KEY FACTORS FOR SUCCESSFUL ACCUPUNTURE IN STROKE PATIENTS

 How can we make acupuncture maximally beneficial for stroke patients? Below are recommendations based on Zhu’s 50 years of clinical experience. There are a few important factors to consider.

I. Time is crucial

There is a misconception that acupuncture is contraindicated in the acute stage of stroke. Quite the contrary, acupuncture should intervene promptly, as early as the first hour after onset. Every hour of delay can potentially harm the outcome. The best treatment windows are, in decreasing order of therapeutic value: (1) the first three hours, (2) the first three days, (3) the first week, (4) the first month, (5) the first three months, and (6) the first six months. Both ischemic and hemorrhagic stroke can receive acupuncture treatment from the first day, but they differ in operation details.

Acupuncture has exceptional value in the first 3 to 72 hours. As evidenced by our own clinical cases, acupuncture seems to be able to salvage the penumbra surrounding the core of the stroke. Usually, about 72 hours after a stroke, cerebral edema starts to form and it is very damaging. Although the mechanism is not well understood, acupuncture triggers changes in the brain that result in the protection of brain cells from necrosis, thereby preventing or reducing edema and consequently promising a better prognosis. The often dramatic results in our stroke patients suggest that acupuncture could promote the reperfusion of the brain in a very short time, perhaps through the activation of the collaterals or the dissolution of fibrin around the clot. More research is needed to understand the mechanism.

Rehabilitation, like acupuncture, should also start as soon as vital signs are stable. This is particularly important for aphasia and dysphagia. Our experience shows that if speech therapy does not begin within the first month, speech recovery will be almost impossible or very limited. Again, ischemic and hemorrhagic strokes call for different types of rehabilitation exercises during the acute phase.

II. The treatment method

1. Choose the right acupuncture style
   Which acupuncture protocol is better for treating strokes? For many years Zhu had used conventional body acupuncture to treat strokes but was not satisfied with the results. So in the 1970’s he started to explore scalp acupuncture and developed Zhu’s Scalp Acupuncture. Often people are amazed at the outcome. For neurological conditions such as strokes, scalp acupuncture is by far the most effective.
2. Do the correct needle manipulation
   Acupuncture is not just about inserting needles at certain points; it is about regulating the qi flow. Hence manipulation of the needles is necessary to affect the qi. The technique and amount of manipulation vary with the type of stroke, stage of the disease, and the patient’s condition. For example:
   • If the patient is hypertensive, nervous or still hemorrhaging, very light stimulation is desirable on the scalp treatment areas.
   • It is not uncommon for the paralyzed side of the body to feel colder to touch. When this happens, the classical technique “Setting Mountain on Fire” often brings miraculous change to the body temperature. “Unblocking the channels, warming the Yang and promoting qi”, as these practices are called in Chinese medicine, will certainly benefit the patient’s recovery. It should be noted, however, that this warming effect is not achievable through electrical stimulation.
   • During the recovery stage, one can use stronger stimulation both on the scalp and body.
   • A comatose stroke patient whose vital signs are stable needs stronger stimulation.
   • Strong stimulation is contraindicated for spasms.
3. Perform appropriate Daoyin
   As mentioned before, acupuncture is not simply an act of inserting needles at certain points. Acupuncture is a complete therapy that involves not only needling but psychological counseling, encouragement, building the patient’s confidence to heal, helping the patient to relax, and teaching the patient how to talk and to move. All these things, which we call “Daoyin,”7 should be organically integrated into every acupuncture session.
   Daoyin has a much broader implication than conventional physical, occupational or speech therapy. Since its content can vary so much, an experienced acupuncturist customizes specific Daoyin activities to suit the needs of the patient at particular points in time. It requires the acupuncturist’s knowledge of the nervous system, the musculoskeletal system, sports medicine, and rehabilitation science, and various traditional Chinese healing modalities such as martial arts and tai chi.
   The following are a few examples of Daoyin:
   • A stroke patient with dysarthria or Broca’s aphasia is instructed to move his/her tongue in different directions and make sounds during acupuncture.
   • A stroke patient with facial palsy is instructed to open/close his/her affected eye, and to exercise his/her face muscles during acupuncture.
   • A stroke patient with paralytic lower limb is instructed to stand and walk with support.
   • A stroke patient with paralytic upper limb is instructed to push and pull on his/her affected arm during needle manipulation.

   Acupuncture with Daoyin is not a replacement but a great enhancement to conventional rehabilitation therapies. However, there are several areas where they differ.

   • Our approach is proactive. We help a patient sit before he can sit on his own. We make the first attempt to stand when the patient cannot even imagine or believe it is possible. We provide whatever support the patient needs to regain his lost function instead of waiting for the first sign of the function to come back spontaneously. A proactive approach not only speeds up recovery, it boosts the patient’s self-confidence.
   • When doing Daoyin, we give the patient only minimal assistance while taking adequate precaution and safety measures. The more active efforts from the patient, the better the treatment results. By the same token, we discourage the use of orthoses; muscles, tendons and ligaments can be strengthened by proper exercises. We have corrected countless foot inversion without using ankle-foot orthoses (AFO) and without causing any harm to the patient. Orthoses rob the patient’s opportunity to exert effort on his/her own, resulting in muscle atrophy and permanent dependence on a brace.
   • Unlike conventional therapy, we find that supporting a patient on his paralyzed side instead of the good side brings better outcome in the end.

III. The right dose of treatment

Concentration and repetition are necessary to provoke and reinforce plastic changes in the brain. Hence, to achieve speedy functional recovery after a stroke, intensive treatments are paramount. The frequency and duration of acupuncture treatments (needling and Daoyin combined) must be adequate especially in the first three months. A daily three to six hours of focused and active Daoyin engagement is the most desirable. We recommend multiple short sessions to avoid fatigue. The average two to six hours a week that most stroke patients currently receive in outpatient rehabilitation facilities is dismally insufficient.

IV. Management and prevention of complications following a stroke

• Seizures: Because anti-seizure medication is usually sedative, it hampers the rehabilitation process. Scalp acupuncture is an effective substitute without causing adverse side effects.
• Blood thinning: Avoid overuse of warfarin or coumadin to prevent secondary hemorrhage.
• Body postures: Spasticity does not set in immediately after a stroke, and can be avoided if more attention is given to body postures in the first month. Always keep the patient’s head, body, and limbs in normal physiological positions, especially the joints–neck, elbow, wrist, fingers, ankle and feet.
• Dementia and Parkinsonism: These are common after-effects that manifest after a long period of inactivity as the brain atrophies.8,9 Because they are not always apparent immediately after a stroke, they are often neglected in the rehabilitation process. Acupuncture is an excellent preventative treatment.

Conclusion: Maximizing the Benefits of Acupuncture in Stroke Rehabilitation

Acupuncture can be a major benefit to stroke rehabilitation when administered correctly. Results are most remarkable in the acute stage. First, treatment must begin promptly. Earlier intervention promises fewer deficits. Second, an effective acupuncture system should be employed. Scalp acupuncture excels over body acupuncture in treating neurological conditions such as strokes. After insertion, needles should be manipulated to ensure qi flow. Third, appropriate Daoyin must be carried out simultaneously. Finally, treatments have to be repeated frequently for reinforcement. In this manner a stroke patient will achieve a faster and more complete recovery.

By sharing our experience, we hope that acupuncture treatments for stroke can be optimized and that future research on this topic can yield more meaningful results.

References

1. Véronique R, Go A, Lloyd-Jones D, Adams R, Berry J, Brown T, et al. Heart Disease and Stroke Statistics – 2011 Update: A Report from the American Heart Association. Circulation Journal of the Americn Heart Association. http://circ.ahajournals.org/content/123/4/e18.full.pdf. Accessed August 11, 2011.
2. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. E Engl J Med. 1995;333:1581-1587.
3. Kelly-Hayes M, Beiser A, Kase CS, Scaramucci A, D’Agostino RB, Wolf PA. The influence of gender and age on disability following ischemic stroke: the Framingham study. J Stroke Cerebrovasc Dis. 2003;12:119 –126.
4. Sze FK, Wong E, Or K, Lau J, Woo J. Does acupuncture improve motor recovery after stroke?: A meta-analysis of randomized controlled trials. Stroke 2002; 33:2604-2619.
5. Sze FK, Wong E, Yi X, Woo J. Does acupuncture have additional value to standard poststroke motor rehabilitation? Stroke. 2002;33:186-194.
6. Siu M. A Speedy Stroke Recovery using Zhu’s Scalp Acupuncture. Available at: http://www.youtube.com/watch?v=fuQ7hiYaj9s. Last accessed August 11, 2011.
7. The concept and practice of Daoyin were depicted in the Emperor’s Classic and archaeological painting from the Han dynasty 200 BC.
8. Handley A, Medcalf P, Hellier K, Dutta D. Movement Disorders after Stroke. Age and Ageing. 2009;38(3):260-266.
9. Tatemichi TK, Desmond DW, Mayeux R, Paik M, Stern Y, Sano M, et al. Dementia After Stroke. Neurology. 1992 Jun;42(6):1185-1193.

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Ming Qing Zhu

Dr. Zhu graduated from the first acupuncture class of Shanghai University of Traditional Chinese Medicine in 1964. He began his medical career at his alma mater’s affiliated Shuguang Hospital seeing a broad patient base. Shortly after, with the launch of the tumultuous Cultural Revolution, Dr. Zhu was sent to the countryside. He was often the only village doctor, treating all kinds of patients including trauma, childbirth, neurological and internal diseases in these early years. Dr. Zhu honed his skills by engaging with patients and drawing inspirations from his teachers, one of whom highly recommended the use of acupuncture points on the scalp. In the ensuing years, Dr. Zhu not only practiced medicine in different clinical settings including acupuncture anesthesia for surgery but also became an instructor at different Chinese medicine teaching hospitals and research institutions across China. Dr. Zhu first encountered remarkable results of scalp acupuncture on a stroke patient by chance. While treating an acute stroke patient, the student who was assisting Dr. Zhu got tired of supporting the patient and let go. To everyone’s surprise, the patient who previously was paralyzed on one side of his body was standing on his own after being needled on his head and doing Daoyin exercises.