point out areas of improvement, which includes stratification of treatment by stroke severity and an adequate posttreatment assessment period to allow for accuracy in finding possible significance in acupuncture use. Should the outcomes in future studies continue to be positive under these measures, stronger recommendations may then be provided, helping to bring acupuncture into larger acceptance in Western medicine.

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