Acupuncture originated in China, where it has been practised for over 3000 years.1 Clinical interest in the west began in the latter part of the twentieth century.2 Acupuncture is a component of Traditional Chinese Medicine (TCM). According to TCM, living beings possess vital energy (Qi) that flows through invisible energy lines (meridians) on the body. Each meridian is linked to specific organs and hormonal secretions. The organs and glands of the body are viewed as interdependent. Good health exists when everything is working in harmony and Qi is flowing smoothly. Disease begins when the flow of Qi is unbalanced by illness, stress and bad lifestyle choices. Inserting acupuncture needles (energy balancers) into specific points along the meridians brings harmony to the flow of Qi and consequently to organs and glands. A good acupuncturist will also pay attention to diet and lifestyle.
TCM is an entire system of medicine. While a TCM-orientated acupuncturist will view a patient's health in terms of vital energy and work to restore the balance and flow of Qi, a clinically-oriented western acupuncturist is likely to make a more conventional western diagnosis, regard acupuncture as stimulating nerve endings, and view it as just one of a range of therapeutic options.3
Acupuncture treatment involves inserting thin needles through the patient’s skin at specific points and at varying depths. Acupuncture therapy generally involves several weekly or fortnightly treatments. Most courses consist of up to 12 sessions. A visit to an acupuncturist generally begins with an examination and an assessment of the patient's condition. The acupuncturist identifies where to insert the needles. The depth to which they are inserted varies from between half a centimetre to three or four centimetres. Most sessions last about 30 minutes. The patient will be asked to lie down, either face-up, face-down, or on his or her side, depending on where the needles are to be inserted. The acupuncturist should use single-use disposable sterile needles. As each needle is inserted, the patient should feel it, though initially without any discomfort. When the needle reaches the right depth, however, there should be a deep aching sensation.4 Once inserted, the needles remain there for about 20 minutes. Sometimes, the needles are heated or stimulated with electricity after insertion.
Possible benefits of Acupuncture for stroke
In China, in particular, and in other parts of Asia, there is a strong belief in the benefits of acupuncture in stroke treatment. In a recent survey, 66 percent of Chinese doctors routinely used acupuncture for stroke and 63 percent believed acupuncture to be effective.5 Surveys from 1995 and 1997, respectively, suggest that belief in the legitimacy or efficacy of acupuncture treatments in general (not specifically for stroke treatment) are about 56 percent in the USA and 65 percent in the UK.6
It is believed that acupuncture affects the human body in two principal ways: by influencing blood circulation and by generating biochemical effects, either at the place of application or at a distance.7 Correspondingly, a systematic review of recent research argues that acupuncture could be useful for stroke rehabilitation in two ways.8
Firstly, acupuncture has been observed to modify blood flow to the brain, which could assist in a faster and more effective recovery.9 It might, for example, help in the rehabilitation of stroke patients suffering from aphasia (impairment of language functions). A recent study suggests that acupuncture can increase blood flow to those parts of the brain connected to language that may be damaged by stroke.
Secondly, by inserting needles into the skin, pain receptors are activated and send signals to the central nervous system to release opioid peptides (amino acids produced by the body that affect mood, stress and pain). This relaxes muscles and permits an increased range of motion in the affected limb, allowing for better motor impairment rehabilitation.10
Acupuncture involves very few risks but in a small number of cases it can result in bleeding, fainting or nausea.11 'Acupuncture is a safe therapy, but has adverse effects like any therapeutic approach. The few serious adverse effects that have been reported to be caused by acupuncture were not observed in our study. Bleeding, haematomata and systemic syndromes are common. It is obligatory to use sterile needles, though skin disinfection might not be mandatory in healthy patients who are not immunosuppressed. The medical history taken before acupuncture treatment should at least include enquiries about bleeding or wound healing disorders, immune deficiencies, possible heart diseases (for risk of bacteraemia), possible pregnancy, intake of medication and existing anatomical abnormalities.'12
The treatment usually just requires sterilised acupuncture needles.13 Some practitioners, however, use electricity or heat.
Arguments against using Acupuncture for stroke
It is difficult to measure the benefits of acupuncture accurately. As it involves sticking needles into the body, it is hard to set up a control group to receive placebo or sham treatments in order to determine acupuncture's efficacy in a scientific manner. A meta-review in 2002, focusing on the enhancement of motor recovery after stroke, suggests that
'procedures intimately involving the patient and those that are invasive, such as acupuncture, are associated with more powerful true placebo effects than oral drug treatment. […] Various aspects of the physician-patient relationship may influence the effect of an intervention and that the quality of the communication between physician and patient may influence the patient’s adherence to treatment. Therefore, it is possible that stroke patients who have received acupuncture become more motivated and better adapted to the disability and therefore have a more favorable disability score, although the motor impairment may remain the same.'14
The reviewers' conclusion was largely negative:
'There is no compelling evidence to show that acupuncture is effective in stroke rehabilitation […] there is reasonably good evidence to show that, with stroke rehabilitation, acupuncture has no additional effect on motor recovery but has a small positive effect on disability, which may be due to a true placebo effect and varied study quality.'15
A more recent study confirms these claims.16 It is likely that the validity of acupuncture in stroke rehabilitation will be contested for the foreseeable future.17
Another problem is this: acupuncture does not sit well with western 'scientific' trials because it is not possible to perform a ‘double-blind test’. A double-blind test is an attempt to avoid bias while conducting a clinical trial. It requires that neither the doctor nor the patient know which group is receiving the real treatment and which group is receiving a sham treatment. With acupuncture, the practitioner always knows where the correct points are and the patient often feels a distinctive sensation when the needle is inserted in exactly the right place.
Notes and references
- Wu P, Mills E, Moher D, Seely D 'Acupuncture in Poststroke Rehabilitation'. In Stroke 2010, no 41, pp 171-179, p171
- Ed E Ernst, A White, Acupuncture: A Scientific Appraisal (Oxford: Reed Educational and Professional Publishing, 1999), 3
- Ed E Ernst, A White 1999: 1-2
- C Nordqvist 'What Is Acupuncture? What Are The Benefits Of Acupuncture?' In Medical News Today, 2009 http://wwwmedicalnewstodaycom/articles/156488php
- Zhang S, Li N, Liu M 'Use of acupuncture for stroke in China'. In Acupuncture in Medicine vol 27(4), p146
- Ed E Ernst, A White (1999: 6)
- Wu H, Tang J, Lin X, Lau J, Leung PC, Woo J, Li Y 'Acupuncture for Stroke Rehabilitation'. In Stroke, 2008, vol 39, pp 517-8, p517
- Wu P, Mills E, Moher D, Seely D 2010: 177
- Wu P, Mills E, Moher D, Seely D 2010: 177
- Chau ACM, Cheung RTF, Jiang X, Au-Yeung PKM, Li LSW 'An fMRI Study Showing the Effect of Acupuncture in Chronic Stage Stroke Patients With Aphasia'. In Journal of Acupuncture and Meridian Studies, 2010, vol 3(1), pp 53-7
- Ernst G, Strzyz H, Hagmeister H 'Incidence of adverse effects during acupuncture therapy - a multicentre survey'. In Complementary Therapies in Medicine 2003, vol 11(2), pp 93-7, pp 95-6
- Ernst G, Strzyz H, Hagmeister H, 2003: 96
- This fact is cited as a reason why acupuncture was reintroduced in China in the 1950s. Ed E Ernst, A White 1999: 2
- Sze FK, Wong E, Kevin KH, Lau J, Woo J 'Does acupuncture improve motor recovery after stroke? A meta-analysis of randomised controlled trials'. In Stroke, 2002, no 33(11), pp 2604–2619
- Sze FK, Wong E, Kevin KH, Lau J, Woo J (2002: 2618)
- Hopwood V, Lewith G, Prescott P, Campbell MJ 'Evaluating the efficacy of acupuncture in defined aspects of stroke recovery: A randomised, placebo controlled single blind study'. In Journal of Neurology, 2008, vol 255, pp 858-66
- Recently, all the positive finding in P Wu, E Mills, D Moher, D Seely 2010 has been challenged by Ernst E, Lee MS 'Acupuncture during stroke rehabilitation'. In Stroke, 2010, vol 41, p548