Acupuncture for the Prevention and Treatment of Stroke

Acupuncture for the Prevention and Treatment of Stroke

According to the CDC, Stroke kills about 140,000 Americans each year—that’s 1 out of every 20 deaths.Someone in the United States has a stroke every 40 seconds. Every 4 minutes, someone dies of stroke (2017).  Acupuncture is a 3000 year-old medicine that works to stimulate specific points on the body with fine needles, massage, heat, herbs or other mechanism to help improve body function and promote self-healing.   The use of acupuncture in combination with, or as an alternative to, Western medicine is gaining momentum in the U.S. A 2012 National Health Interview Survey estimated that Americans spent $14.7 billion out-of-pocket on visits to complementary practitioners (2017).  With this, acupuncture is now being used in the prevention and treatment of stroke.

 What is a stroke? 

A stroke is a medical emergency that “occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts (or ruptures)” (National Stroke Association, 2018). There are two kinds of strokes: hemorrhagic and ischemic.  An ischemic stroke is caused when a blockage occurs within a blood vessel that supplies the brain, cutting off oxygen to areas of the brain. A hemorrhagic stroke, commonly referred to as an aneurysm, is when a blood vessel inside the brain bursts or leaks. While hemorrhagic strokes are less common, they are typically more fatal (Stroke.org, 2018).

 What Causes Stroke?

Ischemic strokes, the kind caused by blood clots, account for 85% of all strokes.  These blood clots (also called thrombus [singular] or thrombi [plural]) are usually the result of a build of fatty deposits in the blood that decrease blood flow, as found in diseases like atherosclerosis (Mayo Clinic Staff, 2017). Embolic strokes are a kind of ischemic stroke that occur when a blood clot forms in an area of your body outside of the brain, such as the heart, and then dislodges into your bloodstream and gets stuck in narrower arteries within the brain.  Common causes of hemorrhagic strokes include hypertension, weak vessels or even treatment with blood thinning medications.

Risk Factors for Stroke

While strokes are not always preventable, many treatable factors can influence your risk of experiencing stroke such as obesity, high blood pressure, high cholesterol, cigarette smoking, and excessive drinking.  Additional factors include: cardiovascular disease, and obstructive sleep apnea, personal or family history of stroke, being age 55 or older, your race (African-Americans have a higher risk of stroke than other races) and your gender (men have a higher risk than women.) (Internet Stroke Center, 2018).

 Signs of a Stroke

When treating stroke and potentially mitigating long term side effects, it is important to get the patient treatment immediately.  Therefore, it’s imperative to know the signs of potential stroke.  An easy acronym is think F.A.S.T.:

  • Ask the person to smile. Does one side of the face droop?
  • Ask the person to raise both arms. Does one arm drift downward? Or is one arm unable to raise up?
  • Ask the person to repeat a simple phrase. Is his or her speech slurred or strange?
  • If you observe any of these signs, call 911 immediately (Mayo Clinic Staff, 2017).

Because oxygen isn’t getting to the brain, when it comes to getting treatment for stroke, EVERY MINUTE COUNTS.  Depending on the type of stroke and where in the brain it occurs, patients can experience a myriad of effects such as aphasia (inability to speak), hemiplesia (one-sided paralysis), memory loss, difficulty with balance, vision problems, breathing issues, difficulty swallowing, and behavioral changes.

Immediate Treatment

One of the reasons it’s important to know the signs of stroke and get the patient treatment right away is that many effects can be reversed if treatment is administered within 3-4 hours of the stroke event.  In ischemic strokes, tissue plasminogen activator (r-TPA) is a drug that is typically administered intravenously to patients who are admitted within a 3-4 hour timeframe of their stroke event. This drug works to break up the clots that are preventing oxygen from reaching the areas of the brain blocked by clots and to prevent further clots from forming.  Sometimes, immediate surgery known as a thrombectomy is required to remove the clots.  To perform a thrombectomy, a doctor will thread a catheter through an artery in the groin and insert a wire-cage device called a stent in the blocked artery in the brain. When the stent is opened, the doctor can suction the clot to remove it and reopen the artery.  This procedure is typically done on eligible patients within six hours of onset of acute stroke symptoms but can sometimes be performed as late as 24-hours post-stroke under some circumstances.  For hemorrhagic strokes, a catheter procedure is performed with the goal of inserting a tube to allow blood flow in the compromised vessel or to secure a blood vessel from further rupture (American Stroke Association, 2012).

Post-Acute Stroke Treatment

After an ischemic stroke, doctors may remove plaque from the carotid arteries via a carotid endarterectomy or perform an angioplasty, which uses a stent to help create an open passage way in a clogged artery.  Ischemic stroke patients are usually put on a drug regimen aimed at thinning the blood that may include aspirin, warfarin or other blood thinners and anti-platelet drugs like clopidogrel (common brand name: Plavix) to prevent clots.  Blood pressure will be monitored for all patients and medications may be prescribed to control blood pressure when needed.  Additionally, Statin drugs may be prescribed for patients with high cholesterol.

Once the emergency procedures aimed at stopping the bleeding are performed on hemorrhagic stroke patients, additional surgeries will aim to repair blood vessels or to stop blood flow to keep a vessel from bursting or bleeding again. Sometimes, small blockages and vessels are removed all together.  In some circumstances, intracranial bypass may be performed to increase blood flow in affected areas.  Stereotactic radiation is a minimally invasive procedure that uses highly focused radiation to repair vessels (Mayo Clinic Staff, 2017.)

 Long-Term Treatments for Post-Stroke Sequelae

 “Many stroke survivors have changes in their physical, cognitive, and emotional abilities that impede them from independently performing their daily activities related to work, school, parenting, or leisure” (aota.org, para. 3). In addition to the treatments described above, a variety of additional therapies may be utilized to treat post-stroke patients depending on the deficiencies that result from their stroke.

Physical, occupational and/or speech therapy is commonly used to help improve impaired motor and speech functions.  These therapies often begin within hours of the stroke event, are generally performed frequently within the first few weeks and months of a stroke in an effort to help the body “remember” how to perform various tasks.  For overweight patients and/or those with high cholesterol, the doctor will likely implement dietary restrictions aimed at lowering serum cholesterol and weight loss.  Patients on blood thinning medications will have additional restrictions on foods high in vitamin K such as kale, spinach and other leafy greens that may interfere with the medications’ ability to thin the blood (Mayo Clinic Staff, 2017). Sometimes, stress management techniques are also engaged to help manage blood pressure and prevent the stress that may cause it to spike.

 Acupuncture for Post-Stroke Treatment

Acupuncture has been used in China for thousands of years in the treatment of stroke patients.  However, in the 1950’s, the use of scalp acupuncture (SA) as a specific micro-system began gaining popularity even in the U.S.  According to traditional Chinese medicine (TCM) principles, the “head is where all Yang-meridians meeting together and is the house of the original spirit. Head is also where convergence between meridian/channel qi and blood happens. Brain is the sea of marrow and is the master of Zang-fu organs and meridian/channel functional activities. Acupoints on the head can regulate function of Yin-yang, Qi-blood, and Zang-fu organs” (Liu, Guan, Wang, Xie, Lin, & Zheng, 2012).  In other words, the brain is a major player in the body’s ability to self-regulate and heal.

In their review article on Scalp Acupuncture for Ischemic Stroke, Wang et al. (2012) provide a brief history on the growth of SA in U.S.:

During the 1970s, SA was developed as a complete microacupuncture system based on the traditional acupuncture science, modern anatomy, neurophysiology, and bioholographic theory. In 1984, a standard of nomenclature for acupuncture points was developed and reconfirmed in 1989, indicating 14 therapeutic lines or zones based on a combination of the thoughts of the different schools of scalp acupuncture. A Proposed Standard International Acupuncture Nomenclature: 3.6 Scalp acupuncture lines was formally published in 1991 by the World Health Organization (Introduction, para. 3.)

Modern scalp acupuncture combines traditional Chinese medical theories with Western medical knowledge of the brain.  Dharmandanda and Vickers (2000) state:

Treatment zones have been mapped onto the scalp that are associated with body functions and broad body regions. The zones include a few standard acupuncture points, but the treatment principle for point selection is usually not based on the traditional indication for the point or associated meridian.In general, within a defined zone, the forward part of the zone (nearer the face) is used to treat the upper body, while the rear portion of the zone is used to treat the lower body.  Functional zones, such as sensory, memory, and motor, are usually located at the back and sides of the scalp (para. 3.).

For example, for stroke patients that suffer with speech issues, needles would likely be inserted on the scalp near the areas of the brain that control speech and cognition, as well as the mouth.

While there is limited quality published research to support the efficacy of scalp acupuncture, according to one study, “acupuncture with twirling reinforcing manipulation has distinct effects on acute ischemic stroke patients with different symptoms or stages of disease. Improved muscle tension in the upper and lower limbs, reflected by the variation in the H max /M max ratio, is crucial for recovery of motor function from hemiplegia” (Du, Bao, Dong, & Yang, 2016)but the small sample size in the study makes it difficult to generalize the response for all stroke patients with hemiplegia.  Another study concluded, “Scalp acupuncture seems to improve the neurological deficit score and clinical effective rate when compared with Western conventional medicines alone, and it produces positive but limited effectiveness as an adjunct treatment to conventional care. Electroacupuncture appears to be beneficial for the motor function recovery of patients with acute ischemic stroke and is generally safe” (Chen et al., 2014).

A systematic review and meta-analysis in animals with experimental ischemic stroke concluded use of acupuncture scalp point Baihui (GV20), “could improve infarct volume and neurological function score and exert potential neuroprotective role in experimental ischemic stroke” (Wang, Xie, Lu, Zheng, 2014) but this study was performed on animals so the results may not translate directly in humans.

A 2010 meta-analysis of scalp acupuncture therapy for acute intracerebral hemorrhage put forth several possible mechanisms for how scalp acupuncture works.  The study suggests scalp acupuncture may “improve the absorption rate of hematoma, reduce brain edema, diminish

cerebral vessel permeability, and promote reparation for blood brain barrier (BBB) damage”(Liu, Guan, Wang, Xie, Lin, & Zheng, 2012).  Additional mechanisms suggested include the inhibition in the expression of byproducts released from a hematoma, an increase in immune response with a reduction in the accumulation of certain inflammatory markers, promotion of nerve growth factor gene expression and others.

In his 2015 book, “The Brain’s Way of Healing”, Norman Doidge, M.D. describes theories on neuroplasticity as another possible explanation for how the brain heals after a stroke. The Oxford dictionary defines neuroplasticity as “the ability of the brain to form and reorganize synaptic connections, especially in response to learning or experience or following injury” (2018).  Dr. Doidge describes that the brain’s ability to utilize methods of both Eastern and Western medicine that “requires the active involvement of the whole patient in his or her own care: mind, brain, and body. In this approach, the health professional not only focuses on the patient’s deficits, but also searches for healthy brain areas that may be dormant, and for existing capacities that may aid recovery” (pg. xix).  The central idea of neuroplasticity suggests that repeated experiences can cause structural changes within the brain.  Dr. Doidge describes it as, “neurons that fire together wire together…making synaptic connections between those neurons stronger” (pgs. 7-8).  At NYU Lutheran Hospital in Brooklyn, NY, scalp acupuncture is often performed in combination with speech, occupational and physical therapy to stimulate neurons in the areas of the brain that control the speech and motor functions therapists are working to retrain.

Evidence based medicine takes into account clinical expertise, patient values, and the research evidence when deciding the best course of action for patient care.  While there are not enough random controlled trials to prove the efficacy of scalp acupuncture, the clinical evidence seen by practitioners, the improvements in activities of daily living and overall quality of life that many patients experience, the low cost of treatment and the extremely low risk of side effects has enabled growth in the adoption of scalp acupuncture as a post-stroke treatment modality.

 Acupuncture in the Prevention of Stroke

Can acupuncture help prevent strokes?  While there is limited research on this, acupuncture can be used to help address many of the lifestyle factors that can influence one’s risk of experiencing stroke.  For example, the National Acupuncture Detoxification Association (NADA) protocol uses auricular (ear) acupuncture to help people manage addictions such as over-eating/obesity, cigarette smoking and excessive drinking.   There are also several auricular points specifically indicated for high blood pressure.  While these are examples of specific points for specific indications, a comprehensive acupuncture treatment takes a holistic approach and considers each individual’s constitution and lifestyle choices to manage the underlying cause of disease.  This approach then helps manage many risk factors at one time.

Interestingly, a retrospective cohort study published in 2014 concluded thatpeople with traumatic brain injuries (TBI), who are at increased risk for having a stroke,show decreased risk of stroke with acupuncture treatment than their peers who do not receive acupuncture treatment.  The same study identified “cardiac diseases, hypertension, diabetes, smoking, alcohol intake, unhealthy diet, abdominal obesity, lack of exercise, psychosocial stress and depression as risk factors associated with 90% of stroke risk” (Shih et al.).

 Additional Resources:

If you or someone you know has suffered a stroke, there are a lot of valuable resources to help you assess your treatment options.  StrokeCenter.org, StrokeAssociation.org  and MayoClinic.org all provide great resource for patients and practitioners alike and include information on everything from diagnosis, treatment and support for caregivers to updates on clinical trials and links to valuable resources.  StrokeCamp.org offers retreats to help stroke survivors and their caregivers improve their quality of life.  And of course, your local acupuncturist can work with you to help rehabilitate lost functions and prevent future stroke recurrence.

Biography:

Lauren Kaplan, D.Ac., LAc., graduated with a Bachelor of Communications degree with High Honors from Rutgers College.  She earned her Bachelor of Professional Studies, Master of Acupuncture and Doctor of Acupuncture degrees from Pacific College of Oriental Medicine in New York City.  Lauren is NCCAOM Board Certified and is currently licensed to practice acupuncture in New Jersey where she runs her own practice, Restoration Health Acupuncture & Nutrition.  Dr. Lauren can be reached at lauren@FeelGreatHere.comor at 973-939-3868.

References:

Author not provided (2017, September 24) What Complementary and Integrative Approaches Do Americans Use? Retrieved from https://nccih.nih.gov/research/statistics/NHIS/2012/key-findings

American Stoke Association (2012, October, 23). Effects of Stroke.  Retrieved from http://www.strokeassociation.org/STROKEORG/AboutStroke/EffectsofStroke/Effects-of-Stroke_UCM_308534_SubHomePage.jsp

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Dharmananda, S., Vickers, E.  (2000, December).  Synopsis of Scalp Acupuncture.Institute for Traditional Medicine.  Retrieved from http://www.itmonline.org/arts/newscalp.htm

Doidge, N. (2015) The Brain’s Way of Healing. New York, NY.  Penguin Books.

Du, X., Bao, C., Dong, G., & Yang, X. (2016). Immediate effects of scalp acupuncture with twirling reinforcing manipulation on hemiplegia following acute ischemic stroke: a hidden association study. Neural Regeneration Research11(5), 758–764. http://doi.org/10.4103/1673-5374.182702

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Liu, Z., Guan, L., Wang, Y., Xie, C.-L., Lin, X.-M., & Zheng, G.-Q. (2012). History and Mechanism for Treatment of Intracerebral Hemorrhage with Scalp Acupuncture. Evidence-Based Complementary and Alternative Medicine : eCAM2012, 895032. http://doi.org/10.1155/2012/895032

Mayo Clinic Staff. (2017, November 11). Stroke: Diagnosis and Treatment.Retrieved from https://www.mayoclinic.org/diseases-conditions/stroke/diagnosis-treatment/drc-20350119

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National Center for Chronic Disease Prevention and Health Promotion, Division for Heart Disease and Stroke Prevention (2017, September 6) Stroke Facts.Retrieved from https://www.cdc.gov/stroke/facts.htm

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Wang, W., Xie, C., Lu, L., & Zheng, G. (2014). A systematic review and meta-analysis of Baihui (GV20)-based scalp acupuncture in experimental ischemic stroke. Scientific Reports4, 3981. http://doi.org/10.1038/srep03981

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