ZHOU Qian (周茜), SHENG Shuwei (盛姝薇), ZHANG Jiao (張嬌), ZHAI Dantong (翟丹彤), LI Nana (李娜娜), XIE Xia (解霞)，YU Jiefu (于杰夫)

The First Affiliated Hospital of China Medical University, Shenyang 110001, China

Abstract

Keywords: Acupuncture Therapy; Electroacupuncture; Wrist-ankle Acupuncture; Ischemic Stroke; Neural Conduction;Activities of Daily Living

Stroke is a leading cause of death and disability worldwide[1]. Ischemic stroke is a common type of stroke, accounting for about 60%-80% of all stroke patients[2]. It refers to brain dysfunction caused by ischemia and hypoxia of brain tissue[3]. Ischemic stroke is characterized by high disability and recurrence, and it can seriously damage the patient’s central nervous system and even lead to death[4-6]. Ischemic stroke is a type of disease characterized by a sharp decrease in blood perfusion at the distal end of cerebral arteries,insufficient blood supply and oxygen supply to the brain,and even necrosis of brain tissue[7], followed by neurological deficits, cognitive dysfunction, and ataxia[8-9]. Cerebral atherosclerosis, increased blood viscosity, foreign bodies, congenital vascular malformations, vascular endothelial thickening, arterial plaque formation and rupture, inflammatory factors,and adipokines are common causes of ischemic stroke.

According to statistics, about 80% of patients with ischemic stroke will have different degrees of limb dysfunction[10]. The patient’s lower motor neurons fail to properly regulate the function of the somatic muscle groups, resulting in abnormal muscle strength and mismatched coordination of muscle groups, and consequent motor dysfunction[11]. In the treatment,attention should be paid to the balance of muscle strength among different muscle groups, restoring the damaged nerve function, and promoting the rehabilitation of limb function.

Acupuncture has significant advantages in promoting stroke rehabilitation. Previous studies have confirmed that acupuncture treatment can improve the coordination control ability of patients after stroke and promote the recovery of limb function[12]. The pathogenic mechanism of ischemic stroke is complex,and the course of disease is long, which makes its treatment difficult, and a single treatment often fails to achieve satisfactory results[13]. In this study, we observed the effects of wrist-ankle acupuncture plus electroacupuncture based on conventional rehabilitation therapy on the neurological function and limb movement of patients with ischemic stroke in order to provide a reference for the rehabilitation of ischemic stroke.

1 Clinical Materials

1.1 Diagnostic criteria

The diagnostic criteria of Western medicine referred to the diagnostic description of ischemic stroke in theKey Diagnostic Points for Cerebrovascular Diseases[14].The diagnostic criteria of Chinese medicine referred to the diagnostic description of stroke in theCriteria of Diagnosis and Therapeutic Effects of Diseases and Syndromes in Traditional Chinese Medicine[15]. All patients were diagnosed by CT or MRI examination.

1.2 Inclusion criteria

Met the above diagnostic criteria of Chinese and Western medicine; aged ≥18 years old but ≤75 years old,disease duration ≤6 months; National Institute of Health stroke scale (NIHSS) score ≥5; first-ever onset of stroke,or pre-existing stroke without limb dysfunction; vital signs were stable, conscious, and those who were able to cooperate with the doctor in completing the evaluation of the scale; the patient was able to actively cooperate in completing the treatment and signed the informed consent form.

1.3 Exclusion criteria

Those who belonged to or were accompanied by limb dysfunction caused by traumatic brain injury,tumor, or peripheral neuropathy; combined with speech or mental disorders; accompanied by coagulation dysfunction; had ulcers, injuries, or infections at the points.

1.4 Criteria for withdrawal or dropout

Patients who were mistakenly enrolled after the start of the study when it was found that they did not meet the inclusion criteria; requested to withdraw from the study halfway for any reason; developed treatmentrelated adverse reactions during the course of the study that could not be relieved by treatments; and those who took medications other than those adopted in the study, which had a significant effect on the outcome of the trial.

1.5 Statistical analysis

All data were recorded in Excel 2010, and SPSS version 21.0 statistical software was used to complete data statistics. Measurement data were expressed as mean ± standard deviation (±s) when they were normally distributed, and comparisons between groups were made using two independent samplest-test;comparisons before and after treatment were made using the paired samplest-test. Comparisons of count data and rates were performed using the Chi-square test.P＜0.05 indicated a statistically significant difference.

1.6 General data

Patients were enrolled between September 2020 and March 2022 by means of preadmission recruitment and screening among inpatients. The sample size of this study was estimated based on the mean and standard deviation of the NIHSS score of patients after 4 weeks of treatment[16]. Referring to the results of the pilot study,the scores of the treatment and control groups were(7.05±1.83) and (5.98±1.67), respectively. A two-sided test with α=0.05 and β=0.10 was set. Calculated by PASS 15.0 software that 47 cases were needed in each group,with an estimated dropout rate of 10%, 53 patients were included in each group.

Excel 2007 software was used to generate random numbers, and they were randomly divided into the treatment group and control group at a ratio of 1:1,with 53 cases in each group. The random numbers were enclosed into 106 numbered and sealed opaque envelopes. This study was approved by the Ethics Committee of the First Affiliated Hospital of China Medical University (Ethics No. L2020-07).

A total of 106 patients were included in this study.During the study, 2 patients dropped out of the treatment group, and 1 patient dropped out of the control group. The study flow is shown in Figure 1.

There was no significant difference in the general data between the two groups (P＞0.05). See Table 1.

Figure 1 Study flow chart

Table 1 Comparison of the general data between the two groups

2 Treatment Methods

Patients in both groups were given basic treatments,such as thrombolysis, anti-platelet aggregation and anti-infection, blood pressure and blood glucose control,and anti-cerebral edema, according to theChinese Guidelines for the Diagnosis and Treatment of Acute Ischemic Stroke (2018)[17]and theChinese Expert Consensus on Endovascular Treatment of Acute Ischemic Stroke[18].

2.1 Treatment group

2.1.1 Rehabilitation training

Daily good limb positioning[19]: Special therapists guided patients to correctly place the affected limb in different positions, including supine position, healthyside lying position, affected-side lying position, long sitting position, and wheelchair sitting position.

Limb active and passive activity training[20]: Made the joints of the affected limb in the painless range of passive activities and stretched the affected limb and the surrounding muscle tissue; the healthy hand drove the affected side for active activities, combining with joint control training; practiced wrist and ankle dorsiflexion-induced training and daily activity training.

The above rehabilitation training was 40 min each time, once a day, for 5 consecutive days as a course,with 2 d of rest between courses, for a total of 4 weeks.

2.1.2 Electroacupuncture treatment

Points: Baihui (GV20), Sishencong (EX-HN1), Neiguan(PC6), Sanyinjiao (SP6), Xuehai (SP10), Yanglingquan(GB34), Zusanli (ST36), Shousanli (LI10), and Quchi (LI11)on the affected side[21].

Methods:Acupuncture was performed using Hwato filiform needles (Suzhou Medical Appliance Factory,China) of 0.30 mm in diameter and 25 mm or 40 mm in length. After being inserted, the needle was lifted and twisted to achieve Qi. The G6805-1 electroacupuncture instrument was connected to Quchi (LI11), Shousanli(LI10), Yanglingquan (GB34), and Zusanli (ST 36), using continuous wave, frequency of 20 Hz, 30 min each time,once every other day.

2.1.3 Wrist-ankle acupuncture

Points: Upper 4, Upper 5, Lower 2, Lower 4, and Lower 5 zones[13,22].

Methods:The needle was inserted obliquely into the subcutaneous tissue so that the body of the needle was parallel to the skin, the length of the insertion was 2/3 of the body of the needle, and the exposed portion of the needle was fixed with a sterile application(Figure 2-Figure 4). The treatment was maintained for 2 h each time, once every other day.

Figure 2 Location of Upper 4 and Upper 5 zones of wrist-ankle acupuncture

Figure 3 Location of Lower 2 zone of wrist-ankle acupuncture

Figure 3 Location of Lower 4 and Lower 5 zones of wrist-ankle acupuncture

Electroacupuncture and wrist-ankle acupuncture were performed alternately; that is, electroacupuncture was performed on the previous day, and wrist-ankle acupuncture was performed on the following day.

2.2 Control group

The control group received only rehabilitation training, and the training methods and time were the same as those of the treatment group.

3 Outcome Observation

3.1 Observation items

3.1.1 NIHSS score[14]

The degree of neurological deficit was evaluated by NIHSS. The total NIHSS score was 10 points. Higher scores indicate more severe neurological deficits.

3.1.2 Fugl-Meyer assessment scale (FMA)[23]

The maximum FMA motor function rating was 66 points for the upper limb and 34 points for the lower limb, making a total score of 100 points. Higher scores indicate better limb function.

3.1.3 Berg balance scale (BBS)

The balance ability of the patients was evaluated by BBS, and the total score was 56 points. Higher scores indicate better balance.

3.1.4 Modified Barthel index (BI)

BI was used to evaluate the activities of daily living,and the total score was 100 points. Higher scores indicate a better ability to perform activities of daily living[24].

3.1.5 Nerve conduction velocity (NCV)

NCV of femoral nerve, tibial nerve, sural nerve, and common peroneal nerve were measured by KEYPOINT Danish Dand electromyography evoked potential instrument (Shanghai Langyi Medical Devices Co., Ltd.,China). In the case of the common peroneal nerve, the active electrode was attached to the extensor great toe brevis, the reference electrode was attached to the tendon, and the ground wire was attached to the dorsum of the foot. The distal stimulation was performed between the extensor hallucis longus and its tendon at the ankle, and the proximal stimulation was performed above the capitulum fibula. The distance between the distal and proximal ends was measured,and the conduction velocity of the common peroneal nerve was calculated.

The above indicators were evaluated before and at the end of the treatment.

3.2 Criteria for efficacy assessment

The efficacy was evaluated according to the reduction rate of NIHSS score according to the relevant efficacy criteria in theDiagnostic and Therapeutic Evaluation Criteria for Stroke (Trial)[25]. NIHSS score reduction rate = (NIHSS score before treatment - NIHSS score after treatment) ÷ NIHSS score before treatment ×100%.

Cured: NIHSS score reduction rate ≥90%.

Markedly effective: NIHSS score reduction rate ≥70%but ＜90%.

Effective: NIHSS score reduction rate ≥30% but ＜70%.Invalid: NIHSS score reduction rate ＜30%.

3.3 Results

3.3.1 Comparison of the efficacy

The total effective rate of the treatment group was 92.2%, and the total effective rate of the control group was 76.9%. The difference between the two groups was statistically significant (P＜0.05). See Table 2.

3.3.2 Comparison of the NIHSS, FMA, BBS, and BI scores

There were no significant differences in the NIHSS,FMA, BBS, and BI scores between the two groups before treatment (P＞0.05). After treatment, the NIHSS,FMA, BBS, and BI scores of the two groups were better than those before treatment (P＜0.05); the scores of the treatment group were better than those of the control group, and the differences were statistically significant(P＜0.05). See Table 3.

3.3.3 Comparison of the NCV of the main nerves in the lower limbs

There was no significant difference in the main nerve conduction velocity of lower limbs between the two groups before treatment (P＞0.05). After treatment, the NCV of femoral nerve, tibial nerve, sural nerve, and common peroneal nerve in the treatment group were significantly different from those before treatment(P＜0.05), and also significantly different from those in the control group (P＜0.05). In the control group, only NCV of the femoral nerve was significantly different from that before treatment (P＜0.05). See Table 4.

3.3.4 Adverse reactions

There were no treatment-related adverse reactions in the two groups during the study.

Table 2 Comparison of the clinical efficacy between the two groups Unit: case

Table 3 Comparison of the NIHSS, FMA, BBS, and BI scores between the two groups (±s) Unit: point

Table 3 Comparison of the NIHSS, FMA, BBS, and BI scores between the two groups (±s) Unit: point

Note: NIHSS=National Institute of Health stroke scale; FMA=Fugl-Meyer assessment scale; BBS=Berg balance scale; BI=Barthel index;compared with the same group before treatment, 1) P＜0.05; compared with the control group after treatment, 2) P＜0.05.

Group n Time NIHSS FMA BBS BI Treatment 51 Before treatment 7.43±2.09 41.26±6.61 17.76±4.06 57.63±11.06 After treatment 4.11±2.341)2) 87.17±10.511)2) 39.39±5.871)2) 75.39±12.871)2)Control 52 Before treatment 7.76±2.53 42.55±5.94 18.13±4.48 58.09±12.18 After treatment 5.77±2.141) 72.61±9.211) 47.34±5.611) 67.14±10.611)

Table 4 Comparison of the NCV of the major nerves in the lower limbs between the two groups (±s) Unit: m/s

Table 4 Comparison of the NCV of the major nerves in the lower limbs between the two groups (±s) Unit: m/s

Note: NCV=Nerve conduction velocity; compared with the same group before treatment, 1) P＜0.05; compared with the control group after treatment, 2) P＜0.05.

Group n Time Femoral nerve Tibial nerve Sural nerve Common peroneal nerve Treatment 51 Before treatment 45.17±5.63 35.34±3.36 36.41±4.11 42.71±3.53 After treatment 55.17±2.071)2) 42.17±1.341)2) 42.75±1.281)2) 47.84±1.061)2)Control 52 Before treatment 43.92±6.65 36.72±4.51 37.65±4.71 43.81±4.65 After treatment 47.63±1.971) 38.11±2.35 39.03±2.64 45.27±2.73

4 Discussion

With the aging of the population, acute ischemic stroke has become one of the main diseases leading to death and disability and is on the rise year by year,seriously affecting the physical health and quality of life of residents[26]. Due to abnormalities in the higher nerve centers, nerve damage causes control disorders and movement disorders in the corresponding limbs[27]. At the same time, nerve conduction disorders can also cause muscle tension and proprioception abnormalities in the dominant area, and further lead to core muscle atrophy, weakened control and balance dysfunction,which seriously affect the daily life of patients[27-28].

Chinese medicine believes that the occurrence of ischemic stroke is related to the imbalance of Qi and blood, phlegm and blood stasis blocking collaterals, and Yin-Yang imbalance; it belongs to the syndrome of deficiency in the root and excess in the tip. Acupuncture is widely used in the treatment of stroke. It has the functions of relaxing tendons, unblocking collaterals,mediating Yin and Yang, and regulating Qi and blood.Modern studies have found that point stimulation can stimulate the repair and remodeling of damaged cranial nerves through the input of stimulus signals[29]. Baihui(GV20) is the meeting of all Yang, and the combination of Sishencong (EX-HN1) and Baihui (GV20) can awaken the mind and activate Yang Qi of the whole body.Shousanli (LI10) and Quchi (LI11) can promote blood circulation and dissipate blood stasis, and thus can unblock meridians of the upper limbs. Zusanli (ST36)and Xuehai (SP10) can tonify Qi and blood, and unblock meridians of the lower limbs. Yanglingquan (GB34) is the He-sea point of the Gallbladder Meridian, and has the function of regulating the ascending and descending of Qi of Zang-Fu organs. Modern studies have found that Yanglingquan (GB34) can regulate the expression levels of neuroreceptors and RNA[29].Wrist-ankle acupuncture plays a therapeutic role by stimulating the corresponding points under the skin of the wrist and ankle. It has the advantages of fewer points, less pain, and convenient point selection. It can stimulate specific points under the skin, relieve spasm in the affected area through conduction of nerve endings, improve blood circulation, and further promote the recovery of limb function of patients[30]. It has also been pointed out that wrist-ankle acupuncture stimulates meridian Qi in the skin through the skin→collaterals→meridians→Fu organs→Zang organs, thus promoting the movement of Qi and blood in the body and regulating Yin and Yang[31].

The results of this study showed that after 4 weeks of treatment, the neurological function, NCV, lower-limb motor function, balance ability, and ADL of the two groups were improved compared with those before treatment, and the treatment group was significantly better than the control group, and the total response rate of the treatment group was also better than that of the control group. These results suggest that the addition of electroacupuncture and wrist-ankle acupuncture to routine rehabilitation training can promote the recovery of neuromuscular function in patients with ischemic stroke, improve the motor and living ability of patients, and enhance clinical efficiency.This method is worthy of promotion.

Conflict of Interest

The authors declare that there is no potential conflict of interest in this article.

Acknowledgments

This work was not funded by any project.

Statement of Informed Consent

This study was approved by the Ethics Committee of the First Affiliated Hospital of China Medical University (Ethics No. L2020-07). Informed consent was obtained from all individual participants or their relatives in this study.

Received: 18 August 2022/Accepted: 28 December 2022