Acupuncture in the treatment of stroke: Invitation to the discussion.
Effective stroke treatment remains an urgent problem of neurology in general and a challenge to the clinical skill of every doctor who is in contact with this disease. Both primary and alternative methods of treatment and rehabilitation continue to be studied by scientists from different countries, including Ukraine. One such example is the article by O.E. Kovalenko and ME Čihikova "Influence of reflexotherapy on the dynamics of a headache in the complex treatment of patients after a stroke," which led to discussions about the feasibility of using alternative methods in the treatment of stroke.
Clinical guidelines for stroke treatment were last updated in 2017 (Australia) . It was an update to previous clinical guidelines published in 2010 based on evidence-based medicine.
The updated clinical guidelines in 2017 highlight several key points . Thus, the patient's intense activity outside the bed should not begin within the first 24 hours after the onset of a stroke for some patients (but all patients should start such activity no later than 48 hours after the stroke). Moreover, the minimum duration of the planned rehabilitation therapy is 3 hours per day, of which at least 2 hours the patient has to perform practical tasks during this time actively. Management of secondary complications caused by primary disorders should begin in the acute phase of the disease and continue in the periods of prolonged treatment. This tactic includes prevention strategies, early detection, and reduction of complications.
Stroke management involves the use of an integrated approach with the use of adequate medical and non-drug therapies. Among non-drug methods, physiotherapy occupies the leading place. Physiotherapists seek to restore sensorimotor functions in the upper and lower parts of the body, functional mobility (e.g., walking), etc. Physiotherapy also helps to reduce problems with the musculoskeletal system, respiratory tract, or minimize complications (for example, an allergic syndrome).
Acupuncture among other physiotherapeutic methods takes an ambiguous place in the treatment of stroke. As part of traditional Chinese medicine, it is indeed an acceptable complementary method in the rehabilitation of stroke, not only in Asia [2, 3], but also in the West  because of its impact on spasticity, loss of function and mobility, depression, aphasia, hemiplegia, and pain relief. Therefore, the use of acupuncture was included in the recommendation on the rehabilitation of post-stroke patients [1, 5-7] by meta-analysis data [8-10].
However, data from randomized controlled trials and meta-analyses showed varying degrees of acupuncture effectiveness in stroke rehabilitation, and only in the systematic review of 2015 , the strength of recommendations for its use was assessed using the GRADE approach (classification of recommendations, development, and evaluation). In the end, acupuncture really demonstrates certain benefits in stroke rehabilitation (improvement in neurological function: RR = 1.34; improved swallowing: RR = 1.61; 1.49; 1.07; disability: SMD = 0.49 or 0.07) . The poor quality of evidence and insufficient information on possible harm in the analyzed studies led to the weak recommendation of the GRADE approach that acupuncture can improve stroke rehab.
Comparing the above-mentioned recommendations for the rehabilitation of post-stroke patients in 2010 and 2017, we noted some changes regarding the use of acupuncture. Thus, the 2010 edition contained a general recommendation without determining its strength, which indicated that the daily use of acupuncture alone or in combination with traditional herbal medicines is not recommended for the rehabilitation of stroke.
But in 2017, recommendations are divided into strengths and weaknesses. Consequently, the strong recommendation "Against" states that for the acute, subacute or chronic phase of stroke, acupuncture should not be used to improve daily activity. ADL The "CONVENIENT" weaknesses contain information that, for acute stroke patients, acupuncture should not be used to treat dysphagia and / or spasticity in normal practice, except as part of scientific research. Also, there is a weak recommendation "FOR" that emphasizes that acupuncture can be used for patients with postnatal depression or depressive symptoms.
It is worth noting that we did not find individual recommendations for the use of acupuncture for a headache in the treatment and rehabilitation of post-stroke patients. Article O.E. Kovalenko and ME Čihikova, "The effect of reflexotherapy on the dynamics of a headache in the complex treatment of patients after a stroke," demonstrates the possibility of using this method in such patients and opens the door for scientific discussion on this topic.
- Stroke Foundation. Clinical Guidelines for Stroke Management 2017. Melbourne Australia. 2017. URL: https://informme.org.au/en/Guidelines/Clinical-Guidelines-for-Stroke-Management-2017;
- Wu P, Mills E, Moher D, Seely D. Acupuncture in poststroke rehabilitation: A systematic review and meta-analysis of randomized trials. Stroke. 2010;41:e171–179. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20167912 DOI: https://doi.org/10.1161/STROKEAHA.109.573576;
- Lee JD et al. The cerebrovascular response to traditional acupuncture after stroke. Neuroradiology. 2003;45:780–4. PMID: https://www.ncbi.nlm.nih.gov/pubmed/12942221 DOI: https://doi.org/10.1007/s00234-003-1080-3;
- Hopwood V, Lewith GT. Does acupuncture help stroke patients become more independent? J Altern Complement Med. 2005;11(1): 175–7 (2005). DOI: https://doi.org/10.1089/acm.2005.11.175;
- Acupuncture Introduction. Stroke Engine. 2015. URL: http://www.strokengine.ca/intervention/acupuncture/;
- Acupuncture: Best Practices. Stroke Engine. 2015. URL: www.strokengine.ca/best_practice/acupuncture-best-practices/;
- The Ottawa Panel. Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation. Top Stroke Rehabil 2006;13(2):1–269. [PubMed] https://doi.org/10.1310/3TKX-7XEC-2DTG-XQKH;
- Kong JC, Lee MS, Shin BC, Song YS, Ernst E. Acupuncture for functional recovery after stroke: a systematic review of shamcontrolled randomized clinical trials. CMAJ Canadian Medical Association Journal 2010;182(16):1723-9 Journal Website; DOI: https://doi.org/10.1503/cmaj.091113 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20876268;
- Lim SM, Yoo J, Lee E, Kim HJ, Shin S, Han G, Ahn HS Acupuncture for spasticity after stroke: a systematic review and metaanalysis of randomized controlled trials. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25628750 DOI: https://doi.org/10.1155/2015/870398;
- Zhang ZJ, Chen HY, Yip XC, Ng R, Wong VT. The effectiveness and safety of acupuncture therapy in depressive disorders: systematic review and meta-analysis. Journal of affective disorders 2010;124(1-2):9-21 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19632725 DOI: https://doi.org/10.1016/j.jad.2009.07.005;
- Xin Z, Xue-Ting L, De-Ying K. GRADE in systematic reviews of acupuncture for stroke rehabilitation: recommendations based on high-quality evidence. Scientific reports. 2015; 5:16582. DOI: https://doi.org/10.1038/srep16582 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26560971