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
Trang 1© 2018 JTCM All rights reserved.
RESEARCH ARTICLE Scalp-cluster acupuncture with electrical stimulation can improve motor and living ability in convalescent patients with post-stroke hemiplegia
WangXiaohong, ZhangQi, Cui Baojuan, Sun Junhua, Ye Lan, Huang Laigang, Wang Daoqing
aa
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
Hospi-tal 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
Abstract
OBJECTIVE: To determine whether patients with
post-stroke hemiplegia could benefit from
long-term treatment with scalp cluster (SC)
acu-puncture combined with electrical stimulation (ES)
and to evaluate the feasibility of this treatment to
improve motor and living abilities
METHODS: Twenty patients were enrolled and
di-vided into two groups: SC acupuncture and SC
acu-puncture 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
4 weeks of treatment
RESULTS: Following 4 weeks treatment, all the
pa-tients exhibited significant improvements in as-pects of motor ability, living ability, and the
severi-ty of neurological deficits The experimental group (SC + ES) scored higher on the Fugl-Meyer assess-ment scale (68 ± 12) and the modified Barthel In-dex (49 ± 9) than the control (SC) group (50 ± 13,
36 ± 13, respectively)
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;
Elec-trical stimulation; Scalp cluster acupuncture
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 rea-son 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 dis-eases, including chronic pain,3 weight management,4 functional dyspepsia,5 and especially hemiplegia.6-9 Re-ports show that acupuncture can improve post-stroke depression,10and that scalp-cluster (SC) acupuncture is more effective than traditional scalp acupuncture in
Trang 2treating patients with post-stroke hemiplegia.11,12
How-ever, this method requires keeping needles in patients'
scalp acupoints repeatedly over several months
Addi-tionally, it can result in complications such as skin
ede-ma and pain, which might force some patients to
dis-continue 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
fquency in electrical acupuncture is higher, which
re-sults in stronger stimulation of the acupoints In
theo-ry, electrical acupuncture might be more effective than
traditional acupuncture, which would shorten the
dura-tion of treatment and decrease complicadura-tions that
re-sult from long-term acupuncture To our knowledge,
there have not been any similar studies that examined
the effect of SC acupuncture combined electrical
stimu-lation 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
pa-tients with post-stroke hemiplegia
METHODS
Participants
This was a blinded randomized controlled trial (RCT)
that aimed to determine whether SC acupuncture
com-bined with electrical stimulation (ES) was more
effec-tive than SC acupuncture alone in treating post-stroke
hemiplegia All patients were diagnosed with cerebral
stroke according with the diagnostic criteria for
hemor-rhagic stroke in "Diagnostic Essentials of
Cerebrovascu-lar Diseases" revised by the Chinese Fourth Conference
on Cerebrovascular Disease of the Chinese Medical
As-sociation in 1995.13Patients with post-stroke
hemiple-gia, hospitalized in the department of rehabilitation at
the Second Hospital of Shandong University from
Jan-uary 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
diag-nosis met the criteria outlined in "stroke syndrome
di-agnostic criteria (Trial)", established in 1994 by the
acute encephalopathy research group of the State
Ad-ministration of Traditional Chinese Medicine of the P
R.C;14 (c) timing was ≥ 2 weeks and ≤ 3 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
neuro-logical deficits was at least 10 These scores were
deter-mined 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:
(a) unconsciousness; (b) medically unstable; (c) uncon-trolled seizures (> 1 per week for the last 2 months); (d) severely impaired communication or cognition; (e)
oth-er confounding neurological conditions affecting the re-habilitation training; (f) other medical issues affecting the rehabilitation training or acupuncture therapy The study was conducted at the rehabilitation depart-ment of an urban general hospital in China and ap-proved by the ethics committee of the Second Hospital
of Shandong University The research was conducted
in accordance with the Declaration of the World Medi-cal 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 con-trol (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 acupunc-ture and those entering the experimental group re-ceived SC acupuncture combined with ES
Selection of the therapeutic acupoints followed the fol-lowing principles According to the method developed
by Yu Zhishun, the surface of the scalp was divided
in-to seven sections: (a) parietal area: the line from Baihui (GV 20) to Qianding (GV 21) and the bilateral paral-lel lines 1 and 2 inches to either side; (b) anterior pari-etal area: the line from Qianding (GV 21) to Xinhui (GV 22) and the bilateral parallel lines 1 and 2 inches
to either side; (c) frontal area: the line from Xinhui (GV 22) to Shenting (GV 24) and the bilateral parallel lines 1 and 2 inches to either side; (d) occipital area: the line from Qiangjian (GV 18) to Naohu (GV 17) and the bilateral parallel lines 1 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) tem-poral area: one point 0.5 inches inferior to Touwei (ST 8), the point 0.5 inches anterior and inferior to the pa-rietal nodule, and the line between these two points Major acupoints, including the parietal area and the an-terior parietal area were used in all patients
Additional-ly, adjunct acupoints were selected as follows: (a) for pa-tients with language disorders, we selected the tempo-ral or nuchal area; (b) for patients with visual impair-ment, 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 se-lected acupoints at the beginning of each treatment Acupuncture therapy was given 5 times a week for
4 weeks using sterilized needles (0.40 mm × 50 mm) Three to five needles were used in each area Needles
Trang 3were angled 15 degrees to the skin and inserted 40 mm
into the acupoint, reaching below the galea
aponeuroti-ca Needles remained this way for 6 h per day In the
control group, the needles were twirled every 2 h In
ex-perimental group, the needles in the parietal and
anteri-or parietal areas were connected to the electric
acupunc-ture apparatus (Huatuo® SDZ-II, Suzhou medical
sup-plies 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
Rehabilitation training
Patients with post-stroke hemiplegia generally require
additional rehabilitation therapy to during their
recov-ery Due to ethical considerations, rehabilitation
ther-apy following the Bobath concept was administered
to all patients throughout the entire study, including
correction of poor posture, active and passive
move-ment of joints in the extremities while lying down,
training of hand function, turning and movement on
the bed, training of sitting balance, and others
Reha-bilitation therapy lasted 30-45 min, once per day, 5 d
per week
Outcomes
All participants underwent 3 blinded assessments: The
Fugl-Meyer assessment scale for motor ability, the
mod-ified 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
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
di-vided 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
Modified barthel index
This scale comprises 10 topics, with each topic ranging
from 0 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
Neurological deficit scale
A neurological deficit scale that included
unconscious-ness, staring, facial paralysis, myodynamia of
extremi-ties and hands, and poor walking ability, was generally
used to quantitatively evaluate the severity of neuro-logical 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 va-lidity of the adverse event If necessary, the doctor stopped the procedure and treated the adverse event immediately The evaluator recorded the date and seri-ousness of the event and analyzed the relationship be-tween the event and the treatment The evaluator also recorded other possible causes in addition to the treat-ment The ethics committee was then tasked with de-ciding whether or not to remove this patient from the study
Statistical analysis
The results are presented as mean ± standard deviation
( xˉ ± s) Theχ2test and Student-t test were used to
de-termine whether differences were statistically
cant A P-value less than 0.05 was considered
signifi-cant All statistical tests are two tailed Statistical analy-sis was performed using SPSS 19.0 (IBM Corp Re-leased 2010 IBM SPSS Statistics for Windows, Ver-sion 19.0 Armonk, NY, USA)
RESULTS
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 be-tween the two groups (Table 1) There were no
report-ed adverse events in the study
Changes in motor ability
The Fugl-Meyer assessment scale showed no difference between groups at the beginning of treatment Follow-ing 4 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)
Changes in living ability
The modified Barthel Index indicated that living
abili-ty clearly improved in both groups following 4 weeks
of treatment As with motor ability, living ability im-proved more in the experimental group than in the control group (Table 3)
Trang 4Changes of the severity of neurological deficits
After 4 weeks of treatment, neurological deficits
be-came 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
treat-ment improved daily living and motor abilities
signifi-cantly more than traditional scalp acupuncture
Follow-ing 4 weeks of treatment, the severity of motor
disor-der was lessened from severe to modisor-derate in both
groups, which indicates that scalp acupuncture can
im-prove motor ability in patients with hemiplegic
Fur-ther, mean Fugl-Meyer scores in the experimental
group averaged 18 points higher than those in the
con-trol group This means that the ES can increase the effi-cacy of SC acupuncture In terms of daily living ability, the average modified Barthel Index revealed that the ex-perimental 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 in-vestigation, and none withdrew from this study However, this trial provides no evidence that SC acu-puncture combined ES results in a greater decrease in severity of neurological deficits than single SC acupunc-ture One reason might be that neurological deficits re-quire a relative long time to improve, and our observa-tion period of only 4 weeks might not have been ade-quate for detecting a difference between the treat-ments 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 observa-tion time to more conclusively determine any
differenc-es in the efficacidifferenc-es of the two treatment methods in terms of improvement in neurological deficits of hemi-plegic patients
Item
Baseline
Week 4
Experimental group
(n = 10)
32±10 68±12
Control group
(n = 10)
30±12 50±13
t value
0.265 3.171
P value
0.794 0.005 Table 2 Changes in motor ability for each group and between groups (xˉ ± s)
Note: control group received scalp-cluster acupuncture Experimental group received scalp-cluster acupuncture combined with electrical stimulation.
Item
Baseline
Week 4
Experimental group
(n = 10)
21±8 49±9
Control group
(n = 10)
21±10 36±13
t value
0.000 2.528
P value
1.000 0.021 Table 3 Changes in living ability for each group and between groups (xˉ ± s)
Notes: control group received scalp-cluster acupuncture Experimental group received scalp-cluster acupuncture combined with electrical stimulation.
Item
Baseline
Week 4
Experimental group
(n = 10)
25±10 12±10
Control group
(n = 10)
24±6 14±7
t value
0.302
－ 0.628
P value
0.766 0.538 Notes: control group received scalp-cluster acupuncture Experimental group received scalp-cluster acupuncture combined with electrical stimulation.
Table 4 Changes in the degree of neurological deficit for each group and between groups (xˉ ± s)
Table 1 Group characteristics (xˉ ± s)
Item
Male (n)
Age (years)
Time since Stroke (weeks)
Left/Right hemiplegia (n)
Experimental group
(n = 10)
7 63.5±6.4 6.9±2.6 6/4
Control group
(n = 10)
6 66.3±7.9 7.5±2.6 4/6
P value
0.639 0.393 0.609 0.371 Notes: control group received scalp-cluster acupuncture Experimental group received scalp-cluster acupuncture combined with electrical stimulation Categorical variables: χ 2test Continuous variables: Student-t test.
Trang 5Our 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
cas-es 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
re-search
In conclusion, our study provided evidence that SC
acupuncture combined ES is an effective and safe
treat-ment for patients with post-stroke hemiplegia, which
is even more effective than traditional SC
acupunc-ture
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