Correlated change in upper limb function and motor cortex activation after verum and sham acupuncture in patients with chronic stroke

Effect of acupuncture combined with rehabilitation training on sensory impairment of patients with stroke: a network meta-analysis

BACKGROUND

The refractory and disabling nature of sensory disorders after stroke seriously affects patients' daily lives and reduces hospital turnover. Acupuncture, as an alternative therapy, is commonly used in combination with rehabilitation training to improve sensory disorders. To compare the effects of different acupuncture-related treatments combined with rehabilitation training on sensory impairment and the daily living ability of patients with stroke, we conducted a network meta-analysis to provide evidence-based findings for clinical practice.

METHODS

Randomized controlled trials on the treatment of sensory disorders in patients with stroke were systematically retrieved from several databases, including China National Knowledge Infrastructure (CNKI), China Science and Technology Journal(VIP), Wanfang Database, Chinese Biological Medical (CBM), PubMed, Embase, Web of Science, Cochrane Library, and Clinical trials. The retrieval period ranged from January 2012 to December 2023. Two independent reviewers screened the included literature, extracted the data, and assessed the risk quality using Cochrane Handbook 5.1.0 and ReviewManager 5.4.1. Stata16.0 software was employed for data analysis. The study protocol was registered in PROSPERO: CRD42023389180.

RESULTS

After screening, 20 studies were included, involving a total of 1999 subjects. The network meta-analysis results indicate that, compared to standard rehabilitation, acupuncture plus massage plus rehabilitation showed the most significant reduction in Numbness Syndrome Scores (MD = -0.71(-1.11,-0.31)). Acupuncture combined with rehabilitation demonstrated the most substantial improvement in Sensory Impairment Scores (MD = -0.59,(-0.68,-0.51)) and daily living ability of patients (MD = 17.16,(12.20,22.12)).

CONCLUSIONS

In comparison to standard rehabilitation, the combination of acupuncture-related treatments and modern rehabilitation training not only improves the symptoms of sensory impairment and numbness after stroke but also enhances the daily living ability of patients, especially when acupuncture is combined with rehabilitation. However, further demonstration is required to strengthen these conclusions.

Global trends and development of acupuncture for stroke: A review and bibliometric analysis

The objective of this review is to elaborate on the status, hotspots, and trends of researches on acupuncture for stroke over the past 26 years. Publications about acupuncture for stroke were downloaded from the Web of Science Core Collection, and these papers were published up to December 31, 2022. A bibliometric analysis of acupuncture for stroke was conducted by CiteSpace (6.2.R4) and VOSviewer (1.6.17). In this study, VOSviewer was used for visual analysis of countries, institutions, authors, journals, keywords, and co-cited references. CiteSpace was used to draw a keyword burst map and a co-cited reference burst map. A total of 534 papers were obtained from the Web of Science Core Collection. The number of papers per year showed a rapid upward trend. The most productive country and institution in this field were China (452) and the Fujian University of Traditional Chinese Medicine (43), respectively. Tao Jing had the highest number of articles (34), and EZ Longa was the most popular author (129 co-citations). Neural Regeneration Research (51) was the most productive journal, and Stroke (1346) was the most co-cited journal. An paper written by EZ Longa was the most influential reference, with the highest citation count. The hotspots and frontiers of this area of research were focused on the mechanisms of acupuncture, especially its neural regenerative or neuroprotective effects. This study used CiteSpace and VOSviewer for bibliometric analysis to provide researchers with information on the research status, hotspots, and trends in acupuncture for stroke research over the past 26 years.

Effects of electroacupuncture on imaging and behavior in rats with ischemic stroke through miR-212-5p

BACKGROUND

Ischemic stroke is a serious disease leading to significant disability in humans worldwide. Increasing evidence suggests that some microRNAs (miRNAs) participate in the pathophysiology of ischemic stroke. A key role for MiR-212 has been found in neuronal function and synaptic plasticity. Ischemic stroke can be effectively treated with electroacupuncture (EA); however, there is a lack of understanding of the relevant mechanisms. In this study, we employed behavioral test and resting-state functional magnetic resonance imaging (rs-fMRI) to detect behavioral and brain function alterations in rats suffering from ischemic stroke. The efficacy of EA therapy and miR-212-5p's role in this process were also evaluated.

METHODS AND RESULTS

Forty rats were randomly divided into the following groups: Sham, middle cerebral artery occlusion/reperfusion (MCAO/R), MCAO/R + EA, MCAO/R + EA + antagomir-negative control and MCAO/R + EA + antagomir-212-5p groups. Behavioral changes were assessed by Catwalk gait analysis prior to and after modeling. Rs-fMRI was performed at one week after EA treatment, amplitude of low-frequency fluctuations (ALFF) and regional homogeneity (ReHo) were calculated to reveal neural activity. Furthermore, neuronal apoptosis in the ischemic penumbra was analyzed using a TUNEL assay. Treatment with EA significantly improved the performance of rats in the behavioral test. The motor and cognition-related brain regions showed decreased ALFF and ReHo following focal cerebral ischemia-reperfusion, and EA treatment could reactivate these brain regions. Moreover, EA treatment significantly decreased MCAO/R-induced cell death. However, the transfection of antagomir-212-5p attenuated the therapeutic effect of EA.

CONCLUSIONS

In conclusion, the results suggested that EA improved the behavioral and imaging outcomes of ischemic stroke through miR-212-5p.

The changes of neuroactivity of Tui Na (Chinese massage) at Hegu acupoint on sensorimotor cortex in stroke patients with upper limb motor dysfunction: a fNIRS study

BACKGROUND

Tui Na (Chinese massage) is a relatively simple, inexpensive, and non-invasive intervention, and has been used to treat stroke patients for many years in China. Tui Na acts on specific parts of the body which are called meridians and acupoints to achieve the role of treating diseases. Yet the underlying neural mechanism associated with Tui Na is not clear due to the lack of detection methods.

OBJECTIVE

Functional near-infrared spectroscopy (fNIRS) was used to explore the changes of sensorimotor cortical neural activity in patients with upper limb motor dysfunction of stroke and healthy control groups during Tui Na Hegu Point.

METHODS

Ten patients with unilateral upper limb motor dysfunction after stroke and eight healthy subjects received Tui Na. fNIRS was used to record the hemodynamic data in the sensorimotor cortex and the changes in blood flow were calculated based on oxygenated hemoglobin (Oxy-Hb), the task session involved repetitive Tui Na on Hegu acupoint, using a block design [six cycles: rest (20 seconds); Tui Na (20 seconds); rest (30 seconds)]. The changes in neural activity in sensorimotor cortex could be inferred according to the principle of neurovascular coupling, and the number of activated channels in the bilateral hemisphere was used to calculate the lateralization index.

RESULT

1. For hemodynamic response induced by Hegu acupoint Tui Na, a dominant increase in the contralesional primary sensorimotor cortex during Hegu point Tui Na of the less affected arm in stroke patients was observed, as well as that in healthy controls, while this contralateral pattern was absent during Hegu point Tui Na of the affected arm in stroke patients. 2. Concerning the lateralization index in stroke patients, a significant difference was observed between lateralization index values for the affected arm and the less affected arm (P < 0.05). Wilcoxon tests showed a significant difference between lateralization index values for the affected arm in stroke patients and lateralization index values for the dominant upper limb in healthy controls (P < 0.05), and no significant difference between lateralization index values for the less affected arm in stroke patients and that in healthy controls (P = 0.36).

CONCLUSION

The combination of Tui Na and fNIRS has the potential to reflect the functional status of sensorimotor neural circuits. The changes of neuroactivity in the sensorimotor cortex when Tui Na Hegu acupoint indicate that there is a certain correlation between acupoints in traditional Chinese medicine and neural circuits.

Acupuncture Alters Brain's Dynamic Functional Network Connectivity in Stroke Patients with Motor Dysfunction: A Randomised Controlled Neuroimaging Trial

Objectives

Neuroimaging studies have confirmed that acupuncture can promote static functional reorganization in poststroke patients with motor dysfunction. But its effect on dynamic brain networks remains unclear. This study is aimed at investigating how acupuncture affected the brain's dynamic functional network connectivity (dFNC) after ischemic stroke.

Methods

We conducted a single-center, randomised controlled neuroimaging study in ischemic stroke patients. A total of 53 patients were randomly divided into the true acupoint treatment group (TATG) and the sham acupoint treatment group (SATG) at a ratio of 2 : 1. Clinical assessments and magnetic resonance imaging (MRI) scans were performed on subjects before and after treatment. We used dFNC analysis to estimate distinct dynamic connectivity states. Then, the temporal properties and strength of functional connectivity (FC) matrix were compared within and between the two groups. The correlation analysis between dynamic characteristics and clinical scales was also calculated.

Results

All functional network connectivity (FNC) matrices were clustered into 3 connectivity states. After treatment, the TATG group showed a reduced mean dwell time and found attenuated FC between the sensorimotor network (SMN) and the frontoparietal network (FPN) in state 3, which was a sparsely connected state. The FC between the dorsal attention network (DAN) and the default mode network (DMN) was higher after treatment in the TATG group in state 1, which was a relative segregated state. The SATG group preferred to increase the mean dwell time and FC within FPN in state 2, which displayed a local tightly connected state. In addition, we found that the FC value increased between DAN and right frontoparietal network (RFPN) in state 1 in the TATG group after treatment compared to the SATG group. Correlation analyses before treatment showed that the Fugl-Meyer Assessment (FMA) lower score was negatively correlated with the mean dwell time in state 3. FMA score showed positive correlation with FC in RFPN-SMN in state 3. FMA-lower score was positively correlated with FC in DAN-DMN and DAN-RFPN in state 1.

Conclusions

Acupuncture has the potential to modulate abnormal temporal properties and promote the balance of separation and integration of brain function. True acupoint stimulation may have a more positive effect on regulating the brain's dynamic function. Clinical Trial Registration. This trial is registered with Chinese Clinical Trials Registry (ChiCTR1800016263).

The Top 100 Cited Articles on Acupuncture in the Last 20 Years: A Bibliometric Analysis

BACKGROUND

Acupuncture has gained increasing international attention in recent decades. The act of incorporating acupuncture treatment into the routine treatment of COVID-19 in China drove us to review the 100 most influential articles of the last 20 years to learn about the current status and trends of acupuncture.

METHOD

Articles related to acupuncture from January 1, 2001, to July 4, 2022, were searched in the Clarivate Analytics Web of Science Core Collection database. The top 100 most cited publications were selected, and information was extracted. Software such as VOSviewer, GraphPad Prism, Scimago Graphica, and CiteSpace were used to visualize and analyze the extracted data.

RESULT

The 100 most cited articles were identified, with an average of 218 citations (range: 131-625). The majority of the top 100 articles were from the USA (n = 53). The institution that published the most highly cited papers was Harvard University (n = 16). The most influential team was Klaus Linde's group. Pain was the top-ranked journal in terms of the number of publications. The largest clusters for co-occurrence keyword analysis focused on acupuncture and electroacupuncture analgesia and brain imaging responses to acupuncture stimulation via functional MRI. The two highest strength burst keywords were "randomized controlled trials" and "osteoarthritis," with "randomized controlled trials" being a consistent burst keyword from 2011 to the present.

CONCLUSION

This study provides insight into articles of historical significance in the field of acupuncture through bibliometric analysis. These data should provide clinicians and researchers with insight into future directions related to acupuncture.

Hintergrund

Die Akupunktur hat in den vergangenen Jahrzehnten zunehmend die internationale Aufmerksamkeit auf sich gezogen. Die Einbeziehung der Akupunktur in die Routinebehandlung von COVID-19 in China hat uns dazu veranlasst, die 100 einflussreichsten Artikel der letzten 20 Jahre zu überprüfen, um etwas über den aktuellen Stand und die Trends in der Akupunktur zu erfahren.

Methode

Artikel mit Bezug zu Akupunktur vom 1. Januar 2001 bis 4. Juli 2022 wurden in der Clarivate Analytics Web of Science Core Collection Datenbank gesucht. Die 100 am häufigsten zitierten Veröffentlichungen wurden ausgewählt und die Informationen wurden extrahiert. Visualisierung und Analyse der extrahierten Daten erfolgten mithilfe der Software VOSviewer, GraphPad Prism, Scimago Graphica und CiteSpace.

Ergebnis

Es wurden die 100 am häufigsten zitierten Artikel ermittelt mit durchschnittlich 218 Zitierungen (Spanne: 131 bis 625). Der Großteil der 100 meistzitierten Artikel stammte aus den Vereinigten Staaten (n = 53). Die Institution, die die meisten zitierten Artikel veröffentlichte, war die Harvard-Universität (n = 16). Das einflussreichste Team war die Gruppe von Klaus Linde. Was die Zahl der Veröffentlichungen betrifft, war Pain die am häufigsten zitierte Zeitschrift. Bei der Analyse der Koinzidenz von Schlüsselwörtern lag der Fokus der größten Cluster auf Akupunktur-und Elektroakupunktur-Analgesie sowie auf den Reaktionen auf Akupunkturstimulation in den bildgebenden Untersuchungen des Gehirns mittels funktioneller MRT. Die beiden stärksten Burst-Schlüsselwörter waren “randomisierte kontrollierte Studien” und “Osteoarthritis,” wobei “randomisierte kontrollierte Studien” von 2011 bis heute durchgängig ein Burst-Schlüsselwort ist.

Schlussfolgerung

Diese Studie bietet einen Einblick in historisch bedeutsame Artikel auf dem Gebiet der Akupunktur mittels bibliometrischer analyse. Diese Daten sollen Klinikern und Forschern einen Einblick in zukünftige Richtungen im Zusammenhang mit Akupunktur geben.

Effect of aging on the cerebral metabolic mechanism of electroacupuncture treatment in rats with traumatic brain injury

Objective

Aging has great influence on the clinical treatment effect of cerebrovascular diseases, and evidence suggests that the effect may be associated with age-related brain plasticity. Electroacupuncture is an effective alternative treatment for traumatic brain injury (TBI). In the present study, we aimed to explore the effect of aging on the cerebral metabolic mechanism of electroacupuncture to provide new evidence for developing age-specific rehabilitation strategies.

Methods

Both aged (18 months) and young (8 weeks) rats with TBI were analyzed. Thirty-two aged rats were randomly divided into four groups: aged model, aged electroacupuncture, aged sham electroacupuncture, and aged control group. Similarly, 32 young rats were also divided into four groups: young model, young electroacupuncture, young sham electroacupuncture, and young control group. Electroacupuncture was applied to "Bai hui" (GV20) and "Qu chi" (LI11) for 8 weeks. CatWalk gait analysis was then performed at 3 days pre- and post-TBI, and at 1, 2, 4, and 8 weeks after intervention to observe motor function recovery. Positron emission computed tomography (PET/CT) was performed at 3 days pre- and post-TBI, and at 2, 4, and 8 weeks after intervention to detect cerebral metabolism.

Results

Gait analysis showed that electroacupuncture improved the forepaw mean intensity in aged rats after 8 weeks of intervention, but after 4 weeks of intervention in young rats. PET/CT revealed increased metabolism in the left (the injured ipsilateral hemisphere) sensorimotor brain areas of aged rats during the electroacupuncture intervention, and increased metabolism in the right (contralateral to injury hemisphere) sensorimotor brain areas of young rats.

Results

This study demonstrated that aged rats required a longer electroacupuncture intervention duration to improve motor function than that of young rats. The influence of aging on the cerebral metabolism of electroacupuncture treatment was mainly focused on a particular hemisphere.

New insights into acupuncture techniques for poststroke spasticity

With the trend of aging population getting more obvious, stroke has already been a major public health problem worldwide. As a main disabling motor impairment after stroke, spasticity has unexpected negative impacts on the quality of life and social participation in patients. Moreover, it brings heavy economic burden to the family and society. Previous researches indicated that abnormality of neural modulation and muscle property corelates with the pathogenesis of poststroke spasticity (PSS). So far, there still lacks golden standardized treatment regimen for PSS; furthermore, certain potential adverse-events of the mainstream therapy, for example, drug-induced generalized muscle weakness or high risk related surgery somehow decrease patient preference and compliance, which brings challenges to disease treatment and follow-up care. As an essential non-pharmacological therapy, acupuncture has long been used for PSS in China and shows favorable effects on improvements of spastic hypertonia and motor function. Notably, previous studies focused mainly on the research of antispastic acupoints. In comparison, few studies lay special stress on the other significant factor impacting on acupuncture efficacy, that is acupuncture technique. Based on current evidences from the clinic and laboratory, we will discuss certain new insights into acupuncture technique, in particular the antispastic needling technique, for PSS management in light of its potential effects on central modulations as well as peripheral adjustments, and attempt to provide some suggestions for future studies with respect to the intervention timing and course, application of acupuncture techniques, acupoint selection, predictive and aggravating factors of PSS, aiming at optimization of antispastic acupuncture regimen and improvement of quality of life in stroke patients. More innovations including rigorous study design, valid objective assessments for spasticity, and related experimental studies are worthy to be expected in the years ahead.

Acupuncture combined with repeated transcranial magnetic stimulation for upper limb motor function after stroke: A systematic review and meta-analysis

BACKGROUND

Upper limb motor dysfunction after stroke is an important factor affecting patients' motor function and daily life. Acupuncture and repetitive transcranial magnetic stimulation are effective methods for stroke rehabilitation. However, a systematic and comprehensive overview of the combined efficacy of the two is lacking.

OBJECTIVE

Through a systematic review and meta-analysis of randomized controlled trials, this study aimed to assess the effectiveness of acupuncture combined with repetitive transcranial magnetic stimulation on upper extremity motor function in post-stroke patients.

METHODS

The relevant randomized controlled trials on acupuncture combined with repetitive transcranial magnetic stimulation in the treatment of upper limb motor disorders after stroke were searched in PubMed, Embase, Cochrane Library, Web of Science CNKI, VIP, Wanfang, and CBM databases. After screening clinical trials that met the inclusion criteria, data extraction was conducted independently by two investigators. Meta-analysis was performed using RevMan 5.4 software.

RESULTS

After the screening, 18 articles were included, with a total of 1083 subjects. The results of meta-analysis showed that combination therapy could effectively improve the patients' upper limb motor function (MD = 7.77, 95%CI [6.32, 9.22], P < 0.05), ability of daily living (MD = 8.53, 95%CI [6.28, 10.79], P < 0.05), and hemiplegic shoulder pain (MD = - 1.72, 95%CI [- 2.26, - 1.18], P < 0.05). Meanwhile, for neurophysiological indexes, combined treatment could significantly shorten the latency of motor evoked potential and central motor conduction time (MD = - 1.42, 95%CI [- 2.14, - 0.71], P < 0.05); (MD = - 0.47, 95%CI [- 0.66, - 0.29], P < 0.05), and also could increase the amplitude of motor evoked potential (SMD = 0.71, 95%CI [0.28, 1.14], P < 0.05).

CONCLUSION

According to the results of the meta-analysis, we can conclude that acupuncture combined with repeated transcranial magnetic stimulation can significantly improve the upper limb motor function and daily living ability of stroke patients.

Study protocol of a randomized controlled trial for the synergizing effects of rTMS and Tui Na on upper limb motor function and cortical activity in ischemic stroke

Upper limb motor dysfunction after stroke is a serious threat to the living quality of patients and their families. Recovery of upper limb motor function after stroke largely relies on the activation and remodeling of neural circuits. rTMS (repetitive transcranial magnetic stimulation) has been proved to promote the reconstruction of neural synapses and neural circuits. However, there are still a large number of patients who cannot fully recover and leave behind varying degrees of dysfunction. Considering the systemic pathology after stroke, in addition to focal brain injury, stroke can also cause extensive dysfunction of peripheral organs. The rehabilitation strategy for stroke should combine the treatment of primary brain lesions with the intervention of secondary systemic damage. The aim of this trial is to verify the efficacy of rTMS synergize with Tui Na (Chinese Massage) on upper limb motor function after ischemic stroke, and to explore the mechanism of activation and remodeling of sensorimotor neural circuits with functional near-infrared spectroscopy. Ninety patients will be randomly assigned to either rTMS + Tui Na + conventional rehabilitation group (the experimental group) or rTMS + conventional rehabilitation group (the control group) in 1:1 ratio. Intervention is conducted five sessions a week, with a total of twenty sessions. The primary outcome is Fugl-Meyer Assessment, and the secondary outcomes include Muscle Strength, Modified Ashworth Assessment, Modified Barthel Index Assessment, motor evoked potentials and functional near-infrared spectroscopy. There are four time points for the evaluation, including baseline, 2 weeks and 4 weeks after the start of treatment, and 4 weeks after the end of treatment. This study is a randomized controlled trial. This study was approved by Institutional Ethics Committee of Shanghai Third Rehabilitation Hospital Affiliated to Shanghai University of Traditional Chinese Medicine (approval No. SH3RH-2021-EC-012) on December, 16th, 2021. The protocol was registered with Chinese Clinical Trial Registry (ChiCTR2200056266), on February 3th, 2022. Patient recruitment was initiated on February 10th, 2022, and the study will be continued until December 2023.

A Novel Approach to Increase Attention during Mirror Therapy among Stroke Patients: A Video-Based Behavioral Analysis

Stroke is a major cause of disability and an evident rehabilitation strategy is crucial. Mirror therapy (MT) is one of the popular rehabilitation methods that is known to be effective as the patients benefit from the mirror illusion. However, the patient’s attention to the mirror illusion during treatment is unclear. Therefore, the present study assesses the duration and frequency of the mirror gaze, distraction, and preparation of sixteen stroke patients during two MT methods using a behavioral coding software. During the 30 min treatment, the total mirror gaze duration during conventional bilateral MT (BMT) was 564.04 s, while it was 1482.45 s in unilateral MT using a screen (UMT). The total distracted time was 945.61 s in BMT, while it was only 162.03 s in UMT. The total preparatory duration was 290.35 s in BMT and 155.53 s in UMT. The total number of distracted bouts were 136.45 in BMT, while it was 73.38 in UMT. The total number of preparatory bouts were 18.42 in BMT and 9.56 in UMT. The average times of gaze duration per bout were 5.52 s in BMT and 21.81 s in UMT. The average times of distraction per bout were 9.22 s in BMT and 3.00 s in UMT. The total number of mirror gaze bouts and average time of preparation per bout did not present a statistical significance in the comparisons of the two methods. This study assesses two methods of MT using observational coding software to evaluate the duration and frequency of the mirror gaze during treatment. The results suggest that UMT may be an alternative option to provide MT for stroke patients to increase their attention towards the mirror.

Efficacy and safety of manual acupuncture for the treatment of upper limb motor dysfunction after stroke: Protocol for a systematic review and meta-analysis

Introduction

The incidence of stroke sequelae among patients is as high as 70%–80%. Flexor spasm is the most common stroke sequela, presenting a heavy burden to the patients and their families. This study will evaluate the results of randomized controlled trials to determine the efficacy and safety of hand manipulation acupuncture for the treatment of upper limb motor dysfunction after stroke.

Methods

Eight databases, including China National Knowledge Infrastructure, Chinese Scientific Journal Database, Cochrane Central Register of Controlled Trials, Embase, MEDLINE, PubMed, Wanfang Database, and Web of Science, will be searched using English and Chinese search strategies. In addition, manual retrieval of research papers, conference papers, ongoing experiments, and internal reports, among others, will supplement electronic retrieval. All eligible studies published on or before January 15, 2021 will be selected. To enhance the effectiveness of the study, only clinical randomized controlled trials related to the use of manual acupuncture for the treatment of upper limb motor dysfunction after stroke will be included.

Analysis

The Fugl-Meyer upper extremity assessment will be the primary outcome measure, whereas the Wolf Motor Function Test, Modified Ashworth Scale, arm movement survey test table, and upper extremity freehand muscle strength assessment scores will be the secondary outcomes. Side effects and adverse events will be included as safety evaluations. To ensure the quality of the systematic evaluation, study selection, data extraction, and quality assessment will be independently performed by two authors, and a third author will resolve any disagreement.

Ethics and dissemination

This systematic review will evaluate the efficacy and safety of manual acupuncture for the treatment of upper limb motor dysfunction after stroke. Since all included data will be obtained from published articles, it does not require ethical approval and will be published in a peer-reviewed journal.

INPLASY registration number: INPLASY202110071.

Effects of GV14 Acupuncture on Cerebral Blood Flow Velocity in the Basilar and Middle Cerebral Arteries and CO2 Reactivity during Hypercapnia in Normal Individuals

The Governing Vessel 14 (GV14) (Dazhui) is one of the acupuncture points referred to as "seven acupoints for stroke." Nevertheless, there is a scarcity of research on the effects of acupuncture treatment at GV14. This study investigated the effects of acupuncture at GV14 on cerebral blood flow (CBF), especially that in the basilar artery (BA) and the middle cerebral arteries (MCA). Sixteen healthy men aged 20 to 29 years were enrolled in this study. CBF velocity and cerebrovascular reactivity (CVR) were measured using transcranial Doppler sonography (TCD). The following were assessed: closed circuit rebreathing- (CCR-) induced carbon dioxide (CO₂) reactivity, modified blood flow velocity at 40 mmHg (CV40) on BA and MCAs, blood pressure (BP), and heart rate (HR). Observed results were obtained after comparison with the baseline evaluation. Statistically significant elevations in CO₂ reactivity were recorded in the BA (3.28 to 4.70, p < 0.001) and MCAs (right: 3.81 to 5.25, p=0.001; left: 3.84 to 5.12, p=0.005) after acupuncture at GV14. The CV40 increased statistically significantly only in the BA (45.49 to 50.41, p=0.003). No change was observed in BP (106.83 to 107.08 (mmHg), p=0.335) and HR (77 to 75 (bpm), p=0.431). Acupuncture at GV14 improved CBF velocity. These results could be explained by the regulation of endothelium-dependent vessel dilation effected by acupuncture. This trial is registered with Korean Clinical Trial Registry (http://cris.nih.go.kr; registration number: KCT0004787).

Neuroplasticity of Acupuncture for Stroke: An Evidence-Based Review of MRI

Acupuncture is widely recognized as a potentially effective treatment for stroke rehabilitation. Researchers in this area are actively investigating its therapeutic mechanisms. Magnetic resonance imaging (MRI), as a noninvasive, high anatomical resolution technique, has been employed to investigate neuroplasticity on acupuncture in stroke patients from a system level. However, there is no review on the mechanism of acupuncture treatment for stroke based on MRI. Therefore, we aim to summarize the current evidence about this aspect and provide useful information for future research. After searching PubMed, Web of Science, and Embase databases, 24 human and five animal studies were identified. This review focuses on the evidence on the possible mechanisms underlying mechanisms of acupuncture therapy in treating stroke by regulating brain plasticity. We found that acupuncture reorganizes not only motor-related network, including primary motor cortex (M1), premotor cortex, supplementary motor area (SMA), frontoparietal network (LFPN and RFPN), and sensorimotor network (SMN), as well as default mode network (aDMN and pDMN), but also language-related brain areas including inferior frontal gyrus frontal, temporal, parietal, and occipital lobes, as well as cognition-related brain regions. In addition, acupuncture therapy can modulate the function and structural plasticity of post-stroke, which may be linked to the mechanism effect of acupuncture.

Progress of Acupuncture Therapy in Diseases Based on Magnetic Resonance Image Studies: A Literature Review

The neural mechanisms of acupuncture are not well-understood. Over the past decades, an increasing number of studies have used MRI to investigate the response of the brain to acupuncture. The current review aims to provide an update on acupuncture therapy in disease. The PubMed, Embase, Web of Science, and Cochrane Library databases were searched from inception to January 31, 2021. Article selection and data extraction were conducted by two review authors. A total of 107 publications about MRI in acupuncture were included, the collective findings of which were as follows: (1) stroke and GB34 (Yanglingquan) are the most studied disease and acupoint. Related studies suggested that the mechanism of acupuncture treatment for stroke may associate with structural and functional plasticity, left and right hemispheres balance, and activation of brain areas related to movement and cognition. GB34 is mainly used in stroke and Parkinson's disease, which mainly activates brain response in the premotor cortex, the supplementary motor area, and the supramarginal gyrus; (2) resting-state functional MRI (rs-fMRI) and functional connectivity (FC) analysis are the most frequently used approaches; (3) estimates of efficacy and brain response to acupuncture depend on the type of sham acupuncture (SA) used for comparison. Brain processing after acupuncture differs between patients and health controls (HC) and occurs mainly in disorder-related areas. Factors that influence the effect of acupuncture include depth of needling, number and locations of acupoints, and deqi and expectation effect, each contributing to the brain response. While studies using MRI have increased understanding of the mechanism underlying the effects of acupuncture, there is scope for development in this field. Due to the small sample sizes, heterogeneous study designs, and analytical methods, the results were inconsistent. Further studies with larger sample sizes, careful experimental design, multimodal neuroimaging techniques, and standardized methods should be conducted to better explain the efficacy and specificity of acupuncture, and to prepare for accurate efficacy prediction in the future.

Effect of Acupuncture on Neuroplasticity of Stroke Patients with Motor Dysfunction: A Meta-Analysis of fMRI Studies

Objective

To analyze the pattern of intrinsic brain activity variability that is altered by acupuncture compared with conventional treatment in stroke patients with motor dysfunction, thus providing the mechanism of stroke treatment by acupuncture.

Methods

Chinese and English articles published up to May 2020 were searched in the PubMed, Web of Science, EMBASE, and Cochrane Library databases, China National Knowledge Infrastructure, Chongqing VIP, and Wanfang Database. We only included randomized controlled trials (RCTs) using resting-state fMRI to observe the effect of acupuncture on stroke patients with motor dysfunction. R software was used to analyze the continuous variables, and Seed-based d Mapping with Permutation of Subject Images (SDM-PSI) was used to perform an analysis of fMRI data. Findings. A total of 7 studies comprising 143 patients in the treatment group and 138 in the control group were included in the meta-analysis. The results suggest that acupuncture treatment helps the healing process of motor dysfunction in stroke patients and exhibits hyperactivation in the bilateral basal ganglia and insula and hypoactivation in motor-related areas (especially bilateral BA6 and left BA4).

Conclusion

Acupuncture plays a role in promoting neuroplasticity in subcortical regions that are commonly affected by stroke and cortical motor areas that may compensate for motor deficits, which may provide a possible mechanism underlying the therapeutic effect of acupuncture.

Anti-spastic effect induced by waggle needling correlates with KCC2-GABAA pathway in post-stroke spasticity rats

Although clinical efficacy of waggle needling has been confirmed, therapeutic mechanisms still remain poorly understood. Reduction of GABA was involved in the etiology of spasticity. Recently, accumulated evidences suggest that the inhibitory effect of GABA is determined by low intracellular chloride concentration, which is predominantly mediated by KCC2. This study was designed to investigate whether KCC2-GABAA pathway was involved in the mechanism underlying acupuncture intervention in rats with middle cerebral artery occlusion (MCAO). Three days after modeling, the rats received waggle needling, routine needling and placebo needling for 7 consecutive days. After treatment, the muscle spasticity, motor function and infarct volumes were tested. KCC2 and GABAAγ2 levels were detected via western blotting, RT-PCR and immunofluorescence. KCC2 antagonist and agonist were administered after the last intervention. We found that acupuncture, particularly waggle needling, could remarkably alleviate muscle spasticity, reverse motor deficits and reduce cerebral infraction in MCAO rats, possibly due to its effects on up-regulating expressions of KCC2 and GABAAγ2 in the cortical infarct regions. However, the effects were blocked by KCC2 antagonist. In summary, this study suggests that improvements in muscle spasticity and motor function induced by waggle needling correlates with the activation of KCC2-GABAA pathway.

Fire Acupuncture versus conventional acupuncture to treat spasticity after stroke: A systematic review and meta-analysis

BACKGROUND

Post-stroke spasm is currently a complex clinical problem that remains to be resolved. Due to its excellent efficacy and few side effects, clinicians have used fire acupuncture to treat post-stroke spasticity in China.

OBJECTIVES

The purpose of this study was to evaluate the clinical efficacy of fire acupuncture compared with conventional acupuncture to treat post-stroke spasms and provide a detailed summary of the commonly used acupoints.

METHODS

Eight databases (MEDLINE/PubMed, Web of Science, the Cochrane database, EMBASE, CBM, CNKI, WanFang, and VIP) were searched for randomized controlled trials (RCTs) published from database inception through August 30, 2020. RCTs that compared fire acupuncture with conventional acupuncture as a treatment intervention for patients with spasticity after stroke were included. Revman 5.3 software was used to calculate risk ratios (RR) and standard mean differences (SMD) with 95% confidence intervals (CI). Methodological evaluation or critical appraisal of the included articles was assessed using RoB-2.

RESULTS

Sixteen studies with a total of 1,118 patients were included. Although according to the standards of the Rob 2.0 tool, most studies are considered to have some problems. Comprehensive analysis of the results revealed a consistent trend indicating several advantages of using fire needles compared to conventional acupuncture in treating post-stroke spasms, including the effective rate, recovery rate, and improvement of multiple scales represented by MAS. Concerning secondary outcomes, using the scales of FMA, BI, or NDS in this random model meta-analysis, fire acupuncture exhibited better performance compared to acupuncture [SMD = 2.27, 95%CI [1.40,3.13 (random-effects model) ], [SMD = 1.46,95% CI [1.03,1.90 (random-effects model)], and [SMD = 0.90, 95%CI [0.44,1.35 (random-effects model)], respectively, with moderately high heterogeneity. When the effective rate was used as an outcome in the subgroup analysis, fire needles performed better than conventional acupuncture with respect to damage to the upper or lower limbs, and the thickness and depth of acupuncture. When the modified Ashworth scale (MAS) was used as the outcome, and the damage occurred in the lower extremity, the acupuncture depth exceeded 15mm, or the duration of stroke was longer than six months, the fire needles did not perform better than conventional acupuncture, [SMD = 0.01, 95%CI [-0.47,0.48 (fix-effects model)], [SMD = 0.21 [-0.51,0.93(random-effects model)], and [SMD = 0.76, 95%CI [-0.08,1.60 (random-effects model)], respectively. The acupoints identified with the highest frequencies in this study were Yang-meridian, including LI11-Quchi (nine times), LI4-Hegu (seven times), and ST36-Zusanli (five times). Moreover, no serious adverse effects were reported in any of the studies included in this analysis.

CONCLUSIONS

Despite several limitations, this was the first meta-analysis to focus on the treatment of post-stroke spasticity using fire needle acupuncture compared with conventional acupuncture. Our results confirmed that fire needles could provide a better clinical effect than conventional acupuncture, which will help standardize fire needle treatment strategies for post-stroke spasms.

Exploring Representation of Diverse Samples in fMRI Studies Conducted in Patients With Cardiac-Related Chronic Illness: A Focused Systematic Review

Introduction/Purpose: Cardiovascular disease (CVD) is the leading cause of death worldwide, and in the United States alone, CVD causes nearly 840,000 deaths annually. Using functional magnetic resonance imaging (fMRI), a tool to assess brain activity, researchers have identified some brain-behavior connections and predicted several self-management behaviors. The purpose of this study was to examine the sample characteristics of individuals with CVD who participated in fMRI studies. Methods: A literature search was conducted in PubMed, CINAHL, and Scopus. No date or language restrictions were applied and research methodology filters were used. In October 2017, 1659 titles and abstracts were identified. Inclusion criteria were: (1) utilized an empirical study design, (2) used fMRI to assess brain activity, and (3) focused on patients with CVD-related chronic illness. Articles were excluded if they: were theory or opinion articles, focused on mental or neuropathic illness, included non-human samples, or were not written in English. After duplicates were removed (230), 1,429 titles and abstracts were reviewed based on inclusion criteria; 1,243 abstracts were then excluded. A total of 186 studies were reviewed in their entirety; after additional review, 142 were further excluded for not meeting the inclusion criteria. Forty-four articles met criteria and were included in the final review. An evidence table was created to capture the demographics of each study sample. Results: Ninety eight percent of the studies did not report the racial or ethnic composition of their sample. Most studies (66%) contained more men than women. Mean age ranged from 38 to 78 years; 77% reported mean age ≥50 years. The most frequently studied CVD was stroke (86%), while hypertension was studied the least (2%). Conclusion: Understanding brain-behavior relationships can help researchers and practitioners tailor interventions to meet specific patient needs. These findings suggest that additional studies are needed that focus on populations historically underrepresented in fMRI research. Researchers should thoughtfully consider diversity and purposefully sample groups by including individuals that are: women, from diverse backgrounds, younger, and diagnosed with a variety of CVD-related illnesses. Identifying and addressing these gaps by studying more representative samples will help healthcare providers reduce disparities and tailor interventions for all CVD populations.

Synergistic Effect of Combined Mirror Therapy on Upper Extremity in Patients With Stroke: A Systematic Review and Meta-Analysis

Background: There is an increasing trend for researchers to combine mirror therapy with another rehabilitation therapy when treating the upper extremity of patients with stroke.

Objective: To evaluate the synergistic effect of combined mirror therapy (MT) on the upper extremity in patients with stroke and to judge efficacies of four combined mirror therapy subgroups [EMGBF group: electromyographic biofeedback (EMGBF) + MT; MG group: mesh glove (MG) + MT; AT group: acupuncture (AT) + MT; ES group: EMG-triggered electrical stimulation (ES) + MT].

Methods: CNKI, Wan Fang, VIP, Web of Science, ScienceDirect, PubMed, OVID LWW, and Cochrane were used. We searched these databases for randomized controlled trials published from January 2013 to August 2019, which presented results of combining mirror therapy with other rehabilitation therapies. Quality assessments were performed using the Cochrane Handbook criteria in order to accurately review interventions. The primary outcomes were measured by the Fugl–Meyer Assessment—upper extremity (FMA-UE).

Results: Ten trials, with a total of 444 patients whose upper limb functions were damaged after stroke, were included in the meta-analysis. Compared with the control group, a remarkable effect of combined mirror therapy [all: weight mean difference in random effects model (WMD): 8.07, 95% confidence interval (CI) 5.87, 10.26] on functional recovery of the upper limb was detected. However, a high value of heterogeneity (χ2 = 20.09, df = 9; I² = 55%) was found. The subgroup analysis (EMGBF group: WMD = 8.95, 95% CI 6.33, 11.58; ES group: WMD = 10.14, 95% CI: 5.67, 15.01) showed moderate improvement in functional recovery of the upper extremity in patients with stroke when mirror therapy was combined with conventional therapy. Furthermore, no difference in efficacy on upper extremity in patients with stroke was observed between the EMGBF group and the ES group.

Conclusion: Despite the heterogeneity, the results indicate that combining mirror therapy with another rehabilitation therapy on the upper extremity in patients with stroke is better than single rehabilitation therapy. However, more randomized controlled clinical trials and larger sample sizes are required for an in-depth meta-analysis.

Acupuncture for poststroke hemiplegia focusing on cerebral bilateral connections: study protocol for a randomised controlled neuroimaging trial

INTRODUCTION

Acupuncture is safe and effective for improving the motor function of poststroke hemiplegic patients, but there still exists a certain gap between clinical practice and understanding its neural mechanisms. The cerebral functional reconstruction after unilateral motor pathway injury exhibits a bilateral tendency, however current studies seldom pay attention to it. Hence, based on cerebral bilateral connections, the underlying mechanism of acupuncture in stroke rehabilitation remains an area for further research. The results of this study will increase our understanding of acupuncture-induced motor recovery in patients who had suffered a stroke and demonstrate the differences in brain response and clinical assessments.

METHODS AND ANALYSIS

This is a single-centre, randomised controlled, paralleled neuroimaging trial, with patients and outcome assessors blinded. Thirty patients who had a stroke with motor dysfunction meeting the inclusion criteria will be randomly assigned (2:1) to receive either 10 sessions true or sham acupoints treatments (five sessions per week for 2 weeks). All the participants will receive conventional standard medical care and rehabilitation. Motor function assessments and neuroimaging scanning will be conducted before and after the entire acupuncture treatment. The clinical and neuroimaging data will be analysed, respectively. The voxel-mirrored homotopic connectivity will be the primary outcome and the primary effect indicator. The secondary outcomes comprise clinical evaluations and neuroimaging assessments, which include Fugl-Meyer Assessment, the National Institutes of Health Stroke Scale, fractional anisotropy and gray matter volume. The Needle Sensation Assessment Scale is an additional outcome. The correlation analysis will be explored between the neuroimaging indicators, clinical motor assessments and needle sensation.

ETHICS AND DISSEMINATION

The protocol has been approved by the ethics committee of Dongzhimen Hospital affiliated to Beijing University of Chinese Medicine (DZMEC-KY-2018-04). The results of the neuroimaging trial will be disseminated through peer-reviewed publications and conferences.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trials Registry (ChiCTR 1800016263).

Somatosensory Stimulation With XNKQ Acupuncture Modulates Functional Connectivity of Motor Areas

Xingnao Kaiqiao (XNKQ) acupuncture is an acupuncture technique used for stroke patients. In 24 healthy volunteers, we applied this complex acupuncture intervention, which consists of a manual needle-stimulation on five acupuncture points (DU26 unilaterally, PC6, and SP6 bilaterally). XNKQ was compared to three control conditions: (1) insertion of needles on the XNKQ acupuncture points without stimulation, (2) manual needle-stimulation on five nearby non-acupuncture points, and (3) insertion of needles on the non-acupuncture points without stimulation. In a within-subject design, we investigated functional connectivity changes in resting-state functional magnetic resonance imaging (fMRI) by means of the data-driven eigenvector centrality (EC) approach. With a 2 × 2 factorial within-subjects design with two-factor stimulation (stimulation vs. non-stimulation) and location (acupuncture points vs. non-acupuncture points), we found decreased EC in the precuneus after needle-stimulation (stimulation<non-stimulation), whereas the factor location showed no statistically significant EC differences. XNKQ acupuncture compared with needle-stimulation on non-acupuncture points showed decreased EC primarily in subcortical structures such as the caudate nucleus, subthalamic nucleus, and red nucleus. Post-hoc seed-based analysis revealed that the decrease in EC was mainly driven by reduced temporal correlation to primary sensorimotor cortices. The comparison of XNKQ acupuncture with the other two (non-stimulation) interventions showed no significant differences in EC. Our findings support the importance of the stimulation component of the acupuncture intervention and hint toward the modulation of functional connectivity by XNKQ acupuncture, especially in areas involved in motor function. As a next step, similar mechanisms should be validated in stroke patients suffering from motor deficits.

ClinicalTrials.gov ID: NCT02453906

Lateralisation of Cerebral Response to Active Acupuncture in Patients with Unilateral Ischaemic Stroke: An Fmri Study

Objective

Acupuncture is beneficial in treating stroke neuropsychiatric symptoms. The present study aimed to identify functional brain response to active acupuncture in patients with unilateral ischaemic stroke using functional MRI (fMRI).

Methods

A total of 10 patients aged 47–65 years with left hemispheric ischaemic stroke received single-session manual acupuncture at the TE5 point of the affected (right) forearm. A 6-min tactile control procedure in which an acupuncture needle tip was alternately touched and removed from the skin at the acupuncture point for 30 s each was performed first, followed by active acupuncture in a blocking paradigm consisting of six 30-s twist blocks of rotation interspersed between six 30-s blocks of rest. A whole brain scan was simultaneously conducted on a 3.0-T imager. Activated and deactivated brain regions during tactile stimulation and active acupuncture relative to rest were obtained via group analysis.

Results

Compared to tactile stimulation, needling with twist manipulation modulated many more widespread brain areas. All the brain areas activated and deactivated by active acupuncture relative to tactile stimulation were distributed in the primary sensorimotor and medial frontal cortex of the unaffected, but not the affected hemisphere.

Conclusions

Active acupuncture results in lateralisation of functional cerebral response to the contralateral unaffected hemisphere in patients with unilateral stroke. This lateralisation may represent an effect of acupuncture in enhancing a compensatory process by redistributing functions into the intact cortex, particularly in the unaffected hemisphere.

The quality of reporting of randomized controlled trials of electroacupuncture for stroke

Background

Electroacupuncture (EA), as an extension technique of acupuncture based on traditional acupuncture combined with modern electrotherapy, is commonly used for stroke in clinical treatment and researches. However, there is still a lack of enough evidence to recommend the routine use of EA for stroke. This study is aimed at evaluating the quality of reporting of randomized controlled trials (RCTs) on EA for stroke.

Methods

RCTs on EA for stroke were evaluated by using CONSORT guidelines and STRICTA guidelines. Microsoft Excel 2010 and the R software were used for descriptive statistics analyses.

Results

Seventy studies involving 5468 stroke patients were identified. The CONSORT scores ranged from 16.2 to 67.6% and STRICTA scores from 29.4 to 82.4%. The central items in CONSORT as eligibility criterion, sample size calculation, primary outcome, method of randomization sequence generation, allocation concealment, implementation of randomization, description of blinding, and detailed statistical methods were reported in 100, 6, 68, 37, 14, 10, 16, and 97% of trials, respectively. The reporting of items in STRICTA as acupuncture rationale was 1a (91%), 1b (86%) and 1c 0%; needling details 2a (33%), 2b (97%), 2c (29%), 2d (64%), 2e (100%), 2f (55%) and 2 g (66%); treatment regimen 3a (69%) and 3b (100%); other components of treatment 4a (86%) and 4b (13%); practitioner background item 5 (16%); control intervention(s) 6a (93%) and 6b (10%).

Conclusions

The quality of reporting of RCTs on EA for stroke was generally moderate. The reporting quality needs further improvement.

Acupuncture for stroke rehabilitation

BACKGROUND

Stroke is the second most common cause of death in the world and in China it has now become the main cause of death. It is also a main cause of adult disability and dependency. Acupuncture for stroke has been used in China for hundreds of years and is increasingly practiced in some Western countries. This is an update of the Cochrane review originally published in 2006 .

OBJECTIVES

To determine the efficacy and safety of acupuncture therapy in people with subacute and chronic stroke. We intended to test the following hypotheses: 1) acupuncture can reduce the risk of death or dependency in people with subacute and chronic stroke at the end of treatment and at follow-up; 2) acupuncture can improve neurological deficit and quality of life after treatment and at the end of follow-up; 3) acupuncture can reduce the number of people requiring institutional care; and 4) acupuncture is not associated with any intolerable adverse effects.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (June 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane Library 2015, Issue 7), MEDLINE (1966 to July 2015, Ovid), EMBASE (1980 to July 2015, Ovid), CINAHL (1982 to July 2015, EBSCO), and AMED (1985 to July 2015, Ovid). We also searched the following four Chinese medical databases: China Biological Medicine Database (July 2015); Chinese Science and Technique Journals Database (July 2015); China National Infrastructure (July 2015), and Wan Fang database (July 2015).

SELECTION CRITERIA

Truly randomised unconfounded clinical trials among people with ischaemic or haemorrhagic stroke, in the subacute or chronic stage, comparing acupuncture involving needling with placebo acupuncture, sham acupuncture, or no acupuncture.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed quality, extracted and cross-checked the data.

MAIN RESULTS

We included 31 trials with a total of 2257 participants in the subacute or chronic stages of stroke. The methodological quality of most of the included trials was not high. The quality of evidence for the main outcomes was low or very low based on the assessment by the system of Grades of Recommendation, Assessment, Development and Evaluation (GRADE).Two trials compared real acupuncture plus baseline treatment with sham acupuncture plus baseline treatment. There was no evidence of differences in the changes of motor function and quality of life between real acupuncture and sham acupuncture for people with stroke in the convalescent stage.Twenty-nine trials compared acupuncture plus baseline treatment versus baseline treatment alone. Compared with no acupuncture, for people with stroke in the convalescent phase, acupuncture had beneficial effects on the improvement of dependency (activity of daily living) measured by Barthel Index (nine trials, 616 participants; mean difference (MD) 9.19, 95% confidence interval (CI) 4.34 to 14.05; GRADE very low), global neurological deficiency (seven trials, 543 participants; odds ratio (OR) 3.89, 95% CI 1.78 to 8.49; GRADE low), and specific neurological impairments including motor function measured by Fugl-Meyer Assessment (four trials, 245 participants; MD 6.16, 95% CI 4.20 to 8.11; GRADE low), cognitive function measured by the Mini-Mental State Examination (five trials, 278 participants; MD 2.54, 95% CI 0.03 to 5.05; GRADE very low), depression measured by the Hamilton Depression Scale (six trials, 552 participants; MD -2.58, 95% CI -3.28 to -1.87; GRADE very low), swallowing function measured by drinking test (two trials, 200 participants; MD -1.11, 95% CI -2.08 to -0.14; GRADE very low), and pain measured by the Visual Analogue Scale (two trials, 118 participants; MD -2.88, 95% CI -3.68 to -2.09; GRADE low). Sickness caused by acupuncture and intolerance of pain at acupoints were reported in a few participants with stroke in the acupuncture groups. No data on death, the proportion of people requiring institutional care or requiring extensive family support, and all-cause mortality were available in all included trials.

AUTHORS' CONCLUSIONS

From the available evidence, acupuncture may have beneficial effects on improving dependency, global neurological deficiency, and some specific neurological impairments for people with stroke in the convalescent stage, with no obvious serious adverse events. However, most included trials were of inadequate quality and size. There is, therefore, inadequate evidence to draw any conclusions about its routine use. Rigorously designed, randomised, multi-centre, large sample trials of acupuncture for stroke are needed to further assess its effects.

The Status of the Quality Control in Acupuncture-Neuroimaging Studies

Using neuroimaging techniques to explore the central mechanism of acupuncture gains increasing attention, but the quality control of acupuncture-neuroimaging study remains to be improved. We searched the PubMed Database during 1995 to 2014. The original English articles with neuroimaging scan performed on human beings were included. The data involved quality control including the author, sample size, characteristics of the participant, neuroimaging technology, and acupuncture intervention were extracted and analyzed. The rigorous inclusion and exclusion criteria are important guaranty for the participants' homogeneity. The standard operation process of acupuncture and the stricter requirement for acupuncturist play significant role in quality control. More attention should be paid to the quality control in future studies to improve the reproducibility and reliability of the acupuncture-neuroimaging studies.

[Effectiveness of acupuncture in spasticity of the post-stroke patient. Systematic review]

OBJECTIVE

To determine the effectiveness of acupuncture for reducing spasticity in post-stroke patients.

DESIGN

Literature review.

DATA SOURCE

The literature search was performed using scientific databases from January 2000 to January 2013.

SELECTION OF STUDIES

Out of the 110 studies that were found, nine random and controlled trials were included. Inclusion criteria were based on clinical trials in which participants were over 18 years old, who were suffering with post-stroke spasticity, and one of the experimental groups was treated with acupuncture.

DATA EXTRACTION

The variables were the passive resistance to stretching of the affected limb, and the degree of personal dependence. The variables were assessed by the Modified Ashworth Scale and Barthel Index.

METHODS

The search was performed in the PUBMED, COCHRANE Library, PEDro, Dialnet, CSIC, CINAHL, databases. Search terms included the combination of keywords "acupuncture"; "muscle spasticity"; "stroke".

RESULTS

Passive resistance to stretching, the degree of personal dependence, and motor function of the affected limb showed statistically significant improvements in at least one study included; however, these improvements are not clinically relevant changes. Passive resistance improved in the elbow, ankle, knee, and wrist. An increased joint range was observed, except for the elbow, forearm, and thumb. Improved of the patient dependency was also observed.

CONCLUSIONS

Although improvements relative to the reduction of spasticity are shown, the results have failed to demonstrate the effectiveness of the technique for this ailment. It would take a greater number of studies to calculate the size of the reported effects with homogeneous procedures in the design as well as in the duration, frequency, and measurement tools.

Using acupoint-to-acupoint penetrative needling to treat post-stroke spastic paralysis: a clinical progress review

OBJECTIVE

To determine the characteristics and advantages of acupoint-to-acupoint penetrative needling (AAPN) treatment for post-stroke spastic paralysis (PSSP) to improve the clinical outcomes of this disease in the future.

METHODS

Randomized, controlled trials of PSSP patients receiving AAPN treatment were searched from MEDLINE, EMBASE, and China National Knowledge Infrastructure Database between January 2006 and June 2013. Key words included: clinic or clinical, acupuncture, needling, acupoint-to-acupoint, penetrative or penetration or penetrating, stroke or apoplexy or cerebral infarction or cerebral hemorrhage, spastic paralysis or spasticity or palsy, and hypermyotonia. Language was limited to English and Chinese. Case series reports, review articles, and, animal studies were excluded.

RESULTS

AAPN showed better clinical results on PSSP than other acupuncture treatments, especially when combined with adjunct therapies such as electroacupuncture, bloodletting, and rehabilitation. The greatest benefit was achieved with rehabilitation combined with penetration from Yang-channel acupoints to Yin-channel acupoints in the upper limbs, and from Yin-channel acupoints to Yang-channel acupoints in the lower limbs with a reinforcing maneuver.

CONCLUSION

AAPN is an effective treatment for PSSP, and it can accelerate and enhance functional repair of PSSP patients.

Functional Brain Correlates of Upper Limb Spasticity and Its Mitigation following Rehabilitation in Chronic Stroke Survivors

Background. Arm spasticity is a challenge in the care of chronic stroke survivors with motor deficits. In order to advance spasticity treatments, a better understanding of the mechanism of spasticity-related neuroplasticity is needed. Objective. To investigate brain function correlates of spasticity in chronic stroke and to identify specific regional functional brain changes related to rehabilitation-induced mitigation of spasticity. Methods. 23 stroke survivors (>6 months) were treated with an arm motor learning and spasticity therapy (5 d/wk for 12 weeks). Outcome measures included Modified Ashworth scale, sensory tests, and functional magnetic resonance imaging (fMRI) for wrist and hand movement. Results. First, at baseline, greater spasticity correlated with poorer motor function (P = 0.001) and greater sensory deficits (P = 0.003). Second, rehabilitation produced improvement in upper limb spasticity and motor function (P < 0.0001). Third, at baseline, greater spasticity correlated with higher fMRI activation in the ipsilesional thalamus (rho = 0.49, P = 0.03). Fourth, following rehabilitation, greater mitigation of spasticity correlated with enhanced fMRI activation in the contralesional primary motor (r = -0.755, P = 0.003), premotor (r = -0.565, P = 0.04), primary sensory (r = -0.614, P = 0.03), and associative sensory (r = -0.597, P = 0.03) regions while controlling for changes in motor function. Conclusions. Contralesional motor regions may contribute to restoring control of muscle tone in chronic stroke.

Modulatory effect of acupuncture at Waiguan (TE5) on the functional connectivity of the central nervous system of patients with ischemic stroke in the left basal ganglia

Objective

To study the influence of acupuncture at Waiguan (TE5) on the functional connectivity of the central nervous system of patients with ischemic stroke.

Methods

Twenty-four patients with ischemic stroke in the left basal ganglia were randomized based on gender to receive TE5 acupuncture (n = 12) or nonacupoint acupuncture (n = 12). Each group underwent sham acupuncture and then verum acupuncture while being scanned with functional magnetic resonance imaging. Six regions of interest (ROI) were defined, including bilateral motor, somatosensory, and bilateral basal ganglia areas. The functional connectivity between these ROIs and all voxels of the brain was analyzed in Analysis of Functional NeuroImages(AFNI) to explore the differences between verum acupuncture and sham acupuncture at TE5 and between TE5 acupuncture and nonacupoint acupuncture. The participants were blinded to the allocation.

Result

The effect of acupuncture on six seed-associated networks was explored. The result demonstrated that acupuncture at Waiguan (TE5) can regulate the sensorimotor network of the ipsilesional hemisphere, stimulate the contralesional sensorimotor network, increase cooperation of bilateral sensorimotor networks, and change the synchronization between the cerebellum and cerebrum. Furthermore, a lot of differences of effect existed between verum acupuncture and sham acupuncture at TE5, but there was little difference between TE5 acupuncture and nonacupoint acupuncture.

Conclusion

The modulation of synchronizations between different regions within different brain networks might be the mechanism of acupuncture at Waiguan (TE5). Stimulation of the contralesional sensorimotor network and increase of cooperation of bilateral hemispheres imply a compensatory effect of the intact hemisphere, whereas changes in synchronization might influence the sensorimotor function of the affected side of the body.

Trial Registration

Chinese Clinical Trial Registry ChiCTR-ONRC-08000255

Prolonged repeated acupuncture stimulation induces habituation effects in pain-related brain areas: an FMRI study

Most previous studies of brain responses to acupuncture were designed to investigate the acupuncture instant effect while the cumulative effect that should be more important in clinical practice has seldom been discussed. In this study, the neural basis of the acupuncture cumulative effect was analyzed. For this experiment, forty healthy volunteers were recruited, in which more than 40 minutes of repeated acupuncture stimulation was implemented at acupoint Zhusanli (ST36). Three runs of acupuncture fMRI datasets were acquired, with each run consisting of two blocks of acupuncture stimulation. Besides general linear model (GLM) analysis, the cumulative effects of acupuncture were analyzed with analysis of covariance (ANCOVA) to find the association between the brain response and the cumulative duration of acupuncture stimulation in each stimulation block. The experimental results showed that the brain response in the initial stage was the strongest although the brain response to acupuncture was time-variant. In particular, the brain areas that were activated in the first block and the brain areas that demonstrated cumulative effects in the course of repeated acupuncture stimulation overlapped in the pain-related areas, including the bilateral middle cingulate cortex, the bilateral paracentral lobule, the SII, and the right thalamus. Furthermore, the cumulative effects demonstrated bimodal characteristics, i.e. the brain response was positive at the beginning, and became negative at the end. It was suggested that the cumulative effect of repeated acupuncture stimulation was consistent with the characteristic of habituation effects. This finding may explain the neurophysiologic mechanism underlying acupuncture analgesia.

Non-pharmaceutical therapies for stroke: mechanisms and clinical implications

Stroke is deemed a worldwide leading cause of neurological disability and death, however, there is currently no promising pharmacotherapy for acute ischemic stroke aside from intravenous or intra-arterial thrombolysis. Yet because of the narrow therapeutic time window involved, thrombolytic application is very restricted in clinical settings. Accumulating data suggest that non-pharmaceutical therapies for stroke might provide new opportunities for stroke treatment. Here we review recent research progress in the mechanisms and clinical implications of non-pharmaceutical therapies, mainly including neuroprotective approaches such as hypothermia, ischemic/hypoxic conditioning, acupuncture, medical gases and transcranial laser therapy. In addition, we briefly summarize mechanical endovascular recanalization devices and recovery devices for the treatment of the chronic phase of stroke and discuss the relative merits of these devices.

The possible role of stem cells in acupuncture treatment for neurodegenerative diseases: a literature review of basic studies

This review reports on recent findings concerning the effects of acupuncture and electroacupuncture (EA) on stem cell mobilization and differentiation, in particular with regard to neurogenesis. Traditional Chinese acupuncture has a history of over 2,500 years and is becoming more popular worldwide. Evidence has demonstrated that acupuncture may be of benefit in stroke rehabilitation, parkinsonism, dementia, and depression. This article reviews recent studies concerning the effects of acupuncture/EA on stem cell mobilization and on progenitor cell proliferation in the CNS. The reviewed evidence indicates that acupuncture/EA has beneficial effects in several neurodegenerative diseases, and it may prove to be a nondrug method for mobilizing stem cells in the CNS.

Acupuncture Enhances Effective Connectivity between Cerebellum and Primary Sensorimotor Cortex in Patients with Stable Recovery Stroke

Recent neuroimaging studies have demonstrated that stimulation of acupuncture at motor-implicated acupoints modulates activities of brain areas relevant to the processing of motor functions. This study aims to investigate acupuncture-induced changes in effective connectivity among motor areas in hemiparetic stroke patients by using the multivariate Granger causal analysis. A total of 9 stable recovery stroke patients and 8 healthy controls were recruited and underwent three runs of fMRI scan: passive finger movements and resting state before and after manual acupuncture stimuli. Stroke patients showed significantly attenuated effective connectivity between cortical and subcortical areas during passive motor task, which indicates inefficient information transmissions between cortical and subcortical motor-related regions. Acupuncture at motor-implicated acupoints showed specific modulations of motor-related network in stroke patients relative to healthy control subjects. This specific modulation enhanced bidirectionally effective connectivity between the cerebellum and primary sensorimotor cortex in stroke patients, which may compensate for the attenuated effective connectivity between cortical and subcortical areas during passive motor task and, consequently, contribute to improvement of movement coordination and motor learning in subacute stroke patients. Our results suggested that further efficacy studies of acupuncture in motor recovery can focus on the improvement of movement coordination and motor learning during motor rehabilitation.

Acupuncture modulates the functional connectivity of the default mode network in stroke patients

Abundant evidence from previous fMRI studies on acupuncture has revealed significant modulatory effects at widespread brain regions. However, few reports on the modulation to the default mode network (DMN) of stroke patients have been investigated in the field of acupuncture. To study the modulatory effects of acupuncture on the DMN of stroke patients, eight right hemispheric infarction and stable ischemic stroke patients and ten healthy subjects were recruited to undergo resting state fMRI scanning before and after acupuncture stimulation. Functional connectivity analysis was applied with the bilateral posterior cingulate cortices chosen as the seed regions. The main finding demonstrated that the interregional interactions between the ACC and PCC especially enhanced after acupuncture at GB34 in stroke patients, compared with healthy controls. The results indicated that the possible mechanisms of the modulatory effects of acupuncture on the DMN of stroke patients could be interpreted in terms of cognitive ability and motor function recovery.

Selection of acupoints for managing upper-extremity spasticity in chronic stroke patients

BACKGROUND

This study investigated the clinical efficacy of electroacupuncture (EA) in inhibiting upper-extremity spasticity in chronic stroke patients, and also in mapping a unique preliminary acupoint-selection protocol.

METHODS

Fifteen patients were divided into two groups: patients in the control group (n=6) received minimal acupuncture (MA), and those in the experimental group (n=9) received EA. Four acupoints, which include Neiguan (PC6), Shaohai (HT3), Zeqian (Ex-UE, A32), and Shounizhu (EX-UE), were treated near the motor points of the muscles for elbow flexion, forearm pronation, and finger flexion. Both groups were treated for twelve sessions, 20 minutes per session, for 6 weeks (two sessions per week). The outcome measures in this study included angle of muscle reaction (R1), passive range of motion (R2), and dynamic component (R2-R1).

RESULTS

In the experimental group, the R2-R1 of the elbow joint was significantly decreased at 1 (P=0.0079), 3 (P=0.0013), and 6 weeks (P=0.0149) after treatment compared with pretreatment levels (P<0.05). The between-group difference in the R2-R1 of the elbow joint after the 6-week treatment was statistically significant.

CONCLUSION

Combining the 6-week EA and standard rehabilitation treatment reduced the spasticity of the elbow for chronic stroke survivors. However, no significant effect was observed in the spasticity of the wrist joints. The choice of acupoints and the frequency of EA have to be taken into account to achieve a positive treatment effect. The correlation between acupoints and motor points provides a model of acupoint selection to improve spasticity.

Upper limb rehabilitation following stroke: current evidence and future perspectives

Stroke is a leading cause of disability worldwide, with its risk increasing with age. Upper limb hemiparesis is common and associated with persistent impairments and associated disabilities. Older stroke populations often suffer multiple comorbidities and restoring independence is complex. Recovery of upper limb function can be crucial for individuals to return to independent living and to participate in community life. This review describes upper limb recovery post-stroke, and some of the new therapeutic approaches available to promote recovery. Technologies (including virtual reality and telehealth) offer the opportunity for more home-based therapies, longer programs and greater access to rehabilitation for older individuals. However, the trials continue to exclude older individuals, so acceptability is poorly understood. Upper limb rehabilitation remains a research frontier, which has been energized by new technologies, but is grounded by the basic need to find ways to allow older individuals to recover independence. This paper aims to review the applicability and generalizability of current research to the older stoke survivor. Future research priorities need to be tailored to consider the older mean age of individuals in stroke rehabilitation.

Acupuncture in subacute stroke: no benefits detected

BACKGROUND

There is debate concerning the effect of acupuncture on rehabilitation following stroke, with key reviews unable to find evidence of benefit. This lack of evidence may be due to poor study design, small sample size, and insufficient theoretical background.

OBJECTIVE

The present study was designed to determine whether acupuncture combined with conventional physical therapy improves motor function and activities of daily living in patients with subacute stroke compared with conventional physical therapy alone.

DESIGN

A multicenter, single-blinded, randomized study was conducted.

SETTING

Four rehabilitation centers in the Jiangsu province of China participated in this study.

PATIENTS

One hundred eighty-eight patients with subacute stroke admitted to the hospital were randomized into an acupuncture group and a conventional rehabilitation group.

INTERVENTIONS

A combination of body and scalp acupuncture was used for 3 months in the acupuncture group. All patients underwent conventional stroke rehabilitation.

MEASUREMENTS

The Fugl-Meyer Assessment (FMA) and Barthel Index (BI) were performed at baseline and at 1, 3, and 6 months after inclusion in the study.

RESULTS

No statistically significant differences were found at baseline between the groups. No statistically significant differences were found between the groups using the FMA motor scores and the BI scores at baseline or at 1, 3, or 6 months. Significant improvements were found in each group following treatment.

CONCLUSIONS

In patients with subacute stroke, the addition of body and scalp acupuncture to a regimen of conventional physical therapy does not result in further improvement in either motor function or ADL beyond the effect of conventional physical therapy alone.

Specific neuroprotective effects of manual stimulation of real acupoints versus non-acupoints in rats after middle cerebral artery occlusion

The objective of this study was to investigate the effectiveness and specific effects of acupuncture on ischemic-induced damage in rats after permanent middle cerebral artery occlusion. Cerebral ischemia was induced by middle cerebral artery occlusion in male Wistar rats. The rats were divided into the following 4 groups: normal controls, ischemic, real acupuncture-treated (Shuigou, DU26), and non-acupoint-treated groups. On the third postoperative day, neurological deficit scores, cerebral blood flow, infarction volume, and neuronal cell death counts were measured. In the real acupuncture-treated group, the neurological deficit scores and cerebral blood flow were improved (p < 0.05) and the infarction volume and neuronal cell death counts were reduced (p < 0.01) compared to the ischemic and non-acupoint-treated groups. The present study demonstrated that real acupuncture was effective against focal ischemia-induced damage in rats after middle cerebral artery occlusion, and the effects were specifically related to the right needling location.

Development of a disease-specific health-related quality of life questionnaire for patients with post-stroke spasticity

OBJECTIVE

This study was designed to develop a disease-specific health-related quality of life (HR-QOL) measure for patients with post-stroke spasticity.

METHODS

Based on responses from 20 patients with post-stroke spasticity and an extensive literature search, items potentially used to measure these patients' recovery status were identified and the Apoplexy Spastic-Paralysis Questionnaire (ASPQ) was formed. A sample of 106 patients was then tested twice using the ASPQ, the Self-rating Depression Scale (SDS) and the Stroke-specific Quality of Life (SS-QOL). Clinicians also examined all the patients using the Ashworth Scale (AS). Internal reliability was assessed using Cronbach's coefficient alpha, while construct validity was determined using principal component analysis (PCA). Empirical validity was evaluated between patients with depression and those without depression by single factor analysis. Sensitivity was examined by calculating the Spearman correlation coefficient between the changes in scores of the ASPQ, the AS and the SS-QOL.

RESULTS

The ASPQ had adequate internal consistency reliability (alpha = 0.874) and sensitivity, with significant correlations between the changes in scores of the AS, the SS-QOL and the ASPQ, with three domains. In a construct validity test, six factors were extracted; the overall variance explained by all factors was 72.6%. For empirical validity, mean values of 19 items and 3 domains were all higher in the depressive patients than in the non-depressive patients.

CONCLUSION

The ASPQ is a reliable and valid self-rating scale for measuring the HR-QOL in patients with post-stroke spasticity.

Acupuncture therapy for stroke patients

Acupuncture is one of the most important parts of Traditional Chinese Medicine, has been used for more than 3000 years as prevention and treatment for various diseases in China as well as in adjacent regions, and is widely accepted in western countries in recent years. More and more clinical trials revealed that acupuncture shows positive effect in stroke, not only as a complementary and alternative medicine for poststroke rehabilitation but also as a preventive strategy which could induce cerebral ischemic tolerance, especially when combined with modern electrotherapy. Acupuncture has some unique characteristics, which include acupoint specificity and parameter-dependent effect. It also involves complicated mechanism to exert the beneficial effect on stroke. Series of clinical trials have shown that acupuncture primarily regulates the release of neurochemicals, hemorheology, cerebral microcirculation, metabolism, neuronal activity, and the function of specific brain region. Animal studies showed that the effects of acupuncture therapy on stroke were possibly via inhibition of postischemic inflammatory reaction, stimulation of neurogenesis and angiogenesis, and influence on neural plasticity. Mechanisms for its preconditioning effect include activity enhancement of antioxidant, regulation of the endocannabinoid system, and inhibition of apoptosis. Although being controversial, acupuncture is a promising preventive and treatment strategy for stroke, but further high-quality clinical trials would be needed to provide more confirmative evidence.

Acupuncture regulates the glucose metabolism in cerebral functional regions in chronic stage ischemic stroke patients--a PET-CT cerebral functional imaging study

Background

Acupuncture has been applied to aid in the recovery of post-stroke patients, but its mechanism is unclear. This study aims to analyze the relationship between acupuncture and glucose metabolism in cerebral functional regions in post-stroke patients using ¹⁸ FDG PET-CT techniques. Forty-three ischemic stroke patients were randomly divided into 5 groups: the Waiguan (TE5) needling group, the TE5 sham needling group, the sham point needling group, the sham point sham needling group and the non-needling group. Cerebral functional images of all patients were then acquired using PET-CT scans and processed by SPM2 software.

Results

Compared with the non-needling group, sham needling at TE5 and needling/sham needling at the sham point did not activate cerebral areas. However, needling at TE5 resulted in the activation of Brodmann Area (BA) 30. Needling/sham needling at TE5 and needling at the sham point did not deactivate any cerebral areas, whereas sham needling at the sham point led to deactivation in BA6. Compared with sham needling at TE5, needling at TE5 activated BA13, 19 and 47 and did not deactivate any areas. Compared with needling at the sham point, needling at TE5 had no associated activation but a deactivating effect on BA9.

Conclusion

Needling at TE5 had a regulating effect on cerebral functional areas shown by PET-CT, and this may relate to its impact on the recovery of post-stroke patients.

Electroacupuncture Pretreatment as a Novel Avenue to Protect Brain against Ischemia and Reperfusion Injury

Electroacupuncture (EA) pretreatment is a recent observation which has been shown to induce ischemic tolerance mimicking the ischemic pretreatment, suggesting that EA pretreatment may be a promising preventive strategy for the patients with high risk of acute ischemia/reperfusion injury. It was first described in the brain, then in the heart where EA stimulation at acupoint prior to ischemia led to neuroprotection and myocardial protection and induced rapid and delayed ischemic tolerance. Then the optimal parameters and acupoint specificity of EA pretreatment to induce protective effect were proved. Many studies have shown that protective mechanisms of EA pretreatment may involve a series of regulatory molecular pathways including activity enhancement of antioxidant, regulation of the endocannabinoid system, involvement of beta-adrenergic receptor, and postreceptor signaling pathway, inhibition of apoptosis. Recently, the neuroprotective and cardioprotective effect of EA pretreatment had been demonstrated in patients undergoing craniocerebral tumor resection or heart valve replacement surgery. Thus, the purpose of this paper is to collect the evidence for the neuroprotective effect of EA pretreatment, to summarize the proposed protective mechanisms of EA pretreatment, and to discuss the possibility of EA pretreatment as a new preventive strategy for patients with high risk of ischemia in clinic.

Clinical effects of scalp electrical acupuncture in stroke: a sham-controlled randomized clinical trial

OBJECTIVES

The majority of individuals who survive a stroke are disabled because of persisting neurological impairments. The objective of this study was to evaluate the efficacy of subcutaneous electrical stimulation of the scalp in spontaneous functional recovery of patients with chronic ischemic stroke, by evaluating clinical, neurological, and functional findings.

SUBJECTS AND METHODS

Sixty-two (62) subjects who were at least 18 months postdiagnosis of ischemic stroke were randomized to receive 10 sessions of placebo or active low-frequency electrical stimulation (2/100 Hz) using subcutaneous acupuncture needles over the scalp. Functional and neurological evaluations were indexed by the Barthel, Rankin, and National Institutes of Health Stroke Scale (NIHSS).

RESULTS

Results show that there was a significant difference in functional improvement between the sham and active group as indexed by NIHSS scale. The active group had a larger functional improvement after 10 sessions of scalp electrical acupuncture. The other two functional scales (Rankin and Barthel) failed to show significant differences between the two treatment groups.

CONCLUSIONS

These results support further testing of scalp electrical acupuncture for the treatment of stroke as well further mechanistic studies to understand mechanisms associated with the observed improvement. Further studies need to consider longer follow-up assessments to investigate potential functional changes associated with electrical acupuncture.

Characterizing acupuncture stimuli using brain imaging with FMRI--a systematic review and meta-analysis of the literature

BACKGROUND

The mechanisms of action underlying acupuncture, including acupuncture point specificity, are not well understood. In the previous decade, an increasing number of studies have applied fMRI to investigate brain response to acupuncture stimulation. Our aim was to provide a systematic overview of acupuncture fMRI research considering the following aspects: 1) differences between verum and sham acupuncture, 2) differences due to various methods of acupuncture manipulation, 3) differences between patients and healthy volunteers, 4) differences between different acupuncture points.

METHODOLOGY/PRINCIPAL FINDINGS

We systematically searched English, Chinese, Korean and Japanese databases for literature published from the earliest available up until September 2009, without any language restrictions. We included all studies using fMRI to investigate the effect of acupuncture on the human brain (at least one group that received needle-based acupuncture). 779 papers were identified, 149 met the inclusion criteria for the descriptive analysis, and 34 were eligible for the meta-analyses. From a descriptive perspective, multiple studies reported that acupuncture modulates activity within specific brain areas, including somatosensory cortices, limbic system, basal ganglia, brain stem, and cerebellum. Meta-analyses for verum acupuncture stimuli confirmed brain activity within many of the regions mentioned above. Differences between verum and sham acupuncture were noted in brain response in middle cingulate, while some heterogeneity was noted for other regions depending on how such meta-analyses were performed, such as sensorimotor cortices, limbic regions, and cerebellum.

CONCLUSIONS

Brain response to acupuncture stimuli encompasses a broad network of regions consistent with not just somatosensory, but also affective and cognitive processing. While the results were heterogeneous, from a descriptive perspective most studies suggest that acupuncture can modulate the activity within specific brain areas, and the evidence based on meta-analyses confirmed some of these results. More high quality studies with more transparent methodology are needed to improve the consistency amongst different studies.

Neural acupuncture unit: a new concept for interpreting effects and mechanisms of acupuncture

When an acupuncture needle is inserted into a designated point on the body and mechanical or electrical stimulation is delivered, various neural and neuroactive components are activated. The collection of the activated neural and neuroactive components distributed in the skin, muscle, and connective tissues surrounding the inserted needle is defined as a neural acupuncture unit (NAU). The traditionally defined acupoints represent an anatomical landmark system that indicates local sites where NAUs may contain relatively dense and concentrated neural and neuroactive components, upon which acupuncture stimulation would elicit a more efficient therapeutic response. The NAU-based local mechanisms of biochemical and biophysical reactions play an important role in acupuncture-induced analgesia. Different properties of NAUs are associated with different components of needling sensation. There exist several central pathways to convey NAU-induced acupuncture signals, Electroacupuncture (EA) frequency-specific neurochemical effects are related to different peripheral and central pathways transmitting afferent signals from different frequency of NAU stimulation. More widespread and intense neuroimaging responses of brain regions to acupuncture may be a consequence of more efficient NAU stimulation modes. The introduction of the conception of NAU provides a new theoretical approach to interpreting effects and mechanisms of acupuncture in modern biomedical knowledge framework.