Li Zhu,Jun-Li Wang,Tong-Sheng Su＊

1College of Acupuncture and Massage, Shanxi University of Traditional Chinese Medicine, Xianyang 712083, China. 2College of Basic Medical, Shanxi University of Traditional Chinese Medicine, Xianyang 712083, China. 3Third Department of Acupuncture and Moxibustion,Shanxi Hospital of Traditional Chinese Medicine,Xi'an 710003,China.

Abstract

Keywords:Jing acupoints bloodletting,Sangzhi(Mori Ramulus),Stroke,Shoulder-hand syndrome(SHS)

Highlights

The purpose of this paper is to explore more effective treatment of shoulder-hand syndrome after stroke.The combination of acupuncture and medicine broadens the clinical treatment ideas, but it is more limited to the theoretical level, less clinical practice support,and lack of basic experimental evidence.Based on the basic theory of traditional Chinese medicine and the research results of modern medicine, this paper is expected to help patients to solve the pain to the greatest extent.

Background

Stroke is a sudden cerebral blood circulation disorder,also known as cerebrovascular accident and stroke,which often results in a series of sequelae such as hemiplegia, speech disorders, swallowing disorders,cognitive disorders, etc. Shoulder-hand syndrome(SHS) is a complication of limb hemiplegia after stroke, which is mainly manifested by sudden swelling and pain in the hand.

It usually occurs in the convalescence of stroke,most common 1-3 months after onset. Once SHS occurs, it will seriously hinder the later rehabilitation.If left untreated, the hand and fingers will deform,resulting in a complete loss of hand function.Therefore, treatment should be performed early.Intervention and treatment of SHS after stroke is crucial. Some studies have shown that once patients stop late rehabilitation, motor function of the affected limbs may even worsen, and about 67% of stroke survivors rarely use the affected limb in 4 years after stroke, which seriously affects the motor function of the affected limb[1].

At present, there is no specific treatment method for SHS in clinical practice. Comprehensive treatment methods of traditional Chinese and Western medicine are mostly used in clinical practice. Western medicine commonly includes symptomatic treatment drugs,closed therapy, sympathetic nerve block and resection,various physical and rehabilitation therapies, among which rehabilitation therapy is the most common.Traditional Chinese medicine (TCM) mostly includes acupuncture, massage, Chinese herbal medicine and other methods [2]. In recent years, acupuncture has played an increasingly important role in the treatment of this disease,and a variety of acupuncture treatments have been formed. Studies have shown that [3]bloodletting combined with TCM has a more significant effect. As a special kind of acupuncture therapy, bloodletting therapy is a kind of acupuncture therapy, which involves piercing superficial blood vessels through specific acupoints using three-edged needle or milli-needle,and releasing a small amount of blood, thus achieving the purpose of treating diseases.Jing acupoints are the most common used acuponts, as one of the Five-Shu acupoints (the general terms of acupoints that the twelve meridians are located below the elbow and knee of the body), Jing acupoints is distributed at the end of the fingers and toes where the twelve meridians of the human body pass by. These acupoints are Shaoshang (LU 11), Shangyang (LI 1),Lidui (ST 45), Yinbai (SP 1), Shaochong (HT 9),Shaoze (SI 1), Zhiyin (BL 67), Yongquan (KI 1),Zhongchong (PC 9), Guanchong (SJ 1), Zuqiaoyin(GB 44) and Dadun (LR 1), which have the functions of stimulating the meridians, dredging the meridians and unblocking the collaterals. Bloodletting therapy is helpful to protect ischemic brain cells, reduce the occurrence and development of cerebral edema, and enhance the repair ability of brain. Sangzhi (Mori Ramulus)as a common rheumatism herb,has the effect of removing dampness and collaterals, expelling wind and benefiting water, can be used to cure rheumatism,limb paralysis, edema. Therefore, the study of the combined treatment of SHS after stroke is of great value.

The pathogenesis of SHS after stroke

At present, the mechanism of SHS after stroke has not been clarified. Studies have shown that stroke often has a significant effect on the control of motor function of the upper limbs, especially the effect of the opponent's function.The damage mechanism is mainly derived from the nervous system. It is caused by cerebral stroke that increases the excitability of motor neurons, decreases spontaneous activation, and changes in activation patterns, which leads to contracture of the affected limb, passive joint impedance, and changes in muscle fiber type [5]. At present, most scholars believe that the occurrence and development of SHS after stroke is the result of a combination of factors, including impaired shoulder-hand pump function, dysfunction of the sympathetic nervous system, neurogenic inflammation[6].

In the theory of TCM, SHS after stroke belongs to the categories of “partial dryness”. The basic pathogenesis is Qi (the vital force which is believed to flow through the body along routes known as meridians;illness is attributed to changes in the flow of Qi according to the construct of Chinese medicine)and blood stagnation after internal stroke. After apoplexy,the patient abandoned the affected limb. Over time, it results in pain in the affected shoulder and hand,swelling of upper limb, limited movement and even muscle contracture, joint deformation, impaired hand function and other symptoms.

Mechanism on the treatment of SHS after stroke by Jing acupoints bloodletting therapy

Theoretical basis of TCM for Jing acupoints bloodletting therapy

Bloodletting therapy belongs to the external treatment of TCM, also is a kind of unique acupuncture treatment. As early as in the classic of Chinese medicine Huang Di Nei Jing, the indications and contraindications of bloodletting therapy have been well documented. The Jing acupoints are at the end of the limbs, where the Qi and blood of the twelve meridians start, pass and gather. Jing acupoints bloodletting therapy is widely used in clinical practice,not only for acute syndrome, heat syndrome, positive evidence, but also for neurological diseases and recalcitrance.

As confluence points of Qi and blood, Jing acupoints bloodletting therapy can promote the movement of Qi and blood. SHS is the results of Qi and blood stagnation in the affected limb. Strong stimulation of Jing acupoints can dredge the twelve meridians Qi and blood,and make the circulation of Qi and blood around the body, so as to smooth the meridians of finger,wrist and shoulder joints, clear the stasis, which significantly improve the symptoms of the affected limb swelling, spasm atrophy, adverse flexion [8], and finally achieve the relative balance of Yin and Yang.

Modern study on the treatment of SHS after stroke by Jing acupoints bloodletting therapy

In terms of anatomy, Jing acupoints are located at the end of limbs, with thin skin. There are a lot of connective tissue rich in blood vessels and nerve endings. Although strong stimulation produces strong sense of needle,it is easy to stimulate twelve meridians and Qi, making twelve meridians and Qi flow as a circle,so as to achieve the effect of curing diseases[9].

From the perspective of neurophysiology,the area of sensory representative area and motor representative area projected by human fingers on the cerebral cortex is several times larger than the total area of 12 thoracic spinal nerve afferent representative area. The whole hand's reflection area in the cerebral cortex is almost equal to the area reflected by the whole lower limbs.The Jing acupoints are located at the fingertip of the human body,with a large number of capillary networks,a large number of sensory devices, and the collection of multiple nerves, and the number of neurons associated with the brain is bound to be more, so the Jing acupoints at the fingertip are rich in blood supply and sensitive in sensation. By stimulating these sensitive parts, a small amount of bleeding can be caused, and the nerves associated with them can be reflexively improved, which achieve the effect of regulating brain function [10]. In terms of cerebral blood flow, Jing acupoints bloodletting therapy can obviously promote blood circulation, reduce peripheral vascular resistance, and improve peripheral blood microcirculation. It can not only prevent the state of local ischemia and hypoxia, but also promote the recovery of tissue cells and the proliferation of neural stem cells in the ischemic area[11].

Using the Jing acupoints bloodletting therapy to treat the patients with stroke sequelae [12], it achieved improvement of the National Institute of Health Stroke Scale(NIHSS)score,Activities of Daily Living(ADL)index score and hemorheology index in the observation group, and the total clinical effective rate was significantly higher than that in the control group. The study found that Jing acupoints bloodletting could significantly reduce the level of TNF-α and IL-6 and other inflammatory cytokines. It can reduce the inflammatory injury of brain tissue, effectively improve the nerve function of patients, significantly improve the microcirculation state of swollen limbs,and promote the recovery of nerve function. Bing Yan[13] et al. randomly divided 60 patients with post-stroke SHS who met the inclusion criteria into treatment group and control group. The treatment group was treated with Jing acupoints bloodletting,while the control group was treated with routine acupuncture. After 2 weeks of treatment, the total effective rate and the effective rate of the treatment group were 96.7% and 55.7%, respectively, which were much higher than that of the control group.Research shows that [14] the bloodletting therapy can obviously improve the local microcirculation of the body by regulating the blood flow rate and viscosity,improving the stasis state of microcirculation system,promoting the repair of vascular endothelium,regulating the immune function, and improving the hemorheology so as to achieve the purpose of treating diseases. In the study on the treatment of SHS [15]after stroke by Jing acupoints bloodletting, the obvious efficiency was better than that of the control group,and the platelet aggregation rate, plasma viscosity and hematocrit were significantly lower than those before treatment(P ＜0.05).

Treatment of SHS after stroke with Sangzhi(Mori Ramulus)

Theoretical basis of TCM for treating SHS with Sangzhi(Mori Ramulus)

In clinical,the main principle for the treatment of SHS after stroke is promoting Qi and blood circulation,detumescence and relieving pain. Sangzhi (Mori Ramulus) tastes bitter in nature, and which acts on liver meridian (one of the twelve meridians that runs from the inside of the foot at the great toe,and extends to the anterior chest). It could smooth the meridians and improve joint function, which is often used for rheumatism pain, limb contracture, especially for upper limb shoulder and arm joint pain [16]. Zhu Jian et al. used Sangzhi (Mori Ramulus) as the main medicine to wash the affected limb to treat SHS after stroke, which has a significant effect. It can relieve the swelling and pain of SHS patients in the recovery period of apoplexy to a certain extent, thus improving the rehabilitation effect of upper limb motor function of patients, without adverse reactions, and has a high safety[17].

Modern pharmacology of Sangzhi(Mori Ramulus)in treating SHS after stroke

Sangzhi (Mori Ramulus) belongs to the liver meridian.According to the literature research [18], the TCM which generally belongs to the liver meridian contains flavonoids, alkaloids and sugars. It has the pharmacological effects of analgesia,anti-inflammatory and antispasmodic, nutrition. It has a certain therapeutic effect on rheumatic arthralgia.The main components of mulberry branches are flavonoids, which mainly include quercetin, quercetin,rutin,isoquercetin and so on.The flavonoids contained in Sangzhi (Mori Ramulus) have antibacterial,anti-inflammatory, hypolipidemic, hypoglycemic and other pharmacological effects. By regulating the inflammatory mediators IL-1 β and IL-6, the intracellular environment tends to the balance of inflammation and anti-inflammatory system, and then play an anti-inflammatory effect [19, 20]. The animal experiments carried out by scholars at home and abroad showed that the flavonoid extract of Sangzhi(Mori Ramulus) had a good inhibitory effect on edema caused by drugs[21],so it can be inferred that Sangzhi(Mori Ramulus) has a certain therapeutic effect on SHS after stroke. Some studies[22, 23]have used Jing acupoints bleeding combined with Chinese herbs such as Sangzhi (Mori Ramulus) fumigation and washing to treat the edema and pain of hemiplegia limbs after stroke.The improvement of symptoms in the treatment group is significantly better than that in the control group.

Conclusion

SHS is one of the common complications after ischemic stroke.For the effects of discharging neurons,promoting cerebral blood flow and improving the brain micro-circulation, Jing acupoints bloodletting therapy can effectively relieve the clinical symptoms of the patients with SHS after stroke. Sangzhi (Mori Ramulus), with the ability of dredging the meridian and relieving the pain, is also has certain treatment functions to the SHS. In clinical practice, the combination of Jing acupoints bloodletting and Sangzhi (Mori Ramulus) have been widely used in the treatment of various diseases.Through the analysis the treatment effects and mechanism of Jing acupoints bloodletting therapy and Sangzhi (Mori Ramulus) on SHS after stroke, we provide theoretical support for combination therapy.