Châm cứu cụm da đầu bằng kích thích điện có thể cải thiện khả năng vận động và sinh hoạt ở bệnh nhân liệt nửa người sau đột quỵ Wang Xiaohong, Zhang Qi, Cui Baojuan, Sun Junhua, Ye Lan, Huang Laigang, Wang Daoqing aa KẾT QUẢ: Sau vài tuần điều trị, tất cả các bệnh nhân đều có những cải thiện đáng kể về các khía cạnh của khả năng vận động, khả năng sống và mức độ nghiêm trọng của các thiếu hụt thần kinh. nhóm (SC + ES) đạt điểm cao hơn trên thang đánh giá Fugl-Meyer (68 ± 12) và Chỉ số Barthel sửa đổi (49 ± 9) so với nhóm đối chứng (SC) (lần lượt là 50 ± 13, 36 ± 13) Wang Xiaohong , Khoa Lão khoa, Bệnh viện thứ hai của Đại học Sơn Đông, Tế Nam 250031, Trung Quốc Zhang Qi, Cui Baojuan, Huang Laigang, Wang Daoqing, Khoa Y học phục hồi chức năng, Bệnh viện thứ hai của Đại học Sơn Đông, Tế Nam 250031, Trung Quốc Ye Lan, Sun Junhua , Trung tâm Ung thư, Bệnh viện thứ hai của Đại học Sơn Đông, Tế Nam 250031, Trung Quốc Được hỗ trợ từ Quỹ Khoa học Tự nhiên tỉnh Sơn Đông (No ZR2011HL019, ZR2014HL060) Thư gửi: Giáo sư Wang Daoqing, Khoa Phục hồi chức năng Tôi dicine, Bệnh viện thứ hai của Đại học Sơn Đông, Tế Nam 250031, Trung Quốc sdeywdq@163.com Điện thoại: + 86-531-85875491 Được chấp nhận: Ngày 12 tháng 7 năm 2017 KẾT LUẬN: Khi bệnh nhân liệt nửa người sau đột quỵ được điều trị bằng phương pháp châm cứu SC với ES, vận động và khả năng sống có thể cải thiện nhiều hơn nếu họ được điều trị bằng châm cứu SC một mình © 2018 JTCM Tất cả các quyền Từ khóa: Đột quỵ; Phục hồi chức năng; Liệt nửa người; Kích thích điện; Châm cứu cụm da đầu MỤC TIÊU Tóm tắt: Để xác định xem liệu bệnh nhân liệt nửa người sau đột quỵ có thể được hưởng lợi từ điều trị lâu dài bằng châm cứu cụm da đầu (SC) kết hợp với kích thích điện (ES) hay không và để đánh giá tính khả thi của phương pháp điều trị này nhằm cải thiện khả năng vận động và sinh hoạt ĐẶT VẤN ĐỀ Đột quỵ não phổ biến trên toàn cầu và dẫn đến nhiều khuyết tật.1 Liệt nửa người là một trong những biến chứng phổ biến nhất sau đột quỵ. Nó thường gây suy giảm khả năng vận động, là nguyên nhân chính làm giảm các hoạt động trong cuộc sống hàng ngày và xã hội hóa.2 Nhiều loại các liệu pháp vật lý đã được sử dụng cho bệnh nhân liệt nửa người sau đột quỵ để cải thiện khả năng vận động và sinh hoạt hàng ngày của họ Tuy nhiên, kết quả đối với một số bệnh nhân liệt nửa người không khả quan. Châm cứu được sử dụng để điều trị một số bệnh mãn tính, bao gồm đau mãn tính, quản lý 3 cân nặng, 4 chứng khó tiêu chức năng, 5 và đặc biệt là liệt nửa người.6-9 Các báo cáo cho thấy châm cứu có thể cải thiện trầm cảm sau đột quỵ, 10 và châm cứu theo cụm da đầu (SC) hiệu quả hơn châm cứu da đầu truyền thống về PHƯƠNG PHÁP: 20 bệnh nhân được ghi danh và chia thành hai nhóm: châm cứu SC và châm cứu SC với ES (SC và SC + ES, tương ứng ) Tất cả những người tham gia cũng được đào tạo phục hồi chức năng Tất cả những người tham gia được đánh giá mù bằng thang đánh giá Fugl-Meyer về khả năng vận động, Chỉ số Barthel được sửa đổi về khả năng sống và thang điểm về mức độ thiếu hụt thần kinh. Kết quả được đánh giá ở ba điểm trước khi phân nhóm ngẫu nhiên, khi bắt đầu hoặc điều trị, và sau nhiều tuần điều trị JTCM | www journaltcm com 452 ngày 15 tháng 6 năm 2018 | Tập 38 | Vấn đề | Wang XH và cộng sự / Bài báo nghiên cứu điều trị bệnh nhân liệt nửa người sau đột quỵ. 11,12 Tuy nhiên, phương pháp này đòi hỏi phải giữ kim tiêm vào huyệt da đầu của bệnh nhân liên tục trong vài tháng, ngoài ra, nó có thể dẫn đến các biến chứng như phù nề da và đau, có thể buộc một số bệnh nhân ngừng điều trị Châm cứu điện là phương pháp cải tiến kích thích huyệt bằng cách cho dòng điện có tần số nhất định qua kim So với phương pháp xoay kim truyền thống, tần số kích thích trong châm cứu điện cao hơn, dẫn đến kích thích huyệt mạnh hơn. Theo lý thuyết, châm cứu điện có thể hiệu quả hơn châm cứu truyền thống, giúp rút ngắn thời gian điều trị và giảm các biến chứng do châm cứu lâu dài. Theo hiểu biết của chúng tôi, chưa có bất kỳ nghiên cứu nào tương tự kiểm tra tác dụng của châm cứu SC kết hợp kích thích điện trong điều trị bệnh nhân dưỡng bệnh wi liệt nửa người sau đột quỵ Ở đây, mục tiêu của nghiên cứu này là xác định xem liệu châm cứu SC kết hợp với ES có hiệu quả hơn châm cứu SC đơn thuần trong điều trị bệnh nhân liệt nửa người sau đột quỵ (a) bất tỉnh; (b) không ổn định về mặt y tế; (c) co giật không kiểm soát (> mỗi tuần trong những tháng cuối cùng); (d) giao tiếp hoặc nhận thức bị suy giảm nghiêm trọng; (e) các tình trạng thần kinh gây nhiễu khác ảnh hưởng đến quá trình đào tạo phục hồi chức năng; (f) các vấn đề y tế khác ảnh hưởng đến việc đào tạo phục hồi chức năng hoặc liệu pháp châm cứu Nghiên cứu được thực hiện tại khoa phục hồi chức năng của một bệnh viện đa khoa thành thị ở Trung Quốc và được sự chấp thuận của ủy ban đạo đức của Bệnh viện thứ hai của Đại học Sơn Đông T
Online Submissions: http://www.journaltcm.com info@journaltcm.com J Tradit Chin Med 2018 June 15; 38(3): 452-456 ISSN 0255-2922 © 2018 JTCM All rights reserved RESEARCH ARTICLE TOPIC Scalp-cluster acupuncture with electrical stimulation can improve motor and living ability in convalescent patients with post-stroke hemiplegia Wang Xiaohong, Zhang Qi, Cui Baojuan, Sun Junhua, Ye Lan, Huang Laigang, Wang Daoqing aa RESULTS: Following weeks treatment, all the patients exhibited significant improvements in aspects of motor ability, living ability, and the severity of neurological deficits The experimental group (SC + ES) scored higher on the Fugl-Meyer assessment scale (68 ± 12) and the modified Barthel Index (49 ± 9) than the control (SC) group (50 ± 13, 36 ± 13, respectively) Wang Xiaohong, Department of Geriatric Medicine, the Second Hospital of Shandong University, Jinan 250031, China Zhang Qi, Cui Baojuan, Huang Laigang, Wang Daoqing, Department of Rehabilitation Medicine, the Second Hospital of Shandong University, Jinan 250031, China Ye Lan, Sun Junhua, Cancer Center, the Second Hospital of Shandong University, Jinan 250031, China Supported by Grants from the Natural Science Foundation of Shandong Province (No ZR2011HL019, ZR2014HL060) Correspondence to: Prof Wang Daoqing, Department of Rehabilitation Medicine, the Second Hospital of Shandong University, Jinan 250031, China sdeywdq@163.com Telephone: +86-531-85875491 Accepted: July 12, 2017 CONCLUSION: When patients with post-stroke hemiplegia are treated using SC acupuncture with ES, motor and living ability can improve more than if they were treated with SC acupuncture alone © 2018 JTCM All rights reserved Keywords: Stroke; Rehabilitation; Hemiplegia; Electrical stimulation; Scalp cluster acupuncture Abstract OBJECTIVE: To determine whether patients with post-stroke hemiplegia could benefit from long-term treatment with scalp cluster (SC) acupuncture combined with electrical stimulation (ES) and to evaluate the feasibility of this treatment to improve motor and living abilities INTRODUCTION Cerebral stroke is common across the globe and leads to a wide range of disabilities.1 Hemiplegia is one of the most common complications following stroke It often causes motor impairment, which is a major reason for reduced activities of daily life and socialization.2 Various physical therapies have been used in patients with post-stroke hemiplegia to improve their motor ability and daily living However, the outcomes for some patients with hemiplegia are not satisfactory Acupuncture has been used to treat several chronic diseases, including chronic pain,3 weight management,4 functional dyspepsia,5 and especially hemiplegia.6-9 Reports show that acupuncture can improve post-stroke depression,10 and that scalp-cluster (SC) acupuncture is more effective than traditional scalp acupuncture in METHODS: Twenty patients were enrolled and divided into two groups: SC acupuncture and SC acupuncture with ES (SC and SC + ES, respectively) All participants also received rehabilitation training All participants were blindly evaluated using the Fugl-Meyer assessment scale for motor ability, the modified Barthel Index for living ability, and a scale for the degree of neurological deficits Outcome was assessed at three points before randomized grouping, at the beginning or treatment, and after weeks of treatment JTCM | www journaltcm com 452 June 15, 2018 | Volume 38 | Issue | Wang XH et al / Research Article treating patients with post-stroke hemiplegia.11,12 However, this method requires keeping needles in patients' scalp acupoints repeatedly over several months Additionally, it can result in complications such as skin edema and pain, which might force some patients to discontinue treatment Electrical acupuncture is an improved method that stimulates acupoints by passing a certain frequency electrical current through needles Compared with the traditional needle-twirling method, stimulation frequency in electrical acupuncture is higher, which results in stronger stimulation of the acupoints In theory, electrical acupuncture might be more effective than traditional acupuncture, which would shorten the duration of treatment and decrease complications that result from long-term acupuncture To our knowledge, there have not been any similar studies that examined the effect of SC acupuncture combined electrical stimulation in treatment of convalescent patients with post-stroke hemiplegia Here, the aim of this study was to determine whether SC acupuncture combined with ES is more effective than SC acupuncture alone in the treatment of patients with post-stroke hemiplegia (a) unconsciousness; (b) medically unstable; (c) uncontrolled seizures (> per week for the last months); (d) severely impaired communication or cognition; (e) other confounding neurological conditions affecting the rehabilitation training; (f ) other medical issues affecting the rehabilitation training or acupuncture therapy The study was conducted at the rehabilitation department of an urban general hospital in China and approved by the ethics committee of the Second Hospital of Shandong University The research was conducted in accordance with the Declaration of the World Medical Association All participants were informed about the study and signed the informed consent to agree that their data could be used for research purposes All participants were numbered sequentially according to the order of enrollment and then divided into the control (SC) and experimental (SC + ES) groups using a randomized digital table Interventions All participants received rehabilitation training Those randomized to the control group received SC acupuncture and those entering the experimental group received SC acupuncture combined with ES Selection of the therapeutic acupoints followed the following principles According to the method developed by Yu Zhishun, the surface of the scalp was divided into seven sections: (a) parietal area: the line from Baihui (GV 20) to Qianding (GV 21) and the bilateral parallel lines and inches to either side; (b) anterior parietal area: the line from Qianding (GV 21) to Xinhui (GV 22) and the bilateral parallel lines and inches to either side; (c) frontal area: the line from Xinhui (GV 22) to Shenting (GV 24) and the bilateral parallel lines and inches to either side; (d) occipital area: the line from Qiangjian (GV 18) to Naohu (GV 17) and the bilateral parallel lines inch to either side; (e) suboccipital area: the lines from Naohu (GV 17) to Fengfu (GV 16) and from Yuzhen (BL 9) to Tianzhu (BL 10); (f ) nuchal area: the line from Fengfu (GV 16) to Fengchi (GB 20), including five acupoints; (g) temporal area: one point 0.5 inches inferior to Touwei (ST 8), the point 0.5 inches anterior and inferior to the parietal nodule, and the line between these two points Major acupoints, including the parietal area and the anterior parietal area were used in all patients Additionally, adjunct acupoints were selected as follows: (a) for patients with language disorders, we selected the temporal or nuchal area; (b) for patients with visual impairment, we selected the occipital area; (c) for patients with mental impairments, we selected the frontal area; (d) for patients with dysphagia, we selected the nuchal area Two traditional Chinese medical practitioners were asked to verify the choice and location of the selected acupoints at the beginning of each treatment Acupuncture therapy was given times a week for weeks using sterilized needles (0.40 mm × 50 mm) Three to five needles were used in each area Needles METHODS Participants This was a blinded randomized controlled trial (RCT) that aimed to determine whether SC acupuncture combined with electrical stimulation (ES) was more effective than SC acupuncture alone in treating post-stroke hemiplegia All patients were diagnosed with cerebral stroke according with the diagnostic criteria for hemorrhagic stroke in "Diagnostic Essentials of Cerebrovascular Diseases" revised by the Chinese Fourth Conference on Cerebrovascular Disease of the Chinese Medical Association in 1995.13 Patients with post-stroke hemiplegia, hospitalized in the department of rehabilitation at the Second Hospital of Shandong University from January 2013 to December 2015, were enrolled with the following inclusion criteria: (a) the diagnosis of stroke was confirmed by CT or MRI of the head; (b) the diagnosis met the criteria outlined in "stroke syndrome diagnostic criteria (Trial)", established in 1994 by the acute encephalopathy research group of the State Administration of Traditional Chinese Medicine of the P R.C;14 (c) timing was ≥ weeks and ≤ months after stroke, and hemiplegia presented on their affected sides; (d) they were at the stable stage of the disease and with clear consciousness; (e) the severity of neurological deficits was at least 10 These scores were determined according to "The scoring criteria of degree of clinical neurological deficits for patients with cerebral stroke (1995)" established in 1995 by the Chinese Fourth Conference on Cerebrovascular Disease of the Chinese Medical Association.15 Exclusion criteria were: JTCM | www journaltcm com 453 June 15, 2018 | Volume 38 | Issue | Wang XH et al / Research Article were angled 15 degrees to the skin and inserted 40 mm into the acupoint, reaching below the galea aponeurotica Needles remained this way for h per day In the control group, the needles were twirled every h In experimental group, the needles in the parietal and anterior parietal areas were connected to the electric acupuncture apparatus (Huatuo® SDZ-II, Suzhou medical supplies factory Co., LTD, Suzhou, China), which stayed energized during the whole treatment The stimulation parameters were: dilatational waves at a frequency of (10 ± 3)-(50 ± 10) times/min and a current intensity of 0.6-1.0 mA used to quantitatively evaluate the severity of neurological deficits According to the diagnostic criteria of the Chinese Fourth Conference on Cerebrovascular Disease in 1995,15 the degree of neurological deficits were divided into three levels as follows: mild (0-15 points), moderate (16-30 points) and severe (31-45 points) Adverse events All patients were required to report any adverse events during acupuncture treatment If any were reported the doctor interviewed the patient and evaluated the validity of the adverse event If necessary, the doctor stopped the procedure and treated the adverse event immediately The evaluator recorded the date and seriousness of the event and analyzed the relationship between the event and the treatment The evaluator also recorded other possible causes in addition to the treatment The ethics committee was then tasked with deciding whether or not to remove this patient from the study Rehabilitation training Patients with post-stroke hemiplegia generally require additional rehabilitation therapy to during their recovery Due to ethical considerations, rehabilitation therapy following the Bobath concept was administered to all patients throughout the entire study, including correction of poor posture, active and passive movement of joints in the extremities while lying down, training of hand function, turning and movement on the bed, training of sitting balance, and others Rehabilitation therapy lasted 30-45 min, once per day, d per week Statistical analysis The results are presented as mean ± standard deviation ( xˉ ± s) The χ2 test and Student-t test were used to determine whether differences were statistically significant A P-value less than 0.05 was considered significant All statistical tests are two tailed Statistical analysis was performed using SPSS 19.0 (IBM Corp Released 2010 IBM SPSS Statistics for Windows, Version 19.0 Armonk, NY, USA) Outcomes All participants underwent blinded assessments: The Fugl-Meyer assessment scale for motor ability, the modified Barthel Index for living ability, and a scale that quantified the degree of neurological deficit Outcome assessment was completed before randomization, at the beginning of treatment, and after the 4-week treatment period RESULTS Fugl-Meyer assessment scale This scale comprises four interdependent parts: motor function in the extremities, range of motion in the joint (including pain score), balance, and sensation The maximum score is 226 In this study, we used the scale for motor function in the extremities (max 100 points) to evaluate motor ability Motor ability was divided into the following five levels: 100 was normal, 96-99 was mild motor disorder, 85-95 was moderate disorder, 50-84 was apparent disorder, and < 50 was a severe disorder Patient characteristics (Trial profile) Twenty patients enrolled in this study (n = 10 per group) Twenty patients were enrolled Five patients were excluded due to serious complications before the experiment Clinical characteristics did not differ between the two groups (Table 1) There were no reported adverse events in the study Changes in motor ability The Fugl-Meyer assessment scale showed no difference between groups at the beginning of treatment Following weeks of treatment, scores increased significantly in both groups Further, the SC + ES group scored even higher than the SC group, indicating that motor ability of experimental group improved more than that of the control group (Table 2) Modified barthel index This scale comprises 10 topics, with each topic ranging from to 15 points The maximum score is 100 points and higher scores indicate better living ability Living ability was divided into four levels: > 60, 60-40, 40-20, and < 20 Changes in living ability The modified Barthel Index indicated that living ability clearly improved in both groups following weeks of treatment As with motor ability, living ability improved more in the experimental group than in the control group (Table 3) Neurological deficit scale A neurological deficit scale that included unconsciousness, staring, facial paralysis, myodynamia of extremities and hands, and poor walking ability, was generally JTCM | www journaltcm com 454 June 15, 2018 | Volume 38 | Issue | Wang XH et al / Research Article trol group This means that the ES can increase the efficacy of SC acupuncture In terms of daily living ability, the average modified Barthel Index revealed that the experimental group (49.00) had a greater living ability than the control group (36.00) Importantly, SC + ES can be considered a safe procedure because no adverse events were reported by the patients of this clinical investigation, and none withdrew from this study However, this trial provides no evidence that SC acupuncture combined ES results in a greater decrease in severity of neurological deficits than single SC acupuncture One reason might be that neurological deficits require a relative long time to improve, and our observation period of only weeks might not have been adequate for detecting a difference between the treatments Another possible reason is that the sample size was too small to confirm whether differences between the two groups were significant In future studies, we will enroll more patients and design a longer observation time to more conclusively determine any differences in the efficacies of the two treatment methods in terms of improvement in neurological deficits of hemiplegic patients Changes of the severity of neurological deficits After weeks of treatment, neurological deficits became less severe in both groups However, the amount of improvement did not significantly differ between the experimental group and the control group (Table 4) Adverse events No adverse events were observed in any patient during the experiments DISCUSSION Here, we aimed to determine whether SC acupuncture plus ES could improve the condition of people with hemiplegic syndrome Our findings show that the treatment improved daily living and motor abilities significantly more than traditional scalp acupuncture Following weeks of treatment, the severity of motor disorder was lessened from severe to moderate in both groups, which indicates that scalp acupuncture can improve motor ability in patients with hemiplegic Further, mean Fugl-Meyer scores in the experimental group averaged 18 points higher than those in the conTable Group characteristics ( xˉ ± s) Experimental group (n = 10) Control group (n = 10) P value 0.639 63.5±6.4 66.3±7.9 0.393 Time since Stroke (weeks) 6.9±2.6 7.5±2.6 0.609 Left/Right hemiplegia (n) 6/4 4/6 0.371 Item Male (n) Age (years) Notes: control group received scalp-cluster acupuncture Experimental group received scalp-cluster acupuncture combined with electrical stimulation Categorical variables: χ2 test Continuous variables: Student-t test Table Changes in motor ability for each group and between groups ( xˉ ± s) Experimental group (n = 10) Control group (n = 10) t value P value Baseline 32±10 30±12 0.265 0.794 Week 68±12 50±13 3.171 0.005 Item Note: control group received scalp-cluster acupuncture Experimental group received scalp-cluster acupuncture combined with electrical stimulation Table Changes in living ability for each group and between groups ( xˉ ± s) Experimental group (n = 10) Control group (n = 10) t value P value Baseline 21±8 21±10 0.000 1.000 Week 49±9 36±13 2.528 0.021 Item Notes: control group received scalp-cluster acupuncture Experimental group received scalp-cluster acupuncture combined with electrical stimulation Table Changes in the degree of neurological deficit for each group and between groups ( xˉ ± s) Experimental group (n = 10) Control group (n = 10) t value P value Baseline 25±10 24±6 0.302 0.766 Week 12±10 14±7 －0.628 0.538 Item Notes: control group received scalp-cluster acupuncture Experimental group received scalp-cluster acupuncture combined with electrical stimulation JTCM | www journaltcm com 455 June 15, 2018 | Volume 38 | Issue | Wang XH et al / Research Article Our study has some limits: (a) the sample size was too small and it only included one center of research Thus, the results might not be applicable in all the cases of hemiplegia; (b) objective markers such as blood analysis data are missing; (c) the mechanism through which scalp acupuncture works is largely unknown These limitations should be considered in future research In conclusion, our study provided evidence that SC acupuncture combined ES is an effective and safe treatment for patients with post-stroke hemiplegia, which is even more effective than traditional SC acupuncture 10 REFERENCES 11 Alexander LD, Black SE, Patterson KK, Gao F, Danells CJ, McIlroy WE Association between gait asymmetry and brain lesion location in stroke patients Stroke 2009; 40 (2): 537-544 Dijkerman HC, Ietswaart M, Johnston M, MacWalter RS Does motor imagery training improve hand function in chronic stroke patients? 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