The Effectiveness of Acupuncture in Reducing After-Effects of Strokes in Patients 40 Years and Older

Abstract

This systematic review article aims to examine the effectiveness of acupuncture as a treatment for the after-effects of stroke in patients 40 years and older. Numerous western medications have been developed to treat stroke symptoms, but they are often accompanied by nausea, dizziness, fatigue, and excess bleeding. Additionally, the average cost of stroke care for a patient in the United States, taking into account rehabilitation, inpatient care, and follow-up appointments, is $140,048.70, placing significant financial burdens on healthcare systems and patients. Incorporating acupuncture as a stroke treatment can aid in lowering patient costs and decreasing after-effects for patients. By analyzing 84 randomized control trials and case studies from PubMed and Google Scholar using curated inclusion and exclusion criteria, this paper concludes that acupuncture can improve impaired motor function in the lower limbs, enhance the quality of daily life of patients, strengthen cognitive function, and reduce post-stroke depression. Acupuncture is seen to be an effective complementary therapy to traditional western stroke medications and treatments. Notably, acupuncture has been shown to alleviate patients’ loss of motor function in their upper extremities by decreasing ankle plantar flexor spasticity and increasing dorsiflexion strength. Acupuncture is a cost-effective treatment that should be implemented as a supplemental therapy for stroke rehabilitation; however, more long term studies should be conducted in order to understand its impact on patients from varied demographics and people with predetermined genetic or environmental risk factors.

Keywords: Stroke rehabilitation; Post-stroke symptoms and after-effects; Standard acupuncture, scalp acupuncture, body acupuncture, dense cranial acupuncture, auriculotherapy, and electrostimulation; Ischemic and hemorrhagic strokes; Quality of daily life, motor function, neurological impacts, post-stroke depression; Western medicine, traditional chinese medicine, integrative medicine.

Introduction

Strokes are caused by disturbances in the blood vessels of the brain, and there are two main types of strokes, ischemic and hemorrhagic¹. In an ischemic stroke, a blood vessel that supplies the brain becomes blocked and impairs blood flow to part of the brain. Ischemic strokes have two types: thrombotic, which are caused by blood clots in vessels, and embolic, which are caused by blood clots or plaque buildup that develops in some section of the body and travels to the brain. Ischemic strokes can develop suddenly, leading brain cells and tissues to die within minutes. Meanwhile, hemorrhagic strokes arise when a blood vessel in the brain ruptures and bleeds, depriving the brain of oxygen and nutrients. The resulting pressure in surrounding tissues fosters irritation and swelling. There are also two types of hemorrhagic strokes: intracerebral and subarachnoid strokes. Intracerebral strokes are typically caused by high blood pressure and have a high risk of mortality. Subarachnoid strokes are often due to aneurysms or arteriovenous malformation, which results when bleeding occurs between the brain and the meninges¹. Due to the wide variety of stroke types, a stroke can be traced to variegated symptoms. When a stroke impacts the left side of the brain, patients typically experience speech and language problems and exhibit more cautious behavior. Patients with strokes affecting the right side of their brain experience vision issues and an inquisitive behavioral style². Strokes impacting either side of the brain can result in varied degrees of paralysis, memory loss, insomnia, fatigue, and decreased attention-spans. Patients also experience strong emotional changes, oftentimes developing depression due to the reduction of their motor skills and loss in dexterity³. In western medicine, the majority of stroke patients are treated using prescribed medications such as blood thinners, which dissolve and treat stroke-causing blood clots. The tissue plasminogen activator (TPA) is the most prevalently used when treating ischemic strokes⁴. TPA injections are given through the arm within three hours of the stroke. It reduces the severity of the stroke by restoring the blood flow back to the regions of the brain affected. However, western stroke medications are also accompanied by side-effects including nausea, dizziness, fatigue, and excess bleeding⁴. With evidence-based practices, advanced technology, precision, emergency care, specialization amongst healthcare professionals, and pharmaceutical advancements, western medicine is effective at diagnoses and treatments, shown by the aforementioned medications that stop strokes at their source. However, while western medicine remains prominent in global healthcare, it has several drawbacks: critics point to an over reliance on medications, potentially neglecting holistic approaches and lifestyle factors⁵. In certain instances, holistic approaches, such as Traditional Chinese Medicine, can prevent the future occurrence of an illness and address its root cause, whereas western medicine is sometimes only effective in addressing the symptoms of the disease⁶. Due to these qualities of both types of medicine, integrative medicine (combining both approaches) holds great potential for curing illnesses and diseases. However, as shown in the image below, while western and holistic approaches to medicine perfectly complement one another, oftentimes eastern medicine is overlooked in the medical field.

In the United States, the average cost of stroke care for a patient, including their rehabilitation, inpatient care, and follow-up appointments, is $140,048⁸. With strokes being one of the most common and fatal conditions–every 3 minutes and 14 seconds, someone dies of stroke⁹ –they place significant financial burdens on healthcare systems and patients, especially those from communities of color. Research has shown that certain ethnic groups are more susceptible to strokes and stroke-induced death than others, most prominently African-Americans¹⁰. Furthermore, in recent data from a longitudinal JAMA Network Open study¹¹, concerning disparities emerge: Asian Americans and Pacific islands are not only the most susceptible to intracerebral hemorrhage strokes compared to other ethnic groups, but they are far likelier to experience long-term health complications.

However, despite the greater risks of stroke for people of said ethnicities, current studies exploring the impact of acupuncture for stroke rehabilitation are heavily centered in China, leading to a lack of knowledge in terms of the impact of acupuncture for people across varied demographics. In order to prevent the occurrence of strokes and mitigate their lingering impact, vulnerable populations should have increased healthcare literacy to enhance their awareness regarding alternative medicine and therapies.

While western medicine treatments incur significant financial burdens on stroke patients, using eastern medicine approaches, specifically acupuncture, alongside conventional medicine can lower patient costs¹³. Acupuncture¹⁴ involves the insertion of very thin needles into the skin, directed at specific pressure points to strategically stimulate nerves and muscles. Originating in China, it is based on the belief of Qi (Chi)–the flow of energy in life–circulating throughout one’s body in lines called ‘meridians.’ The needles are inserted in specific acupuncture points (acupoints) within these meridians, stimulating the central nervous system and releasing chemicals to the brain, spinal cord, and muscles.

As it may release endorphins, a natural painkiller chemical, acupuncture has most often been associated with providing pain relief to patients. Acupuncture is used in many different forms as well: auricular acupuncture (needles are inserted into acupoints on the outer ear–the ear is said to be a microsystem that reflects the entire body), electroacupuncture (applies a minute electric current to acupuncture needles to stimulate the points), scalp acupuncture (needles are inserted into acupoints on the scalp), and body acupuncture (needles are inserted into acupoints throughout the body). Another form of acupuncture utilized by several studies in this review is dense cranial electroacupuncture stimulation, in which electrical stimulation, at a higher intensity than general electroacupuncture, is applied to acupuncture needles inserted into acupoints in the scalp or cranial region¹⁴. In its various forms and uses, the benefits and effectiveness of acupuncture is continuously being researched, as it holds much potential for diverse treatments.

Although western medications are effective in stopping strokes at their source, strokes can be accompanied by drastic symptoms post-treatment, ones that can impair day-to-day life. This paper will investigate the effectiveness of acupuncture in alleviating the after-effects of strokes, ultimately aiming to establish the benefits of implementing acupuncture as a complementary therapy to western medicine for stroke rehabilitation. First, the impact of acupuncture on different aspects of post-stroke rehabilitation will be explored, and then research discrepancies, as well as clinical implications of the findings, will be expressed. By highlighting current research on acupuncture for the aftercare for strokes, the researchers of this review aim to contribute to growing discussions of intertwining global healthcare practices to reduce stroke rates and financial burdens on patients of all demographics.

Results

There are several components that comprise stroke rehabilitation, so for the sake of this review, the effects of acupuncture on patients’ motor function, neurological function, cognitive abilities, quality of daily life, and mental health were explored.

Motor Function

Acupuncture has been shown to accelerate the improvement of motor function in post-stroke patients. Combining western rehabilitation techniques with acupuncture steadily helps enhance motor function within the body. A study¹⁶conducted at a hospital affiliated with Chinese medicine deduced that the usage of Zhu’s scalp acupuncture (a comprehensive technique developed by Dr. Ming Qing Zhu) and body acupuncture rebuilt significant body mobility when paired with rehabilitation techniques. Researchers utilized the Manual Muscle Testing (MMT) scale, which measures muscle contraction of the upper and lower extremities, and the Barthel Index, which assesses the muscular ability of activities of daily living, and the Fugl-Meyer Assessment, which clinically assesses upper and lower extremity function. Compared to the scores before the acupuncture treatment, there was a statistically significant difference in all three scores post-treatment, enabling the researchers to ultimately conclude that acupuncture improved limb motor function in 48.9-51.25% of study participants who survived from ischemic stroke. The study included both a group subject to scalp acupuncture and a group subject to body acupuncture, and researchers found that there was a statistically significant difference of efficiency between both methods, with scalp acupuncture being 20% more efficient than body acupuncture. Additionally, the ancient Chinese theory of Yin and Yang (the contrary yet complementary forces present in every circumstance and organism)  was integrated into the treatments: the acupuncture treatment in a passive state represented Yin, and the movement therapy represented Yang. This balance of contrasting treatments can enhance body motor function¹⁶.

Another form of acupuncture, electroacupuncture, was tested to observe any motor function improvement. In one randomized controlled study, patients of first-time ischemic stroke received eight courses of electroacupuncture over one month alongside a conventional rehabilitation program¹⁷.  Applying the Fugl-Meyer Assessment, the researchers assessed that there was a statistically significant improvement in motor function for the study group compared to the control group, particularly in upper-limb motor function. Additionally, randomized controlled trials in China¹⁸ found that if electroacupuncture was given five times a week within ten days of an acute stroke, patients’ ankle plantar flexor spasticity decreased and dorsiflexion strength increased, signifying improvement in muscle strength and mobility within lower extremities. These collective findings indicate that electroacupuncture is a viable method to improve motor function post-stroke. Implementing physical therapy alongside eye and body acupuncture can also lead to enhanced walking ability and impulse control in patients’ lower extremities¹⁹.

One significant aspect of stroke rehabilitation is the restoration of functional independence and the enhancement of quality of daily life for affected individuals. Acupuncture has been demonstrated to effectively reduce spasticity by modulating neural pathways and promoting muscle relaxation. By targeting specific acupuncture points, such as GV20, it helps balance the body’s Yin and Yang, dredge Qi and blood, and weaken the promoting effect of the descending central nervous system, thus alleviating muscle spasm symptoms. The improved muscle control enables post-stroke patients to have an easier time facilitating the execution of daily tasks including walking, eating, and dressing²⁰.Strokes, if resulting in neural damage in the brain stem, can also lead patients to develop dysphagia where they experience difficulty swallowing. A single blind randomized control trial²¹  found that acupuncture treatment can benefit stroke patients with dysphagia, observed by a statistically significant improvement in the Dysphagia Outcome Severity Scale over a four week therapy period.

Acupuncture’s consistent efficacy, as exemplified through short term interventions like Zhu’s scalp acupuncture and electroacupuncture, signifies a promising avenue for enhancing post-stroke motor function. In all the studies cited above, acupuncture has facilitated the establishment of new neural pathways and improved overall innervation and motor control. Incorporating acupuncture into comprehensive stroke rehabilitation programs can significantly enhance the quality of life for patients by addressing motor deficits, reducing spasticity, managing pain, and promoting emotional well-being. This integrative approach underscores the importance of holistic care in optimizing outcomes for stroke survivors. 

Reference	Intervention	Findings	Fugl-Meyer Assessment
15	Control group: antiplatelet aggregation drugs and brain cell-activating drugs; Body acupuncture: treatment based on classic textbook of acupuncture and moxibustion;  Scalp acupuncture: Zhu’s scalp needle treatment	Statistically significant improvement in both upper and lower extremity movement.	body acupuncture group: Pretest/Posttest (upper limb): 15.51/16.62Pretest/Posttest (lower limb): 16.93/18.04Pretest/Posttest (hand): 9.71/9.76 scalp acupuncture group: Pretest/Posttest (upper limb): 15.31/19.24Pretest/Posttest (lower limb): 16.69/20.49Pretest/Posttest (hand): 10.49/10.56
16	Control group: physical and occupational therapy; Study group: electroacupuncture (acupoints including Pai Hui, bilateral Feng Chih., Chien Yu, etc.)	Improvement in upper-limb function in study group compared to control group, particularly in hand and wrist movement and joint range of motion. Lower-limb function improvement was not statistically significant.	study group (mean): Pretest/Posttest (shoulder): 3.8/7.0Pretest/Posttest (lower limb): 2.8/6.1Pretest/Posttest (hand): 2.0/4.6 control group (mean): Pretest/Posttest (shoulder): 2.5/5.3Pretest/Posttest (lower limb): 2.⅕.0Pretest/Posttest (hand): 0.7/1.4
21	Control group: conservative therapy; Study group: neuronavigation-assisted aspiration and electro-acupuncture.	Statistically significant improvement in upper and lower limbs, although around 20% more improvement in lower limb function.	study group (mean) week 0 upper limb: 9.51±7.66week 8 upper limb: 27.36±10.57week 0 lower limb: 9.36±3.14week 8 lower limb: 24.37±9.16 control group (mean): week 0 upper limb: 9.34±5.23week 8 upper limb: 12.27±8.21week 0 lower limb: 9.23±4.36week 8 lower limb: 11.82±7.22

Neurological Impacts

While acupuncture can alleviate the physical pains and symptoms associated with strokes, it can also ameliorate neurological impairments in patients. A study²³ conducted in China utilized International Standard Scalp Acupuncture (ISSA), which is performed by inserting needles in the scalp’s tissue layer, for patients with acute ischemic stroke to observe if ISSA could cause changes in functional connections between cerebral hemispheres and local brain regions. Compared to the control group, the scalp acupuncture group was observed to have a statistically significant difference in National Institutes of Health Stroke Scale (NIHSS) scores. NIHSS scores provide a scale to assess a patient’s probability of stroke recovery, and any score under 6 indicates a high probability of recovery. The pre to post intervention scores were 3.20 ± 2.46 respectively for the intervention group and 1.67 ± 1.05 respectively for the control group. For the acupuncture group, the NIHSS score decreased by a larger amount, signifying that acupuncture can increase patients’ probability of stroke recovery. Additionally, the study explored changes in between the brain regions bilateral BA6 and BA8, which comprise the premotor cortex area, have extensive spinal cord fiber projection, contact with the corpus callosum, and use sensory stimuli to signal corresponding body movement. Researchers found that the functional brain connections between BA6 and BA8 improved in function and synchronization with the combined ISSA and western treatment compared to western treatment alone, highlighting the effectiveness of acupuncture as a complementary treatment to western medicine. Acute ischemic stroke can result from an imbalance between Yin and Yang, disordered Qi, and blood stasis in the cerebral nerves. Selecting acupoints from the dense concentration of meridians in the brain can regulate and guide the Qi. This study concluded that scalp acupuncture can reorganize brain function, regulate cerebral flow and promote the formation and differentiation of neural stem cells and the reorganization of the brain function²³.

A randomized controlled trial²⁴  examined the impact of scalp acupuncture and electroacupuncture in early comprehensive rehabilitation for acute ischemic stroke. Observing the NIHSS scores of participants over a seven week period, the mean change for the acupuncture group was -4.85, while the change in the control group was -4.05. The study also utilized the Montreal Cognitive Assessment (MoCA), which measures function: a score of less than 10 indicates severe cognitive impairment, while the maximum score of 30 is indicated as no cognitive impairment. From week 0 to week 7, the MoCA value increased by 3.24 in the acupuncture group by a statistically significant amount, indicating an improvement in cognitive impairment²⁴. Similarly, a separate study²⁵ utilizing dense cranial electroacupuncture stimulation and body acupuncture found that the MoCA scores of participants increased by 2.2, illustrating that acupuncture can alleviate post-stroke cognitive deterioration.

Acupuncture has also been shown to aid in strengthening cerebral blood flow and neurological deficits. In an experiment conducted at the Loewenstein Rehabilitation Hospital, researchers utilized the methods of acupuncture on either true acupuncture or sham acupuncture points (a control intervention), and Transcranial Doppler ultrasonography to measure cerebral blood flow on both healthy and damaged sections of the brain²⁶.  Measuring the mean flow velocity of the brain was found to provide a significant influence on strengthening cerebral blood flow using true acupuncture, along with decreasing systolic blood pressure. Conclusively, true acupuncture proved to be a promising method to improve issues in cerebral blood flow during post-stroke rehabilitation.

Reference	Intervention	Findings	NIHSS scores
22	Control group: conventional Western medicine treatment, such as anti‐platelet, lipid‐lowering and stabilizing agents, and blood pressure medications; Study group: International Standard Scalp Acupuncture	There was a statistically significant difference in NIHSS scores between both groups; connections between cerebral hemispheres, language processing, and sensory integration were strengthened.	Scalp Acupuncture group (pre-post): 3.20 ± 2.46 Control group (pre-post): 1.67 ± 1.05
23	Control group: physical and occupational therapy; Study group: scalp and body acupuncture.	There was no statistically significant difference in NIHSS scores between both groups, but patients’ neurological deficits, particularly in terms of perception, improved.	Study group (pre-post): 4.85 Control group (pre-post): 4.05
26	Control group: sham acupuncture; Study group: true acupuncture	Not stated, but a significant increase in cerebral blood flow velocity was observed.	Study group (pre): 7.0 ± 3.5 Control group (pre): 7.0 ± 2.0 Post-treatment: NIHSS scores decreased but were not explicitly stated.
27	Control group: scalp and body acupuncture (conventional method); Study group: “Xingnao kaiqiao” acupuncture method combined with “Temporal three needles.”	There was a statistically significant difference in NIHSS scores between both groups, with an improvement in cognitive function and reduced neuronal apoptosis observed.	Study group (pre-post): 2 Control group (pre-post): 1

Psychological Impacts

The benefits of acupuncture are expansive, as acupuncture has been shown to improve both patients’ physical and mental health following a stroke. One study²⁵ conducted in the Department of Rehabilitation at Kowloon Hospital researched the effectiveness of dense cranial electroacupuncture (DCEAS) with body acupuncture to treat post stroke depression. Using the 17-item Hamilton Depression Rating Scale (HAMD-17) and the Montgomery–Åsberg Depression Rating Scale (MADRS), researchers recorded values based on participants’ depressive symptoms in week four and week eight of the trial. In the control group, the HAMD-17 score decreased by 1.6 and the MADRS score increased by 2.9. Meanwhile, the DCEAS and body acupuncture group had a decrease of 4 in the HAMD-17 score and a decrease of 5.2 in the MADRS score. Lower scores on the two aforementioned rating scales correlate with milder/no depression, so the study’s findings indicate that DCEAS and body acupuncture alleviated the severity of depressive symptoms experienced by participants. The electrical stimulation on forehead acupoints produced synergistic effects by modulating brain regions and neurochemical pathways, in turn providing a long-lasting antidepressant effect²⁵. A similar study²⁸ conducted in the Division of Rehabilitation Medicine of Tung Wah Hospital, used the same methods of dense cranial electroacupuncture stimulation alongside body acupuncture and selective serotonin reuptake inhibitors (SSRIs). Researchers strictly analyzed how these different types of acupuncture could impact post stroke depression. Utilizing the 17-item Hamilton Depression Rating Scale (HAMD-17), the Clinical Global Impression – Severity scale (CGI-S) and Barthel Index (BI), researchers were able to surmise the effectiveness of DCEAS on PSD, concluding that there was a noticeable reduction of HAMD-17 amongst participants²⁸.

Since stroke survivors frequently experience emotional disturbances such as depression and anxiety, their quality of life can be greatly impaired. Acupuncture has been shown to have mood-regulating effects, promoting relaxation, reducing stress levels, and improving well-being²⁰. Through these psychological effects, acupuncture contributes to a better overall quality of life for stroke survivors, enabling them to cope more effectively with the challenges of daily living.

With various forms of acupuncture being utilized for stroke rehabilitation, the question of which form of acupuncture may be considered more effective comes to mind. A study²⁷ conducted by Song Zhongtao, et al in the Meizhou People’s Hospital in China treated ischemic stroke patients with two distinct methods of acupuncture: traditional Chinese “Xing Nao kai qiao” temporal three needle form and western standard scalp and body acupuncture. Utilizing the National Institutes of Health Stroke Scale (NIHSS), the researchers assessed the conditions of the patients before  and after the treatments. They found the efficiency rate of the Xing Nao kai qiao group to be 63.9%, higher than the 19.4% of the scalp and body acupuncture group. More specifically, the researchers concluded that the temporal three needle acupuncture showed definite signs of improvement in neurological deficit, potential functional disability, and basic activities of daily living of ischemic stroke patients. Interestingly, this study observed that the traditional Chinese form of acupuncture (“Xing Nao kai qiao”) was more effective than the more commonplace western acupuncture style. These researchers’ insights emphasize the importance of continuing to research traditional acupuncture forms and the role they play in improving patients’ stroke recovery²⁷.

Discussion

The results of these articles conclude that acupuncture can reduce after-effects of strokes by improving a patient’s motor skills, cognitive function, quality of daily life, and mental health.

In terms of neurological impairments, scalp acupuncture can strengthen the functional activities of a middle-aged or elderly acute ischemic stroke patient’s brain, especially in regions related to sensory integration and language processing. This finding provides a basis for the clinical application of international standard scalp acupuncture (ISSA) in treatments for acute ischemic stroke patients²³. Additionally, scalp acupuncture combined with electroacupuncture can cause significant improvements in neurological deficits and cognitive impairments. This is attributed to acupuncture’s ability to accelerate the recovery of brain function in the early post-stroke stages through its neuroprotective, microcirculatory, and metabolic recovery properties²⁴. Following a stroke, many patients also experience some degree of reduced motor function. Acupuncture, particularly at the acupoint TE5 (located on the dorsal side of the forearm), can directly change the functional connectivity among ipsilesional neuronal populations of sensorimotor cortices and sub cortexes in the brain, leading to a change in the sensorimotor network. Acupuncture at this point increases the cooperation between the brain’s hemispheres and thus influences the sensorimotor function on the side of the body the stroke has affected²⁹.

Scalp acupuncture in particular has been found to aid in restoring innervation and enhancing motor control in stroke patients. Due to the cortical function distribution alongside the internal organs and meridian theory, the scalp offers a unique and promising targeted area for acupuncture stimulation. Millineedles penetrate the subcapsular tendon layer of the head, facilitating the treatment of various conditions and aligning with the broader objective of exercise rehabilitation to increase neural connectivity and motor control¹⁶. Electroacupuncture, on the other hand, holds promise for enhancing lower extremity function. The precise application of electrical stimulation to acupuncture points has been shown to reduce ankle plantarflexor spasticity, increase augmented dorsiflexion strength, and improve muscle strength and mobility within the lower limbs¹⁸. The combination of body acupuncture and scalp acupuncture therapy can collaborate to eliminate pathogenic factors, fortify the body’s resistance to adverse elements, and clear blockages in the blood vessels. By improving blood circulation through influencing Qi within the body, motor ability and function of damaged lower extremities are able to be remedied¹⁹.

One of the paramount concerns in stroke rehabilitation is restoring functional independence and improving the ability to perform activities of daily living (ADL). Acupuncture has shown remarkable efficacy in achieving these goals by addressing motor deficits and enhancing coordination. By stimulating specific acupoints, acupuncture facilitates motor control and reduces muscle weakness, therefore aiding in tasks such as walking, dressing, and feeding²². Moreover, acupuncture plays a pivotal role in reducing spasticity, a common post-stroke complication that impedes movement and hampers daily functioning. By targeting specific acupuncture points, acupuncture modulates neural pathways, promotes muscle relaxation, and alleviates muscle spasm symptoms. This not only enhances mobility but also contributes to improved self-care abilities, as evidenced by reduced NIHSS scores and increased BI scores in clinical trials. Emotional disturbances, including depression and anxiety, are prevalent among stroke survivors and significantly impact their quality of life. However, electrical stimulation of acupoints over the frontal body and concentrated in the head proved to be effective in assisting stroke patients with symptoms of diagnosed post-stroke depression. This is because many forehead acupoints are innervated by sensory pathways connected to the brainstem reticular formation, which contain serotonin- and noradrenaline-producing nerves. Thus, the electrical stimulation of said acupoints can have neuromodulatory impacts and regulate moods and cognition information²⁵. 

While the aforementioned findings illustrate the benefits associated with utilizing acupuncture for stroke rehabilitation, it is important to note that there have been only a small quantity of studies conducted regarding this topic, making it challenging to ascertain whether or not acupuncture can definitively alleviate the after-effects of stroke. Other systematic reviews conducted on this topic³⁰,³¹  point to a similar conclusion, stating that acupuncture can be an effective treatment for post-stroke rehabilitation, but poor study quality and relatively low amount of studies performed make it difficult to fully support this claim.

Contradictory Findings

Several studies support similar claims of acupuncture’s benefits in regards to improving motor function and neurological deficits in post-stroke patients. However, with the studies that have contradictory findings, examining the quality of each study provides insight into the validity of the findings. When comparing studies that evaluated changes to patients’ NIHSS scores to draw conclusions²⁰,²³,²⁴, one study²³ appears to be of higher quality compared to another²⁴ given its comparatively more thorough inclusion and exclusion criteria and specific descriptions of acupoints and acupuncture techniques. In the article authored by H. Liu, et al²³, the scalp acupuncture group’s NIHSS scores decreased by an average of 3.20 ± 2.46, while in the article authored by L. Chen, et al²⁴, the combination of scalp acupuncture, body acupuncture, and electroacupuncture led to a decrease of 4.85. However, the latter article did not have statistically significant findings. This could signify that certain types of acupuncture prove more effective than others. When looking at another article that stated that acupuncture did not have any impact on decreasing neurological deficits or improving motor function³², the researchers state that the comparability assessments between the acupuncture group and control group were based on Western medicine, not on the TCM classification of stroke. Despite observing improvements, the findings of this article³² were not statistically significant, and the article also brings up a point on potential biases present in the designs of certain studies themselves.

Another drawback of certain studies²⁰ included a short timespan, which only observed patients for two weeks without any follow ups after the standard acupuncture. In this article, the NIHSS scores decreased by 2, a smaller difference compared to other studies²³,²⁴, which lasted between 6-10 weeks and included a post-treatment follow-up.

On a similar note, two articles¹⁷,³³ had contradictory findings on the statistical significance of acupuncture in improving upper-limb function. One study¹⁷ noted an increase of 18.5 in the Fugl Meyer Assessment scores, while the other³³ increased by 17.33. Both studies were single-blind randomized controlled trials with electroacupuncture as an intervention, but the findings were statistically significant for upper-limb movement in the first study¹⁷, while they were not statistically significant in the other study. A key difference between the conduction of these studies is the number of participants, as one had 63 patients¹⁷, while the other included 204 patients³³. This signifies that a larger patient demographic and group can help get more accurate results in regards to how acupuncture could benefit the typical stroke patient.  

Limitations

One of the primary limitations with this research was that many of the collected studies were concentrated in a singular country, China, preventing the review of articles from a global demographic. Since acupuncture is a component of Traditional Chinese Medicine (TCF), studies utilizing this therapy are primarily centered in China, given the fact that the benefits and use of acupuncture are more acknowledged there. It is also important to recognize the difference in cultural acceptance and understanding of acupuncture between China and other non-Chinese countries. A few non-Chinese scientists may have a prior bias against TCM when conducting a study, as the lack of western knowledge concerning the traditional medication may proliferate doubt regarding its effectiveness; the said bias could potentially cause scientists to ignore or misinterpret data. Conversely, Chinese scientists may push for positive findings in a study concerning acupuncture because of its prevalence and acceptance within their society. This review strived to include articles without any bias, but due to acupuncture being a core treatment used in China, sixteen out of seventeen articles referenced in this review were conducted in China, save for one that was conducted in Israel. The study conducted in Israel²⁶ posed similar methods to the studies conducted in China, including the use of the acupoints LV-3, LV-4, SJ-5, and GB-34. While the Chinese studies utilized around ten acupoints with various methods including electroacupuncture, body acupuncture, and scalp acupuncture, this study utilized a simple approach with Kiiko Matsumoto style true acupuncture versus sham acupuncture. However, this study demonstrates the importance of utilizing patients from varied demographics to assess the impact of acupuncture for addressing neurological deficits.

On the databases that were accessed, the Chinese studies that fit the inclusion criteria were reviewed, but no articles published on a Chinese database were reviewed, as none of the reviewers were familiar with the languages, limiting the expanse of data from which this paper’s conclusions were drawn from. Therefore, this paper was unable to effectively determine the effects of acupuncture for stroke rehabilitation from a global perspective due to a lack of integration of the therapy itself in many countries. Additionally, due to the nature of the inclusion and exclusion criteria, only eighty-four articles were reviewed: although there may have been more studies published examining the impact of acupuncture for stroke rehabilitation, the search strategy used was unable to integrate those findings into this paper. Moreover, some of the reviewed studies combined acupuncture with TCM as an intervention and were excluded due to a potential skewing of data regarding acupuncture’s sole potential as a post-stroke treatment. Thus, potential findings from those studies about the degree of acupuncture’s effectiveness were not included in this review. The studies reviewed and included in this paper primarily used body acupuncture, scalp acupuncture, and electroacupuncture, so alternative forms such as auricular acupuncture were not mentioned in depth due to a lack of studies regarding the therapy. Even with the studies compiled in this review, several studies had a lack of long-term follow up, only reporting results up to six weeks after the treatment while other studies reported up to eighteen weeks. Observing the long-term effects of acupuncture for stroke rehabilitation would enable a more concrete understanding of its impacts.

Clinical Implications

In this review, it was found that acupuncture has numerous beneficial impacts on stroke rehabilitation and holds promise as a complementary therapy to western stroke treatments. However, many published studies on acupuncture for stroke rehabilitation, included or excluded, are short-term, averaging six weeks. Conducting further studies with more long-term follow ups, such as four to six months, would provide a more definitive conclusion on the lasting impact of acupuncture. For instance, several studies observed that acupuncture enabled more movement in lower extremities damaged by a stroke, but it is necessary to determine if that improvement lasts or is temporary and needs to continue to be treated by acupuncture after certain periods of time. Furthermore, more studies need to be conducted analyzing the effectiveness of various forms of acupuncture for stroke rehabilitation against each other: one such contrast being traditional Chinese “Xing Nao kai qiao” temporal three needle form compared to standard scalp and body acupuncture. This would enable an understanding of how acupuncture’s forms impacts the effects it elicits on patients.

Overall, in order to implement acupuncture into stroke rehabilitation treatment, it needs to be accepted and recognized as a medical therapy of value. Increasing awareness and conducting longer studies with larger patient groups of varied demographics would increase acupuncture’s validity as a treatment and aid in this acceptance, enabling hospitals and healthcare systems to practically implement the therapy. For instance, if a patient were considering their post-stroke treatment options, acupuncture could be mentioned as a supplemental therapy to traditional stroke treatments, allowing the patient to explore new avenues.

Closing Thoughts

Established by the articles analyzed in this paper, it can be concluded that acupuncture can relieve after-effects of strokes in patients forty years and older. The effectiveness of acupuncture as a post-stroke treatment demonstrates the potential benefits of integrating it with common western medications and treatments, all in all curating a strengthened method for alleviating stroke after-effects. Notably, acupuncture has been seen to greatly impact post-stroke patients with a loss of motor function in their lower extremities by decreasing ankle plantar flexor spasticity and increasing dorsiflexion strength. In the studies examined, many were based in China as acupuncture is a form of their traditional medicine; therefore, a global demographic of patients was not explored. Due to this, the impact and effectiveness of acupuncture as a stroke-rehabilitation treatment on other ethnic groups is undetermined. Conducting future studies in various countries with populations financially, structurally, or genetically susceptible to strokes, such as Peru, Bosnia, Romania, or even the United States, would determine the effectiveness of acupuncture for stroke rehabilitation in patients of diverse backgrounds. The addition of blinded randomized controlled trials in said diverse populations would also strengthen the quality of the studies conducted, ensuring the results are accurate. Implementing acupuncture treatments in countries other than China, such as impoverished or developing countries, would also increase access to stroke care and treatment, since acupuncture is a low-cost and effective therapy, as well as provide an opportunity to enhance healthcare literary and global awareness. Comparing and contrasting the costs of acupuncture to traditional western treatments, as well as the cost of a combined therapy, can provide insight for patients to make an informed decision on which plans will best suit their goals for recovery from a financial and medical standpoint. To further aid in this implementation, future clinical studies and trials examining the benefits of acupuncture in the long-term, specifically past five years, will be needed. This would determine if acupuncture reduces after-effects of stroke temporarily or for long periods of time. Conclusively, acupuncture provides important benefits to alleviating the after-effects in stroke patients, which is why it should be further studied and implemented alongside western treatments in healthcare systems globally.

Methods

For this article, eighty-four articles were reviewed from PubMed and Google Scholar databases. There were seventeen articles that were included, as they fit within the inclusion criteria, while the remaining sixty-seven articles were excluded. Originally, twenty-one articles had been included, but once the writing process began, four of those articles were retracted due to bias and errors in the research process and were then excluded. When collecting articles from the aforementioned databases, the search terms used were “acupuncture and stroke rehabilitation” and “acupuncture and stroke rehabilitation case studies.” The filters that were applied corresponded with the inclusion criteria, but the “free full text” filter was also applied, which is a factor of limitation regarding the articles that were reviewed.

For the inclusion criteria, articles that were published in the last twenty years (2002-2022) were considered, with the research solely focusing on both ischemic and hemorrhagic strokes. This timeframe was chosen to include studies that were not only outdated, but also relevant to current times, so that findings of the studies could continue to be expanded upon in the present day. Articles exploring strokes were included in order to avoid skewed data within the findings. Studies from an international demographic were included with the aim of addressing the impact of acupuncture on a diverse population of stroke patients, but 16 out of 17 of the studies were based in Chinese hospitals, universities, or stroke rehabilitation centers. Articles with both male and female participants and participants that were forty years and older were also included, as that is the age group that most commonly experiences strokes without prior underlying conditions. As part of the inclusion criteria, original articles, such as randomized control trials, cohorts, case-control studies, and cross-sectional studies were all reviewed, and the citations of meta-analysis articles were used to offer additional sources of information and articles. This ensured that the studies included were conducting experiments that effectively tested the impact of acupuncture for stroke rehabilitation.

In the exclusion criteria, articles with conflicts of interest, anything published before 2002, articles published after 2022, information from blogs or opinion based articles, and non-original articles like meta-analysis, or prospective studies were not included for the main results of this paper. However, one blog and three meta-analysis papers were referenced in the introduction and discussion to provide additional context for the topic being discussed. Prospective studies were excluded as they contain a projection of study results instead of concrete findings from a specific study. Additionally, studies that included participants that had a higher risk for strokes from a predetermined genetic or environmental factor–for example, patients with serious heart, liver, and kidney-related diseases–were excluded in order to avoid confounding variables.

For data abstraction, a collective Google sheet that all researchers could edit was created, with one tab labeled “included articles” and another labeled “excluded articles.” In the “included articles” tab, the headings of the columns were as follows: researcher name, article title, article link, database (PubMed or Google Scholar), study design, study setting, study population, intervention, outcome, and reason for inclusion. In the “excluded articles” tab, the headings were researcher name, article title, article link, brief description, and reason for exclusion. Once this data abstraction form was created, all the articles that were displayed when the search terms and filters as mentioned earlier were applied were initially reviewed by the six researchers through abstract screening. The articles out of those that seemed to fit the general overview of the inclusion criteria were listed onto the form. After that, researchers again went through the eighty-four initially screened articles, and whether they were sorted into the “included articles” tab or the “excluded articles” tab depended on the researcher’s quality assessment. After the eighty four articles were reviewed and twenty-one articles were included, each researcher reviewed the included and excluded articles to confirm if they were in the appropriate category. When disagreements arose, they were resolved by majority consensus. It was collectively determined by all the researchers that only seventeen of the articles fully fit the established inclusion criteria. Examining the interventions and outcomes of the included articles determined the subtopics explored in the results and discussion of this systematic review.

In terms of the timeline for this paper, the preliminary research was first collected and the research question (What is the effectiveness of acupuncture in reducing the after-effects of stroke in patients 40 years and older) was formed on October 22, 2023. Then, the inclusion and exclusion criteria were finalized by November 11, 2023, and the literature review began on November 19, 2023. On January 21, 2024, the first draft of the research paper was started, and on April 8, 2024, the first draft was completed and then thoroughly revised by researchers and mentors. The next few months were spent revising and preparing the paper for publication.

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