Acupuncture Efficacy on Ischemic Stroke Recovery

Electroacupuncture reduces inflammatory damage following cerebral ischemia-reperfusion by enhancing ABCA1-mediated efferocytosis in M2 microglia

Ischemic stroke (IS) is a severe cerebrovascular disease with high disability and mortality rates, where the inflammatory response is crucial to its progression and prognosis. Efferocytosis, the prompt removal of dead cells, can reduce excessive inflammation after IS injury. While electroacupuncture (EA) has been shown to decrease inflammation post-ischemia/reperfusion (I/R), its link to efferocytosis is unclear. Our research identified ATP-binding cassette transporter A1 (Abca1) as a key regulator of the engulfment process of efferocytosis after IS by analyzing public datasets and validating findings in a mouse model, revealing its close ties to IS progression. We demonstrated that EA can reduce neuronal cell death and excessive inflammation caused by I/R. Furthermore, EA treatment increased Abca1 expression, prevented microglia activation, promoted M2 microglia polarization, and enhanced their ability to phagocytose injured neurons in I/R mice. This suggests that EA's modulation of efferocytosis could be a potential mechanism for reducing cerebral I/R injury, making regulators of efferocytosis steps a promising therapeutic target for EA benefits.

Electroacupuncture pretreatment enhances the calcium efflux activity of Na+/Ca2+ exchanger to attenuate cerebral injury by PI3K/Akt-mediated NCX1 upregulation after focal cerebral ischaemia

Electroacupuncture pretreatment is considered as an optimal strategy for inducing cerebral ischaemic tolerance. However, the underlying neuroprotective mechanism of this approach has never been explored from the perspective of calcium homeostasis. Intracellular calcium overload is a key inducer of cascade neuronal injury in the early stage after cerebral ischaemia attack and the Na+/Ca2+ exchanger (NCX) is the main plasma membrane calcium extrusion pathway maintaining post-ischaemic calcium homeostasis. This study aims to investigate whether the regulation of NCX-mediated calcium transport contributes to the cerebroprotective effect of electroacupuncture pretreatment against ischaemic injury and to elucidate the underlying mechanisms involved in this process. Following five days of repeated electroacupuncture stimulation on Baihui (GV20), Neiguan (PC6), and Sanyinjiao (SP6) acupoints in rats, in vivo and in vitro models of cerebral ischaemia were induced through middle cerebral artery occlusion and oxygen/glucose deprivation (OGD), respectively. Firstly, we verified the neuroprotective effect of electroacupuncture pretreatment from the perspective of neurological score, infarct volume and neuronal apoptosis. Our findings from brain slice patch-clamp indicated that electroacupuncture pretreatment enhanced the Ca2+ efflux capacity of NCX after OGD. NCX1 expression in the ischaemic penumbra exhibited a consistent decline from 1 to 24 h in MCAO rats. Electroacupuncture pretreatment upregulated the expression of NCX1, especially at 24 h, and silencing NCX1 by short hairpin RNA (shRNA) administration reversed the protective effect of electroacupuncture pretreatment against cerebral ischaemic injury. Furthermore, we administered LY294002, a phosphatidylinositol 3 kinase (PI3K) inhibitor, prior to inducing ischaemia to investigate the upstream regulatory mechanism of electroacupuncture pretreatment on NCX1 expression. Electroacupuncture pretreatment activates PI3K/Akt pathway, leading to an increase in the expression of NCX1, which facilitates calcium extrusion and exerts a neuroprotective effect against cerebral ischaemia. These findings provided a novel insight into the prevention of ischemic stroke and other similar conditions characterized by brain ischaemia or hypoperfusion.

Bilateral effect of acupuncture on cerebrum and cerebellum in ischaemic stroke patients with hemiparesis: a randomised clinical and neuroimaging trial

BACKGROUND

Acupuncture involving the limb region may be effective for stroke rehabilitation clinically, but the visualised and explanatory evidence is limited. Our objectives were to assess the specific effects of acupuncture for ischaemic stroke (IS) patients with hemiparesis and investigate its therapy-driven modification in functional connectivity.

METHODS

IS patients were randomly assigned (2:1) to receive 10 sessions of hand-foot 12 needles acupuncture (HA, n=30) or non-acupoint (NA) acupuncture (n=16), enrolling gender-matched and age-matched healthy controls (HCs, n=34). The clinical outcomes were the improved Fugl-Meyer Assessment scores including upper and lower extremity (ΔFM, ΔFM-UE, ΔFM-LE). The neuroimaging outcome was voxel-mirrored homotopic connectivity (VMHC). Static and dynamic functional connectivity (sFC, DFC) analyses were used to study the neuroplasticity reorganisation.

RESULTS

46 ISs (mean(SD) age, 59.37 (11.36) years) and 34 HCs (mean(SD) age, 52.88 (9.69) years) were included in the per-protocol analysis of clinical and neuroimaging. In clinical, ΔFM scores were 5.00 in HA group and 2.50 in NA group, with a dual correlation between ΔFM and ΔVMHC (angular: r=0.696, p=0.000; cerebellum: r=-0.716, p=0.000) fitting the linear regression model (R2=0.828). In neuroimaging, ISs demonstrated decreased VMHC in bilateral postcentral gyrus and cerebellum (Gaussian random field, GRF corrected, voxel p<0.001, cluster p<0.05), which fitted the logistic regression model (AUC=0.8413, accuracy=0.7500). Following acupuncture, VMHC in bilateral superior frontal gyrus orbital part was increased with cerebro-cerebellar changes, involving higher sFC between ipsilesional superior frontal gyrus orbital part and the contralesional orbitofrontal cortex as well as cerebellum (GRF corrected, voxel p<0.001, cluster p<0.05). The coefficient of variation of VMHC was decreased in bilateral posterior cingulate gyrus (PPC) locally (GRF corrected, voxel p<0.001, cluster p<0.05), with integration states transforming into segregation states overall (p<0.05). There was no acupuncture-related adverse event.

CONCLUSIONS

The randomised clinical and neuroimaging trial demonstrated acupuncture could promote the motor recovery and modified cerebro-cerebellar VMHC via bilateral static and dynamic reorganisations for IS patients with hemiparesis.

Acupuncture improves neurological function and anti-inflammatory effect in patients with acute ischemic stroke: A double-blinded randomized controlled trial

BACKGROUND AND PURPOSE

Acupuncture exerts an anti-inflammatory effect and is recommended by the World Health Organization as a complementary therapy for stroke. This study investigated the improvement in neurological function outcome in acute-stage intervention of acute ischemic stroke (AIS), and the anti-inflammatory effect of early acupuncture.

METHODS

Fifty patients with AIS were randomly assigned to either a control group (CG, 25 patients, received sham acupuncture) or treatment group (TG, 25 patients, received acupuncture treatment). Acupuncture intervention was administered twice a week for a total of 8 sessions over 4 consecutive weeks. The primary outcome was the changes in the National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), and Barthel Index (BI) scores. The secondary outcome was the changes in serum inflammation-related biomarker levels.(ANAIS trial) RESULTS: A total of 35 patients (18 patients in the CG and 17 patients in the TG) completed the trial. The reduction in NIHSS scores was greater in the TG than in the CG between V2 (second assessment administered after acupuncture intervention) and V1 (first assessment administered before acupuncture intervention; 4.33 ± 1.91 vs. 2.68 ± 1.42, p = 0.005) and between V3 (third assessment administered 28 days after last acupuncture intervention) and V1 (6.00 ± 2.53 vs. 3.83 ± 2.31, p = 0.012). The increase in BI scores was greater in the TG than in the CG between V2 and V1 (28.89 ± 15.39 vs. 14.21 ± 19.38, p = 0.016) and between V3 and V1 (39.41 ± 20.98 vs. 25.00 ± 18.47, p = 0.038). Among participants with high inflammation, the increase in serum IL-12p70 level between V2 and V1 was greater in the TG than in the CG (0.20 ± 0.19 vs. -0.14 ± 0.30, pg/mL p = 0.006).

CONCLUSIONS

Acupuncture improved the neurological function of patients with AIS, and the relationship between acupuncture improving neurological function and anti-inflammatory effect needs further study. In addition, studies with larger sample sizes and longer follow-ups as well as multicenter clinical trials are expected in the future.

Bibliometric Analysis: Research Trends and Performances of Stroke on Acupuncture

Purpose

This study aimed to apply the bibliometric analysis to summarize acupuncture therapy for stroke, demonstrated and evaluated the trends, major research hotspots and frontier areas.

Materials and Methods

Articles on acupuncture for stroke were selected from the Web of Science Core Collection (WoSCC) from the inception of the database up until 2023. CiteSpace software was performed to conduct the collaborative analysis of networks of countries, institutions, authors and cited authors, journals and cited journals, cited references, keywords clustering and burstiness analysis.

Results

A total of 1141 articles were retrieved. China was the most productive country (851) and had the greatest centrality (0.43). Beijing Univ Chinese Med (86) contributed to the most publications. Chen LD (31) and Tao J (31) were the most prolific authors, of which all from Fujian Univ Tradit Chinese Med. Wu P (124) from Canadian College of Naturopathic Medicine, Canada, was the most cited author. Evidence-based Complementary and Alternative Medicine (89) was the most productive journal, while Stroke (744) was first cited journals. Stimulation, recovery, ischemic stroke, electroacupuncture, rehabilitation were the most high-frequency keywords. Future research in this area will pay more attention to the evaluation of the effectiveness of acupuncture therapeutics in treating stroke, conducting the clinical research on cognitive ability, quality of life and partial function of stroke patients, and basic research related to mechanisms.

Conclusion

The publications on acupuncture in stroke have shown major development, but the international cooperation for academic exchange among researchers and institutions remained to be strengthened to promote interdisciplinary and academic innovation. Furthermore, except for the molecular mechanism of acupuncture in treating functional rehabilitation of stroke, exploring the more high-quality clinical studies may become a key point based on the evidence-based medicine.

The immunomodulatory mechanism of acupuncture treatment for ischemic stroke: research progress, prospects, and future direction

Ischemic stroke (IS) is one of the leading causes of death and disability. Complicated mechanisms are involved in the pathogenesis of IS. Immunomodulatory mechanisms are crucial to IS. Acupuncture is a traditional non-drug treatment that has been extensively used to treat IS. The exploration of neuroimmune modulation will broaden the understanding of the mechanisms underlying acupuncture treatment. This review summarizes the immune response of immune cells, immune cytokines, and immune organs after an IS. The immunomodulatory mechanisms of acupuncture treatment on the central nervous system and peripheral immunity, as well as the factors that influence the effects of acupuncture treatment, were summarized. We suggest prospects and future directions for research on immunomodulatory mechanisms of acupuncture treatment for IS based on current progress, and we hope that these will provide inspiration for researchers. Additionally, acupuncture has shown favorable outcomes in the treatment of immune-based nervous system diseases, generating new directions for research on possible targets and treatments for immune-based nervous system diseases.

A bibliometric analysis of acupuncture for cerebral infarction from 1993 to 2023

Objective

This research aims to explore the trends and knowledge domain of acupuncture for cerebral infarction through bibliometrics.

Methods

Publications related to acupuncture for cerebral infarction were retrieved from the Web of Science core collection database from 1993 to December 31, 2023. A domain knowledge graph was then constructed using VOSviewer, CiteSpace, GraphPad Prism, and Scimago Graphica.

Results

The cumulative publication trend shows a steady increase over the years, with China being the most productive country. Notably, Europe exhibits significant close collaboration. Institutional cooperation is primarily observed among Chinese universities specializing in traditional Chinese medicine. Tao Jing is the most prolific author, with his highest number of publications is in "Stroke" journal, and Acupuncture Electro Therapeutics Research is the significant journal. Zhang SH is the most cited author, and Si QM is a prominent author in this field. Rehabilitation treatment after cerebral infarction emerges as a prevalent research focus, with nerve regeneration being a keyword. Long EZ's 1989 paper, published in the journal Stroke, holds significant importance. The prominent papers are Donnan et al. and Wu et al., which covers the following topics: "population-based study," "Baihui Acupoint," "memory deficits," "neurotrophic factor," and "randomized trial."

Conclusion

This bibliometric analysis of acupuncture for cerebral infarction offers insights into the Web of Science database, delineates a knowledge map of countries, authors, institutions, cited authors, keywords, cited references in the field of acupuncture for cerebral infarction, which has a momentous guiding significance for quickly and accurately positioning the key information in the field.

Electroacupuncture Ameliorates Neuronal Injury by NLRP3/ASC/Caspase-1 Mediated Pyroptosis in Cerebral Ischemia-Reperfusion

NLRP3/ASC/Caspase-1 mediated pyroptosis is one of the important causes of cerebral ischemia-reperfusion (I/R) injury. Electroacupuncture (EA) is widely used in clinical treatment of ischemic stroke. However, mechanism of EA on ischemic stroke remains unclear. Therefore, on basis of a previous work, this study used middle cerebral artery occlusion (MCAO) 2 h and then reperfusion 7 days in rats to simulate brain I/R process. EA with Bahui (GV20) and Zusanli (ST36) and VX-765 (a specific inhibitor of Caspase-1) was performed. In this study, we found that EA improved cerebral infarct size and neuronal damage, including ultrastructural injury, and ameliorated nitro/oxidative stress in cerebral I/R. Additionally, EA treatment significantly decreased ASC, Caspase-1, GSDMD, and IL-1β expression and VX-765 treatment significantly decreased NLRP3, Caspase-1, and IL-1β expression. This proved that EA can regulate NLRP3/ASC/Caspase-1 mediated pyroptosis, improve neuronal injury during cerebral I/R, and provide basic experimental data for clinical treatment.

Understanding the mechanism of acupuncture in acute cerebral infraction through a proteomic analysis: protocol for a prospective randomized controlled trial

Background

Acute cerebral infarction (ACI), being the predominant form of stroke, presents challenges in terms of the limited effectiveness of various treatments in improving the neurological function. Although acupuncture shows promise in addressing ACI, the availability of high-quality evidence regarding its efficacy, safety, and underlying mechanism remains insufficient. In this study, we design a multicenter, prospective, single-blind, randomized controlled trial with the aim of evaluating the efficacy and safety of acupuncture for ACI, making an attempt to unveil the molecular mechanisms by proteomic.

Methods

A total of 132 patients involving four hospitals will be randomized at a 1:1:1 ratio in the acupuncture group, control group, and sham acupuncture group. All the patients will receive basic treatment, and the patients in the acupuncture and sham acupuncture groups will also receive either acupuncture or sham acupuncture treatment, respectively, at six sessions each week for a 2 weeks period, followed by 3 months of follow-up. The primary outcome will be the change in the National Institute of Health Stroke Scale (NIHSS) scores after treatment. The secondary outcomes will include the Fugl-Meyer Assessment (FMA) scale scores and the Barthel Index (BI). Adverse events that occur during the trial will be documented. To discover differentially expressed proteins (DEPs) and their roles between the ACI subjects and healthy controls, we will also perform 4D-DIA quantitative proteomics analysis, and the DEPs will be confirmed by enzyme-linked immunosorbent assay (ELISA). This study was approved by the institutional review board of the First Teaching Hospital of Tianjin University of Traditional Chinese Medicine (TYLL2023043). Written informed consent from patients is required. This trial is registered in the Chinese Clinical Trial Registry (ChiCTR2300079204). Trial results will be published in a peer-reviewed academic journal.

Discussion

The results of this study will determine the preliminary efficacy and safety of acupuncture in ACI patients and whether the mechanism of this form of non-pharmacologic stimulation is mediated by a novel therapeutic target for neurorehabilitation through our proteomic analysis.

Clinical trial registration

https://www.chictr.org.cn, identifier ChiCTR2300079204.

Effect of Acupuncture vs Sham Acupuncture on Patients With Poststroke Motor Aphasia: A Randomized Clinical Trial

Importance

Motor aphasia is common among patients with stroke. Acupuncture is recommended as an alternative therapy for poststroke aphasia, but its efficacy remains uncertain.

Objective

To investigate the effects of acupuncture on language function, neurological function, and quality of life in patients with poststroke motor aphasia.

Design, Setting, and Participants

This multicenter, sham-controlled, randomized clinical trial was conducted in 3 tertiary hospitals in China from October 21, 2019, to November 13, 2021. Adult patients with poststroke motor aphasia were enrolled. Data analysis was performed from February to April 2023.

Interventions

Eligible participants were randomly allocated (1:1) to manual acupuncture (MA) or sham acupuncture (SA) groups. Both groups underwent language training and conventional treatments.

Main Outcomes and Measures

The primary outcomes were the aphasia quotient (AQ) of the Western Aphasia Battery (WAB) and scores on the Chinese Functional Communication Profile (CFCP) at 6 weeks. Secondary outcomes included WAB subitems, Boston Diagnostic Aphasia Examination, National Institutes of Health Stroke Scale, Stroke-Specific Quality of Life Scale, Stroke and Aphasia Quality of Life Scale-39, and Health Scale of Traditional Chinese Medicine scores at 6 weeks and 6 months after onset. All statistical analyses were performed according to the intention-to-treat principle.

Results

Among 252 randomized patients (198 men [78.6%]; mean [SD] age, 60.7 [7.5] years), 231 were included in the modified intention-to-treat analysis (115 in the MA group and 116 in the SA group). Compared with the SA group, the MA group had significant increases in AQ (difference, 7.99 points; 95% CI, 3.42-12.55 points; P = .001) and CFCP (difference, 23.51 points; 95% CI, 11.10-35.93 points; P < .001) scores at week 6 and showed significant improvements in AQ (difference, 10.34; 95% CI, 5.75-14.93; P < .001) and CFCP (difference, 27.43; 95% CI, 14.75-40.10; P < .001) scores at the end of follow-up.

Conclusions and Relevance

In this randomized clinical trial, patients with poststroke motor aphasia who received 6 weeks of MA compared with those who received SA demonstrated statistically significant improvements in language function, quality of life, and neurological impairment from week 6 of treatment to the end of follow-up at 6 months after onset.

Trial Registration

Chinese Clinical Trial Registry: ChiCTR1900026740.

Trends and hotspots related to traditional and modern approaches on acupuncture for stroke: A bibliometric and visualization analysis

BACKGROUND

Acupuncture role in stroke treatment and post-stroke rehabilitation has garnered significant attention. However, there is a noticeable gap in bibliometric studies on this topic. Additionally, the precision and comprehensive methodology of cluster analysis remain underexplored. This research sought to introduce an innovative cluster analysis technique (called follower-leading clustering algorithm, FLCA) to evaluate global publications and trends related to acupuncture for stroke in the recent decade.

METHODS

Publications pertaining to acupuncture for stroke from 2013 to 2022 were sourced from the Web of Science Core Collection. For the assessment of publication attributes-including contributing countries/regions (e.g., US states, provinces, and major cities in China) in comparison to others, institutions, departments, authors, journals, and keywords-we employed bibliometric visualization tools combined with the FLCA algorithm. The analysis findings, inclusive of present research status, prospective trends, and 3 influential articles, were presented through bibliometrics with visualizations.

RESULTS

We identified 1050 publications from 92 countries/regions. An initial gradual rise in publication numbers was observed until 2019, marking a pivotal juncture. Prominent contributors in research, based on criteria such as regions, institutions, departments, and authors, were Beijing (China), Beijing Univ Chinese Med (China), the Department of Rehabilitation Medicine, and Lidian Chen (Fujian). The journal "Evid.-based Complement Altern" emerged as the most productive. The FLCA algorithm was effectively employed for co-word and author collaboration analyses. Furthermore, we detail the prevailing research status, anticipated trends, and 3 standout articles via bibliometrics.

CONCLUSION

Acupuncture for stroke presents a vast research avenue. It is imperative for scholars from various global regions and institutions to transcend academic boundaries to foster dialogue and cooperation. For forthcoming bibliometric investigations, the application of the FLCA algorithm for cluster analysis is advocated.

Clinical Efficacy and Immune Effects of Acupuncture in Patients with Comorbid Chronic Pain and Major Depression Disorder: A Double-Blinded, Randomized Controlled Crossover Study

BACKGROUND

Depression and pain are highly comorbid and share biological mechanisms. Acupuncture is commonly used to manage both pain and depression, but the choice of acupoints for specific disorders differs. This study aimed to investigate whether specific acupuncture intervention on pain- and depression-acupoints would have specific efficacy and immune effects in patients with comorbid chronic pain and major depressive disorder (MDD).

METHODS

We performed a subject- and assessor-blinded, crossover, and randomized controlled clinical trial of depression- and pain-specific acupuncture intervention and measured clinical responses and proinflammatory cytokines in patients with comorbid chronic pain and MDD. Specific acupoints for pain and depression were used in random order with a washout interval. Forty-seven patients were enrolled and randomly assigned to two groups: (1) the depression-pain group (23 patients who were treated with depression-specific acupoints and then the pain-specific acupoints after the washout) and (2) pain-depression group (24 patients with the reverse order).

RESULTS

The pain-specific acupoints for pain did not reduce Brief Pain Inventory scores to a significantly greater degree (-0.97 ± 1.69) than the depression-specific acupoints (-0.28 ± 1.88); likewise, the depression-specific acupoints did not significantly ameliorate Hamilton Depression Rating Scale (-4.59 ± 6.02) than the pain-specific acupoints (-6.69 ± 6.61). The pain-specific acupoints improved Beck Depression Inventory-Second Edition (-6.74 ± 9.76) even better than the depression-specific acupoints (-1.92 ± 10.74). The depression-specific acupoints did not significantly decrease the depression-related interleukin (IL)-6 level (-1.24 ± 6.67) than the pain-specific acupoints (-0.60 ± 4.36). The changed levels of IL-1β, tumor necrosis factor (TNF)-α between the depression-specific acupoints (-37.41 ± 194.49; -12.53 ± 54.68) and the pain-specific acupoints (-15.46 ± 87.56; -7.28 ± 27.86) could not reach significantly different, too.

CONCLUSION

This study rejected our hypothesis that the pain-specific acupoints might produce superior analgesic effects than the depression-specific acupoints and vice versa. The cytokine results might imply that pain and depression share common biological mechanisms. (trial registration: https://www.

CLINICALTRIALS

gov: NCT03328819).

Influence of Acupuncture and Other Clinical Factors on the Recovery of Limb Motor Function in Patients After Stroke: A Retrospective Study

Background

Limb motor disorders after stroke are very common, and the clinical related factors of improving limb motor function are still unclear. As a part of comprehensive rehabilitation strategy, acupuncture has been widely used in rehabilitation after stroke in China. But more evidence is needed for the influence of acupuncture and some other clinical factors on post-stroke motor disorders.

Patients and Methods

A retrospective study was conducted using the database of patients with post-stroke motor disorders admitted to the Neurological Rehabilitation Unit of the First Teaching Hospital of Tianjin University of Traditional Chinese Medicine. The included patients were grouped according to whether NIHSS improved or muscle strength improved. The positive logistic regression was used to analyze the influencing factors of possible NIHSS improvement. Combined with the influencing factors of NIHSS improvement and muscle strength improvement, the influencing factors of limb motor function recovery after stroke were obtained.

Results

When analyzing the baseline of the included patients, it was found that patients with NIHSS improvement had earlier acupuncture intervention time (M, (IQR):13.5 (14), OR=0.716, 95% CI [0.591-0.869], p=0.001), more cumulative acupuncture treatment times (M,(IQR):29 (12), OR=0.744, 95% CI [0.608-0.910], p=0.004), and less hypertension history (OR=0.256, 95% CI [0.082-0.801], p=0.019). Smoking history only has positive significance in univariate and multivariate analysis of NIHSS, not muscle strength (OR=0.274, 95% CI [0.097-0.779], p=0.015).

Conclusion

The earlier acupuncture intervention and the more cumulative acupuncture treatment times are, the more beneficial the limb function of stroke patients with motor disorders will be. The previous history of hypertension is the influencing factor of limb motor function not improving in patients with limb motor disorder after a stroke. The effect of smoking history on limb movement function of patients with limb motor disorder after stroke needs further study.

Electroacupuncture-Regulated miR-34a-3p/PDCD6 Axis Promotes Post-Spinal Cord Injury Recovery in Both In Vitro and In Vivo Settings

Electroacupuncture (EA) could enhance neuroregeneration and posttraumatic conditions; however, the underlying regulatory mechanisms remain ambiguous. PDCD6 (programmed cell death 6) is an established proapoptotic regulator which is responsible for motoneuronal death. However, its potential regulatory role in post-spinal cord injury (SCI) regeneration has remained largely unknown. Further investigations are warranted to clarify the involvement of PDCD6 post-SCI recovery and the underlying mechanisms. In our study, based on bioinformatics prediction, we found that miR-34a-3p might be an upstream regulator miRNA for PDCD6, which was subsequently validated through combined utilization of the qRT-PCR, western blot, and dual-luciferase reporter system. Our in vitro results showed that miR-34a-3p might promote the in vitro differentiation of neural stem cell (NSC) through suppressing PDCD6 and regulating other important neural markers such as fibroblast growth factor receptor 1 (FGFR1), MAP1/2 (MAP kinase kinases 1/2), myelin basic protein (MBP), βIII-tubulin Class III β-tubulin (βIII tubulin), and glial fibrillary acidic protein (GFAP). Notably, in the post-SCI rat model, exogenous miR-34a-3p agomir obviously inhibited the expression of PDCD6 at the protein level and promoted neuronal proliferation, motoneurons regeneration, and axonal myelination. The restorations at cellular level might contribute to the improved hindlimbs functions of post-SCI rats, which was manifested by the Basso-Beattie-Bresnahan (BBB) locomotor test. The impact of miR-34a-3p was further promoted by EA treatment in vivo. Conclusively, this paper argues that a miR-34a-3p/PDCD6 axis might be a candidate therapeutic target for treating SCI and that the therapeutic effect of EA is driven through this pathway.

The efficacy and safety of Jin's three-needle therapy vs. placebo acupuncture on anxiety symptoms in patients with post-stroke anxiety: A study protocol for a randomized controlled trial

Background

A large number of clinical RCTs have verified that Jin's three-needle therapy (JTNT) has a great contribution to promoting the function of paralyzed limbs and relieving anxiety disorders for patients with post-stroke anxiety (PSA). However, there is still a lack of sham needle control, and its placebo effect cannot be ruled out. This study firstly verifies the real effectiveness of JTNT. Besides, the changes in serum indexes on the hypothalamic-pituitary-adrenal axis (HPA axis) are observed dynamically by the Enzyme-Linked ImmunoSorbent Assay (ELISA). The activation of different brain regions by JTNT is recorded using resting functional magnetic resonance imaging (rs-fMRI). Therefore, we can provide more practical and powerful evidence-based medical evidence for clinical decisions.

Method

This is a 16 week parallel, single-blind, random, controlled trial, including baseline, 4 weeks of treatment, and 12 weeks of follow-up. A total of 114 participants will be randomly divided into three groups in the proportion of 1:1:1. Participants will receive Jin's three-needle therapy in the active acupuncture group and accept sham needle treatment in the sham acupuncture group. In the waitlist control group, patients will not receive any acupuncture treatment. Outcomes cover three types of indicators, including scale indicators, serum indicators, and imaging indicators. The primary outcome is the change in the performance of anxiety symptoms, which is estimated by the 14-item Hamilton Anxiety Rating Scale (HAMA-14) and the 7-item Generalized Anxiety Disorder scale (GAD-7). Secondary outcomes are physical recovery and daily quality of life, which are evaluated by the National Institute of Health stroke scale (NIHSS) and the Modified Barthel Index Score (MBI Scale). Therefore, the assessment of the scale is carried out at baseline, 2nd, 4th, 8, 12, and 16 weeks. Adrenocorticotropin and cortisol will be quantitatively detected by ELISA at baseline and 4 weeks after treatment. In addition, regional homogeneity analysis (ReHo) will be used to record the activity of brain regions at baseline and 4 weeks after intervention.

Discussion

The study aims to provide high-quality clinical evidence on the effectiveness and safety of JTNT for patients with PSA. In addition, this trial explores a possible mechanism of JTNT for patients with PSA.

Clinical trial registration

Chinese Clinical Trial Registry, identifier [ChiCTR2200058992].

Effect of acupuncture on long-term outcomes in patients with post-stroke dysphagia

BACKGROUND

Acupuncture has been used to treat patients with post-stroke neurological dysfunction.

OBJECTIVE

The purpose of our observational study was to observe the long-term efficacy of acupuncture and investigate whether the acupuncture treatment could short the recovery time of patients with post-stroke dysphagia.

METHODS

Medical records were reviewed to select patients who met the inclusion criteria for post-stroke dysphagia. Exposure factor was defined as received acupuncture during inpatient. Clinical data were obtained at the 6-month follow-up. The primary outcome was the time to improve the score of Food Intake Level Scale (FILS, 0-10) by 3 grades. Cox regression models were used to assess the relationship between acupuncture and recovery of dysphagia.

RESULTS

In acupuncture group, the median time to achieve clinical improvement of dysphagia was 97 days (95% CI, 93-124) compared with 119 days (95% CI, 108-145) in control group, with a statistically significant difference between the two groups (HR = 1.48; 95% CI 1.14-1.92; P = 0.003). At 6 months, 78 patients (60.5%) in acupuncture group reached excellent function and 61 patients (47.3%) in control group (RR = 1.28; 95% CI, 1.02-1.62; P = 0.045). 106 patients (82.2%) in acupuncture group achieved favorable function and 91 patients (70.5%) in control group (RR = 1.17; 95% CI, 1.02-1.35; P = 0.039). The outcome of adjusted multivariable Cox regression models showed that there was a difference in the recovery time of dysphagia between groups, HR = 1.79, 95% CI 1.34-2.39. The rates of adverse events were similar in both groups.

CONCLUSIONS

Acupuncture can promote the recovery of post-stroke dysphagia, and has a better long-term efficacy. Besides, it can reduce the degree of disability and improve the quality of life.

Effects of Acupuncture in Ischemic Stroke Rehabilitation: A Randomized Controlled Trial

Background

Acupuncture is a well-known treatment option for ischemic stroke recovery, but evidence of its effectiveness remains limited. This is a randomized controlled trial to evaluate the effectiveness of acupuncture treatment for ischemic stroke rehabilitation.

Methods

Rehabilitation training was provided to the control group. In acupuncture arm 1, these acupoints were derived from the ancient books, including GV20 (baihui), GV26 (shuigou), PC9 (zhongchong), ST6 (jiache), ST4 (dicang), LI15 (jianyu), LI11 (quchi), LI4 (hegu), GB30 (huantiao), GB31 (fengshi), GB34 (yanglingquan), and GB39 (xuanzhong). In acupuncture arm 2, the acupoints used were GV20 (baihui), PC6 (neiguan), LI11 (quchi), LI10 (shousanli), SJ5 (waiguan), LI4 (hegu), GB30 (huantiao), ST36 (zusanli), GB34 (yanglingquan), SP6 (sanyinjiao), ST41 (jiexi), and LR3 (taichong), which were extracted from Acupuncture and Moxibustion Science. After acupuncture, the needles were left in for 30 min and manually manipulated every 10 min. The three groups received treatment once a day, 5 times a week for 2 weeks. The primary outcome was the National Institutes of Health Stroke Scale (NIHSS), and the secondary outcomes were the Barthel Index (BI) and the Modified Ashworth Scale (MAS). Outcomes were measured in patients both before and after treatment.

Results

A total of 497 patients with ischemic stroke were randomized into either arm 1 (159 cases), arm 2 (173 cases), or the control group (165 cases). After 2 weeks of treatment, the NIHSS scores for arm 1 were lower than those of the control group (P = 0.017); the BI scores were higher in arm two than that in the control group at T2 (P = 0.016) and follow-up (P = 0.020). Additionally, there was no significant difference between arm one and the control group for either the BI scores or the MAS scores (P > 0.05) and no significant difference between arm two and the control group for the MAS scores or the NIHSS scores (P > 0.05).

Conclusion

The clinical efficacy of arm 1 and arm 2 (acupuncture groups) was superior to that of the control group, but there was no difference between the effects of the two acupuncture groups.

Clinical Trial Registration

http://www.chictr.org.cn/index.aspx, identifier: ChiCTR-IOR-16008627.

Electroacupuncture at Zusanli ameliorates the autistic-like behaviors of rats through activating the Nrf2-mediated antioxidant responses

OBJECTIVE

Emerging evidence suggests that acupuncture plays a neuroprotective role in autism. This study aimed to explore the effect of electroacupuncture at Zusanli (ST36) on autistic-like behaviors and the underlying mechanism.

METHOD

Pregnant rats were administered with valproic acid (VPA) on gestational day 12.5 to induce an autism spectrum disorder (ASD) model. The pups were given electroacupuncture at ST36 daily from postnatal day (PND) 28-48. On PND28, the adenoviral vector containing small interfering RNA Nrf2 (Ad-siRNA-Nrf2) was injected into the prefrontal cortex of rats. The behavioral analysis was performed on PND 44-48. On PND48, the animals were euthanized and the brains were collected for further detection. Nissl staining was performed to detect neuronal viability. The biochemical markers of oxidative stress were subsequently measured.

RESULT

Electroacupuncture at ST36 ameliorated the locomotor activity, social behavior, spatial learning and memory and repetitive behavior compared with ASD rats. It was notable that the electroacupuncture decreased oxidative stress markers in the tissues of prefrontal cortex, enhanced translocation of nuclear factor erythroid2-related factor2 (Nrf2) from cytoplasm to nucleus, and up-regulated the levels of NADP(H) quinone oxidoreductase (NQO1) and heme oxygenase (HO-1). However, these effects induced by electroacupuncture at ST36 were abolished after injection of Ad-siRNA-Nrf2.

CONCLUSION

These data suggested that electroacupuncture at ST36 protected nerve function in ASD rats through Nrf2 activation and the antioxidant response.

Sensorimotor Responses in Post-Stroke Hemiplegic Patients Modulated by Acupuncture at Yanglingquan (GB34): A fMRI Study Using Intersubject Functional Correlation (ISFC) Analysis

Motor dysfunction is common in patients with stroke. Acupuncture has become an acceptable alternative method for stroke rehabilitation. Previous studies have shown various functional connectivity changes activated by acupuncture. We introduced intersubject correlation (ISC) and intersubject functional correlation (ISFC) analyses into the functional magnetic resonance imaging (fMRI) for ischemic stroke to seek a common activation and suppression pattern triggered by acupuncture. In this study, 63 ischemic stroke patients with motor dysfunction and 42 normal controls were analyzed. Three functional scans were conducted during the resting state, motor task, and acupuncture at Yanglingquan (GB34) task. Twenty-two sensory, motor, and movement-imagination cortices in the bilateral hemispheres were selected as the region of interest (ROI). We performed ISC and ISFC analyses among these ROIs in three fMRI runs on patients and controls. Subgroup analyses by course or severity were also conducted. The results showed that acupuncture at GB34 triggered ISFC among upper limb motor, upper limb/hand/face, lower limb, tongue/larynx sensory, and movement imagination regions in the patient group. Subgroup ISC and ISFC analyses showed that patients tended to have increasing responses in the early stage of stroke (within 1 month) and decreasing responses afterward (1–3 months). Patients with mild clinical functional damage (NIHSS 2–4) tended to generate more responses via acupuncture than those with moderate damage (NIHSS 5–15). Our findings may help understand the clinical effects and modulatory features of acupuncture based on the group-level post-stroke neuroplasticity.

Modulation of Brain Rhythm Oscillations by Xingnao Kaiqiao Acupuncture Correlates with Stroke Recovery: A Randomized Control Trial

Objectives: In China, Xingnao Kaiqiao (XNKQ) acupuncture has been widely used for stroke treatment. However, its electrophysiological mechanism remains unclear. Hence, this study aims to study how XNKQ acupuncture modulates brain rhythm oscillations of stroke patients, and investigate its correlation with stroke recovery. Design: Randomized control trial. Subjects: Twenty (sub)acute ischemic stroke patients were enrolled and randomly assigned to two groups (an acupuncture group [AG] [n = 10] and a control group [CG] [n = 10]), and four patients (two patients in each group) dropped out of the study. Interventions: All patients received conventional treatments, and the patients in AG received additional XNKQ acupuncture treatment once a day for 10 consecutive days. Outcome measures: Before treatment, 14 days after, and 30 days after treatment onset, their movement impairments and neurologic deficits were measured using the National Institute of Health Stroke Scale (NIHSS), the Fugl-Meyer (FM) Scale, the Modified Rankin Scale (mRS), and the Modified Barthel Index (MBI), and their electroencephalogram data were recorded. Results: Compared with the CG, the AG showed more improvement in FM scores (p = 0.02), as well as decreased relative delta power and increased relative alpha power after 2 weeks' treatment. The decrease of the relative delta power and the increase of the relative alpha power in the ipsilesional frontal area were significantly correlated with the FM improvement (F5, F7, FC1, and Fz electrodes, all |r| > 0.517, p < 0.040). Conclusions: The curative effect of XNKQ acupuncture related to its electrophysiological modulation. This study was registered at the Chinese Clinical Trial Registry (ChiCTR2000038560).

A Time-Dependent Analysis of Association between Acupuncture Utilization and the Prognosis of Ischemic Stroke

This study investigated the time-dependent characteristics of acupuncture and analyzed the association between acupuncture utilization and mortality rates, readmission rates, and complications among ischemic stroke patients. Data from the National Health Insurance Service-National Sample Cohort 2.0 from South Korea were used to track patients with subacute and chronic ischemic stroke, who had survived more than one month after onset, between 2010 and 2013. A total of 2299 patients were followed up until 2015. At baseline, the acupuncture group (n = 195) and the control group (n = 2104) had similar ages (acupuncture group: 69.0 ± 11.1 years; control group: 68.5 ± 11.8 years), but the acupuncture group had more comorbidities (Charlson comorbidity index; acupuncture group: 4.7 ± 2.1, control group: 4.3 ± 2.4). According to time-dependent Cox regression survival analysis, acupuncture treatment was associated with low hazard ratios (HR) for death (HR: 0.32; 95% confidence interval (CI): 0.18–0.60), fewer composite complications (HR: 0.34; 95% CI: 0.21–0.53), and reduced urinary tract infection (HR: 0.24; 95% CI: 0.11–0.54). Many acupuncture session sensitivity analyses were performed to assess the robustness using different criteria to define the acupuncture group, and the results were consistent with those of the main analysis. Therefore, acupuncture treatment might be associated with lower mortality rates and the prevention of complications after ischemic stroke.

Electroacupuncture Alters BCI-Based Brain Network in Stroke Patients

Goal. Stroke patients are usually accompanied by motor dysfunction, which greatly affects daily life. Electroacupuncture is a kind of nondrug therapy that can effectively improve motor function. However, the effect of electroacupuncture is hard to be measured immediately in clinic. This paper is aimed to reveal the instant changes in brain activity of three groups of stroke patients before, during, and after the electroacupuncture treatment by the EEG analysis in the alpha band and beta band. Methods. Seven different functional connectivity indicators including Pearson correlation coefficient, spectral coherence, mutual information, phase locking value, phase lag index, partial directed coherence, and directed transfer function were used to build the BCI-based brain network in stroke patients. Results and Conclusion. The results showed that the brain activity based on the alpha band of EEG decreased after the electroacupuncture treatment, while in the beta band of EEG, the brain activity decreased only in the first two groups. Significance. This method could be used to evaluate the effect of electroacupuncture instantly and quantitatively. The study will hopefully provide some neurophysiological evidence of the relationship between changes in brain activity and the effects of electroacupuncture. The study of BCI-based brain network changes in the alpha and beta bands before, during, and after electroacupuncture in stroke patients of different periods is helpful in adjusting and selecting the electroacupuncture regimens for different patients. The trial was registered on the Chinese clinical trial registry (ChiCTR2000036959).

Combination of stem cell therapy and acupuncture to treat ischemic stroke: a prospective review

Stroke is the second leading cause globally that leads to severe disability and death. Stem cell therapy has been developed over the recent years to treat stroke and diminish the mortality and disability rate of brain injuries. Acupuncture, which can activate endogenous recovery via physical stimuli, has been applied to enhance the recovery and rehabilitation of stroke patients. Attempts have been made to combine stem cell therapy and acupuncture to treat stroke patients and have shown the promising results. This prospective review will look into the possible mechanisms of stem cell therapy and acupuncture and intend to undercover the potential benefit of the combined therapy. It intends to bridge the modern emerging stem cell therapy and traditional acupuncture at cellular and molecular levels and to demonstrate the potential benefit to improve clinical outcomes.

Acupuncture at ST36 Alleviates the Behavioral Disorder of Autistic Rats by Inhibiting TXNIP-Mediated Activation of NLRP3

Autism is a common neurodevelopmental disorder that severely affects patients' quality of life. We aimed to investigate whether acupuncture at Zusanli (ST36) could alleviate the behavior disorder of autistic rats by inhibiting thioredoxin-interacting protein (TXNIP)-mediated activation of NLRP3. An autism model was induced by intraperitoneal injection of pregnant rats with valproic acid (VPA). The pups' behaviors were analyzed using hot plate, open field, Morris water maze, and 3-chamber social interaction tests. Nissl staining was used to visualize neurons in prefrontal cortex. Levels of TXNIP, NLRP3, interleukin (IL)-1β, and caspase were determined by Western blot or quantitative real-time PCR. After ST36 acupuncture, pain sensitivity, autonomous activity, sociability index, sociability preference index, and learning and memory were improved in the autism model rats. Levels of TXNIP, NLRP3, IL-1β, and caspase 1 were decreased after acupuncture. Interference with TXNIP alleviated the behavior disorders and inhibited NLRP3, caspase 1, and IL-1β levels. In summary, ST36 acupuncture reduced TXNIP expression, inhibited the activation of the NLRP3 inflammasome, and alleviated the behavior disorder related to the prefrontal cortex of the autistic rats. These results point to a potential mechanism for acupuncture-induced improvement of autistic behavioral disorders.

China Stroke Registry for Patients With Traditional Chinese Medicine (CASES-TCM): Rationale and Design of a Prospective, Multicenter, Observational Study

Background: Given the complexity of stroke treatment and the current widespread use of traditional Chinese medicine (TCM) in the absence of robust, large, long-term effectiveness and safety studies, and the lack of nationwide epidemiology and clinical characteristics of patients with stroke receiving TCM treatment, the acquisition of data from longitudinal cohorts is essential. We intend to generate the major clinical characteristics of patients with stroke who receive TCM treatment and to investigate the effectiveness and safety of TCM in the Chinese population.

Methods: The China Stroke Registry for Patients with Traditional Chinese Medicine (CASES-TCM) study is a prospective, multicenter, observational disease registry aiming to register 20,000 hospitalized patients. Eligible adult patients with clearly diagnosed acute ischemic stroke or intracerebral hemorrhage within 7 days of symptom onset will be consecutively registered from 126 participating sites across China. Baseline data will be recorded, and all patients will be regularly followed up at 3, 6, 12, and 24 months after stroke onset. Collected data will be entered into a web-based system with high-level data security. The primary outcomes include the distribution of scores on the modified Rankin Scale at the 3-months follow-up, and recurrent stroke events within the 12-months follow-up.

Conclusion: To our knowledge, the CASES-TCM study is the first and largest nationwide registry to document comprehensive data on TCM treatment in patients with acute stroke. The findings of this study will be valuable to improve our knowledge about TCM treatment for patients with stroke and its subsequent outcomes in the actual clinical setting, consequently facilitating and standardizing the optimization of individualized interventions with TCM for stroke prevention and treatment in China.

Study registration: This study was registered with Clinicaltrials.gov (URL: https://clinicaltrials.gov/, Unique identifier: NCT04921397).

Effect of opposing needling on motor cortex excitability in healthy participants and in patients with post-stroke hemiplegia: study protocol for a single-blind, randomised controlled trial

Background

Opposing needling has an obvious curative effect in the treatment of post-stroke hemiplegia; however, the mechanism of the opposing needling in the treatment of post-stroke hemiplegia is still not clear. The purpose of this study is to investigate the effect of opposing needling on the excitability of primary motor cortex (M1) of healthy participants and patients with post-stroke hemiplegia, which may provide insight into the mechanisms of opposing needling in treating post-stroke hemiplegia.

Methods

This will be a single-blind, randomised, sham-controlled trial in which 80 healthy participants and 40 patients with post-stroke hemiplegia will be recruited. Healthy participants will be randomised 1:1:1:1 to the 2-Hz, 50-Hz, 100-Hz, and sham electroacupuncture groups. Patients with post-stroke hemiplegia will be randomised 1:1 to the opposing needling or conventional treatment groups. The M1 will be located in all groups by using neuroimaging-based navigation. The stimulator coil of transcranial magnetic stimulation (TMS) will be moved over the left and right M1 in order to identify the TMS hotspot, followed by a recording of resting motor thresholds (RMTs) and motor-evoked potentials (MEPs) of the thenar muscles induced by TMS before and after the intervention. The primary outcome measure will be the percent change in the RMTs of the thenar muscles at baseline and after the intervention. The secondary outcome measures will be the amplitude (μV) and latency (ms) of the MEPs of the thenar muscles at baseline and after the intervention.

Discussion

The aim of this trial is to explore the effect of opposing needling on the excitability of M1 of healthy participants and patients with post-stroke hemiplegia.

Trial registration

Chinese Clinical Trial Registry ChiCTR1900028138. Registered on 13 December 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05443-x.

Electroacupuncture at GV20‑GB7 regulates mitophagy to protect against neurological deficits following intracerebral hemorrhage via inhibition of apoptosis

The acupuncture penetrating line of Baihui (GV20) to Qubin (GB7) spans the parietal, frontal and temporal lobes. The present study aimed to elucidate the mechanism by which electroacupuncture (EA) at GV20‑GB7 regulates mitophagy in intracerebral hemorrhage (ICH) and whether it serves a neuroprotective role. A whole blood‑induced ICH model was used. Mitophagy‑regulating proteins, including BCL/adenovirus E1B 19 kDa‑interacting protein 3 (BNIP3), PTEN‑induced putative kinase 1 (PINK1), Parkin and apoptosis‑associated proteins were detected by western blotting; autophagy following ICH was evaluated by immunofluorescent techniques; morphological characteristics of mitophagy were observed using transmission electron microscopy; and TUNEL assay was performed to determine the number of apoptotic cells. Immunohistochemistry was used to detect p53 expression. The protective role of EA (GV20‑GB7) via enhanced mitophagy and suppressed apoptosis in ICH was further confirmed by decreased modified neurological severity score. The results showed that EA (GV20‑GB7) treatment upregulated mitochondrial autophagy following ICH and inhibited apoptotic cell death. The mechanism underlying EA (GV20‑GB7) treatment may involve inhibition of p53, an overlapping protein of autophagy and apoptosis. EA (GV20‑GB7) treatment decreased neurobehavioral deficits following ICH but pretreatment with 3‑methyladenine counteracted the beneficial effects of EA (GV20‑GB7) treatment. In conclusion, EA (GV20‑GB7) improved recovery from ICH by regulating the balance between mitophagy and apoptosis.

Electroacupuncture Pretreatment Mitigates Myocardial Ischemia/Reperfusion Injury via XBP1/GRP78/Akt Pathway

Myocardial ischemia/reperfusion injury is a common clinical problem and can result in severe cardiac dysfunction. Previous studies have demonstrated the protection of electroacupuncture against myocardial ischemia/reperfusion injury. However, the role of X-box binding protein I (XBP1) signaling pathway in the protection of electroacupuncture was still elusive. Thus, we designed this study and demonstrated that electroacupuncture significantly improved cardiac function during myocardial ischemia/reperfusion injury and reduced cardiac infarct size. Electroacupuncture treatment further inhibited cardiac injury manifested by the decrease of the activities of serum lactate dehydrogenase and creatine kinase-MB. The results also revealed that electroacupuncture elevated the expressions of XBP1, glucose-regulated protein 78 (GRP78), Akt, and Bcl-2 and decreased the Bax and cleaved Caspase 3 expressions. By using the inhibitor of XBP1 in vitro, the results revealed that suppression of XBP1 expression could markedly increase the activities of lactate dehydrogenase and creatine kinase-MB and cell apoptosis, thus exacerbating stimulated ischemia/reperfusion-induced H9c2 cell injury. Compared with stimulated ischemia/reperfusion group, inhibition of XBP1 inhibited the downstream GRP78 and Akt expressions during stimulated ischemia/reperfusion injury. Collectively, our data demonstrated that electroacupuncture treatment activated XBP1/GRP78/Akt signaling to protect hearts from myocardial ischemia/reperfusion injury. These findings revealed the underlying mechanisms of electroacupuncture protection against myocardial ischemia/reperfusion injury and may provide novel therapeutic targets for the clinical treatment of myocardial ischemia/reperfusion injury.

Evaluating the Long-Term Efficacy of Acupuncture Therapy for Subacute Poststroke Aphasia: Study Protocol for a Randomized, Blinded, Controlled, Multicentre Trial

Background

Poststroke aphasia (PSA) is a disabling condition that decreases the quality of life, and the duration of the disease harms the quality of life of PSA patients. Acupuncture has been widely employed for PSA. There is some evidence for the immediate treatment efficacy of acupuncture for PSA; however, long-term results after acupuncture may be poorer.

Methods

This is a multicentre, randomized, blinded, nonacupoint (NA) acupuncture controlled, multimodal neuroimaging clinical trial. A total of 48 subjects with subacute PSA will be randomly assigned to an acupoint group or an NA control group. The acupoint group will receive acupuncture with normal needling at DU20, EX-HN1, HT5, GB39, EX-HN12, EX-HN13, and CV23. The NA control group will receive acupuncture in locations not corresponding to acupuncture points as sham acupoints. Both groups will receive identical speech and language therapy thrice a week for four weeks. The primary outcome will be the change in the aphasia quotient (AQ) score measured by the Western Aphasia Battery (WAB) test during the 12th week after randomization. Participants will be blindly assessed at prerandomization (baseline) and 4 weeks, 12 weeks, and 24 weeks after randomization. The secondary outcomes include the Boston Diagnostic Aphasia Examination (BDAE) score, the Disease Prognosis Scale score for ischaemic stroke, etc. Magnetic resonance imaging (MRI) and electroencephalogram (EEG) will also be performed at 4-time intervals as secondary outcomes. All scores and image evaluations will be taken at the same point as the linguistic evaluation. The multilevel evaluation technique will be used to assess the long-term efficacy of acupuncture therapy. MRI scans and EEG will be used to assess acupuncture-related neuroplasticity changes. Discussion. The results from our trial will help to supply evidence for the long-term acupuncture effects for PSA over a long follow-up period. It will provide valuable information for future studies in the field of PSA treatment. The trial was registered at the Chinese Clinical Trial Registry on 16 March 2020 (ChiCTR2000030879).

Receptors, Channel Proteins, and Enzymes Involved in Microglia-mediated Neuroinflammation and Treatments by Targeting Microglia in Ischemic Stroke

Stroke is the largest contributor to global neurological disability-adjusted life-years, posing a huge economic and social burden to the world. Though pharmacological recanalization with recombinant tissue plasminogen activator and mechanical thrombectomy have greatly improved the prognosis of patients with ischemic stroke, clinically, there is still no effective treatment for the secondary injury caused by cerebral ischemia. In recent years, more and more evidences show that neuroinflammation plays a pivotal role in the pathogenesis and progression of ischemic cerebral injury. Microglia are brain resident innate immune cells and act the role peripheral macrophages. They play critical roles in mediating neuroinflammation after ischemic stroke. Microglia-mediated neuroinflammation is not an isolated process and has complex relationships with other pathophysiological processes as oxidative/nitrative stress, excitotoxicity, necrosis, apoptosis, pyroptosis, autophagy, and adaptive immune response. Upon activation, microglia differentially express various receptors, channel proteins, and enzymes involved in promoting or inhibiting the inflammatory processes, making them the targets of intervention for ischemic stroke. To inhibit microglia-related neuroinflammation and promote neurological recovery after ischemic stroke, numerous biochemical agents, cellular therapies, and physical methods have been demonstrated to have therapeutic potentials. Though accumulating experimental evidences have demonstrated that targeting microglia is a promising approach in the treatment of ischemic stroke, the clinical progress is slow. Till now, no clinical study could provide convincing evidence that any biochemical or physical therapies could exert neuroprotective effect by specifically targeting microglia following ischemic stroke.

Different acupuncture intervention time-points for improving capacity in motor function and activities of daily living after stroke: A protocol for systematic review and network meta-analysis

BACKGROUND

The incidence of stroke has been found in an increasing trend worldwide, resulting in significant negative effects and severe impairments to survivors in terms of motor function and activities of daily living. Acupuncture therapy has been widely used in the clinical treatment of stroke for a long time, meanwhile, the efficacy has been confirmed by many studies. However, the optimal intervention time-point of acupuncture in stroke is controversial. Therefore, the purpose of our study is to provide scientific evidence and reasonable suggestions for this issue.

METHODS

A computer-based retrieval will be employed in 7 electronic databases: EMBASE Database, PubMed, the Cochrane Library, China National Knowledge Infrastructure (CNKI), Wan Fang databases, Chinese Scientific Journals Database (VIP) and China Biological Medicine Database (CBM), from the establishment date of each database throughout October 2020. Only randomized controlled trials of acupuncture for stroke will be recruited and language is limited to English or Chinese. The outcomes we focus on include the Fugl-Meyer Assessment score and the Barthel Index. Additionally, safety assessments such as adverse events and drop-out cases may also be taken into consideration. The network meta-analysis will be performed based on the Bayesian framework and literature selection will be conducted by 2 trained reviewers. All data analysis will be calculated by Revman5.3, WinBUGS 1.4.3, Stata13.0, and R software 3.6.1. The Assessment of heterogeneity, inconsistency, subgroup, sensitivity, and publication bias will also be done under the guidelines of Cochrane Collaboration's tool.

RESULTS

The results of this study will be submitted to a peer-reviewed journal for publication.

CONCLUSION

This network meta-analysis will provide evidence-based references to evaluate the efficacy of different acupuncture intervention time-points during the treatment of stroke. Furthermore, it will help the clinicians to formulate appropriate medical plans and improve clinical efficacy.

TRIALS REGISTRATION NUMBER

INPLASY2020120060.

Best Practice Recommendations for Stroke Patients with Dysphagia: A Delphi-Based Consensus Study of Experts in Turkey-Part II: Rehabilitation

Dysphagia is one of the most common and important complications of stroke. It is an independent marker of poor outcome following acute stroke and it continues to be effective for many years. This consensus-based guideline is not only a good address to clinical questions in practice for the clinical management of dysphagia including management, diagnosis, follow-up, and rehabilitation methods, but also includes detailed algorithms for these topics. The recommendation paper has been written by a multidisciplinary team and offers 117 recommendations for stroke patients with dysphagia. While focusing on management principles, diagnosis, and follow-up in the 1st part (45 items), rehabilitation details were evaluated in the 2nd part (72 items).

Earlier Acupuncture Enhancing Long-Term Effects on Motor Dysfunction in Acute Ischemic Stroke: Retrospective Cohort Study

Stroke is the leading fatal disease in China. This retrospective study aimed to explore the optimal acupuncture intervention time for long-term efficacy on motor dysfunction in patients suffering from acute ischemic stroke through 1-year of follow-up. Three hundred and nine patients collected at Longhua Hospital from January 2016 to December 2017 were classified into 3 groups based on the acupuncture intervention time, including groups A (within 2 days), B (within 3–7 days) and C (within 8–14 days). All patients had received standard treatment combined with acupuncture therapy. Specifically, acupuncture was performed at the acupoints including LI4 (Hegu), ST40 (Fenglong), DU20 (Baihui), and motor area of the scalp, followed by 2 electroacupuncture protocols based on different muscle tensions once a day for 5 days consecutively. The time-effect relationship was assessed using both the Fugl-Meyer Assessment (FMA) and the modified Barthel index (MBI) on the 90th day and 1st year, respectively. Meanwhile, the modified Rankin scale (mRS), high-sensitivity C-reactive protein (hs-CRP), and fibrinogen (FIB) were also measured during the 1-year follow-up. The favorable outcome rate was 74.4%. One-way univariate analysis of variance (ANOVA) revealed significant differences in FMA and MBI on the 90th day among the 3 groups ([Formula: see text] < 0.05), while no significant differences were observed in FMA, MBI or mRS at the 1st year between groups A and B. The levels of hs-CRP and FIB ([Formula: see text] < 0.05) were markedly reduced. Binary logistic regression analysis suggested that patients with atrial fibrillation (AF) (odds ratio (OR): 3.156), chronic kidney disease (CKD) (OR: 2.563), diabetes mellitus (DM) (OR: 2.174) or stroke history (OR: 1.883) were more inclined to recover poorly from nerve function deficit ([Formula: see text] < 0.05). Earlier acupuncture intervention may have a better long-term effect on motor dysfunction and inflammation during the 1-year follow-up. Moreover, acupuncture within 2 days is probably the optimal treatment time for early recovery on the 90th day.

Mechanisms of Acupuncture in the Regulation of Oxidative Stress in Treating Ischemic Stroke

Ischemic stroke is the major type of cerebrovascular disease usually resulting in death or disability among the aging population globally. Oxidative stress has been closely linked with ischemic stroke. Disequilibrium between excessive production of reactive oxygen species (ROS) and inherent antioxidant capacity leads to subsequent oxidative damage in the pathological progression of ischemic brain injury. Acupuncture has been applied widely in treating cerebrovascular diseases from time immemorial in China. This review mainly lays stress on the evidence to illuminate the possible mechanisms of acupuncture therapy in treating ischemic stroke through regulating oxidative stress. We found that by regulating a battery of molecular signaling pathways involved in redox modulation, acupuncture not only activates the inherent antioxidant enzyme system but also inhibits the excessive generation of ROS. Acupuncture therapy possesses the potential in alleviating oxidative stress caused by cerebral ischemia, which may be linked with the neuroprotective effect of acupuncture.

Electroacupuncture on Trigeminal Nerve-Innervated Acupoints Ameliorates Poststroke Cognitive Impairment in Rats with Middle Cerebral Artery Occlusion: Involvement of Neuroprotection and Synaptic Plasticity

Poststroke cognitive impairment (PSCI) is a severe sequela of stroke. There are no effective therapeutic options for it. In this study, we evaluated whether electroacupuncture (EA) on the trigeminal nerve-innervated acupoints could alleviate PSCI and identified the mechanisms in an animal model. The male Sprague-Dawley rat middle cerebral artery occlusion (MCAO) model was used in our study. EA was conducted on the two scalp acupoints, EX-HN3 (Yintang) and GV20 (Baihui), innervated by the trigeminal nerve, for 14 sessions, daily. Morris water maze and novel object recognition were used to evaluate the animal's cognitive performance. Neuroprotection and synaptic plasticity biomarkers were analyzed in brain tissues. Ischemia-reperfusion (I/R) injury significantly impaired spatial and cognition memory, while EA obviously reversed cognitive deterioration to the control level in the two cognitive paradigms. Moreover, EA reversed the I/R injury-induced decrease of brain-derived neurotrophic factor, tyrosine kinase B, N-methyl-D-aspartic acid receptor 1, α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid receptor, γ-aminobutyric acid type A receptors, Ca²⁺/calmodulin-dependent protein kinase II, neuronal nuclei, and postsynaptic density protein 95 expression in the prefrontal cortex and hippocampus. These results suggest that EA on the trigeminal nerve-innervated acupoints is an effective therapy for PSCI, in association with mediating neuroprotection and synaptic plasticity in related brain regions in the MCAO rat model.

Stroke in China: advances and challenges in epidemiology, prevention, and management

With over 2 million new cases annually, stroke is associated with the highest disability-adjusted life-years lost of any disease in China. The burden is expected to increase further as a result of population ageing, an ongoing high prevalence of risk factors (eg, hypertension), and inadequate management. Despite improved access to overall health services, the availability of specialist stroke care is variable across the country, and especially uneven in rural areas. In-hospital outcomes have improved because of a greater availability of reperfusion therapies and supportive care, but adherence to secondary prevention strategies and long-term care are inadequate. Thrombolysis and stroke units are accepted as standards of care across the world, including in China, but bleeding-risk concerns and organisational challenges hamper widespread adoption of this care in China. Despite little supporting evidence, Chinese herbal products and neuroprotective drugs are widely used, and the increased availability of neuroimaging techniques also results in overdiagnosis and overtreatment of so-called silent stroke. Future efforts should focus on providing more balanced availability of specialised stroke services across the country, enhancing evidence-based practice, and encouraging greater translational research to improve outcome of patients with stroke.

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).

Application of survival analysis techniques to determine the optimal number of acupuncture therapy sessions for stroke patients

BACKGROUND

Acupuncture has shown clinical benefits in stroke patients but there is currently no clear recommendation on the number of acupuncture sessions that should be offered. The aim of this study was to determine the optimal number of acupuncture therapy sessions, following which significant clinical improvement could be anticipated.

METHODS

We performed a retrospective observational study in stroke patients who had received acupuncture therapy as an adjunct treatment at Trang Hospital-a non-academic provincial hospital in Southern Thailand-between 1 July 2016 and 30 June 2017. Significant clinical improvement in activities of daily living (ADLs) was defined as an increase in the Barthel Index of ⩾10 points from baseline. Survival analysis techniques were applied to determine the optimal number of acupuncture therapy sessions.

RESULTS

Of 89 patients, 78% had a significant clinical improvement. Kaplan-Meier analysis estimated that 50% of the patients exhibited significant improvements by the eighth acupuncture therapy session. By the 16th session, the proportion of patients increased to 81%. Subgroup analyses revealed that the clinical improvement did not depend on baseline Barthel index, whereas early treatment (within 3 months of stroke onset) was associated with a faster response than late treatment. The median numbers of sessions required to achieve a significant improvement in the early and late treatment groups were 8 and 11, respectively.

CONCLUSION

Stroke patients who were going to improve saw a significant improvement in Barthel index by the 16th acupuncture session and the marginal improvement declined substantially afterward. Our approach required minimal data available from the medical records of a non-academic facility, yet practical implication could be achieved.

TRIAL REGISTRATION

The study was retrospectively registered on 18 August 2017 with the Thai Clinical Trials Registry (ref. TCTR20170822002).

Effects of acupuncture treatment on motor function in patients with subacute hemorrhagic stroke: A randomized controlled study

OBJECTIVE

The aim of this study was to evaluate the additional effects of acupuncture treatment on motor function in patients with subacute hemorrhagic stroke.

DESIGN

One hundred and thirty-four patients with subacute hemorrhagic stroke were randomized to receive acupuncture treatment plus conventional treatment (treatment group) or conventional treatment only (control group). Acupuncture treatments were given in 24 sessions over 4 weeks, with 3-month follow-up period. Blinded evaluation was based on Fugl-Meyer Assessment, Barthel Index with an intention-to-treat analysis. For those patients who were able to walk, a three-dimensional gait analysis system was employed to objectively record spatiotemporal and kinematic parameters.

RESULTS

Compared with control group, the treatment group showed a significantly greater over-time improvement in total Fugl-Meyer, lower-limb Fugl-Meyer, but not in upper-limb Fugl-Meyer and Barthel Index. The spatiotemporal parameters of velocity, step length, cadence, step width all showed significant difference between the 2 groups. The velocity in treatment group decreased unexpectedly at day 14, then increased sharply and overcame control group at day 28. The treatment group also showed a significantly greater increase in peak circumduction, peak hip hiking, hip range of motion, knee range of motion and a tendency for the ankle range of motion.

CONCLUSIONS

Acupuncture may promote the motor function recovery of hemorrhagic stroke patients in subacute phase mainly by enhancing the lower limb ability. It probably diminishes the compensation strategies earlier to correct the abnormal gait pattern. Although this adjustment may result in a compromise in the improvement of gait velocity temporarily, patients would benefit from it in a long run.

Electroacupuncture ameliorates neuronal injury by Pink1/Parkin-mediated mitophagy clearance in cerebral ischemia-reperfusion

The accumulation of dysfunctional mitochondria induced by the impairment of the autophagy-lysosome pathway (ALP), especially mitophagy is an important cause of cerebral ischemia-reperfusion (I/R) injury. Electroacupuncture (EA) exerts remarkable effects in treating ischemic stroke; however, the detailed mechanism remains unclear. In this study, rats were treated with mitochondrial permeability transition pore (mPTP) opening inhibitor, peroxynitrite (ONOO^-) scavenger, or selective inhibitor of mitophagy activation during 2-h middle cerebral artery occlusion (MCAO) followed by 24 h of reperfusion in combination with EA treatment. RNA-Seq analysis showed that EA treatment in cerebral I/R was linked to the autophagosome, the PI3K/Akt signaling pathway and metabolic pathways. We found that I/R resulted in significantly mitochondrial function impairments including decreased mitochondrial membrane potential (MMP) and ATP levels, aggregation of damaged mitochondria, excessive nitro/oxidative stress, PI3K/Akt/mTOR-mediated ALP dysfunction and deficiency of Pink1/Parkin-mediated mitophagy clearance. The treatment with EA, cyclosporine-A (CsA, a potent inhibitor of mPTP opening) or FeTMPyP (a type of ONOO^- scavenger) could significantly increase MMP and/or ATP levels, improve mitochondrial function and decrease neuronal injury. At the same time, EA also improved ALP dysfunction and the deficiency of mitophagy clearance; however, mitochondrial division inhibitor-1 (Mdivi-1, a selective inhibitor of mitophagy activation) blocked mitophagy clearance and aggravated neuronal injury. Taken together, EA ameliorates nitro/oxidative stress-induced mitochondrial functional damage and decreases the accumulation of damaged mitochondria via Pink1/Parkin-mediated mitophagy clearance to protect cells against neuronal injury in cerebral I/R.

Acupuncture attenuates cognitive impairment, oxidative stress and NF-κB activation in cerebral multi-infarct rats

BACKGROUD

Patients with multiple infarct dementia (MID) have subtle deficits that commonly go unnoticed, and are at risk of developing Alzheimer's disease. Oxidative stress induced by ischaemic injury results in intracellular calcium accumulation and neuronal apoptosis, leading to cognitive impairment by triggering various cellular signal transduction pathways. Several studies have suggested that NF-κB in the presence of p53 has a pro-apoptotic function in various models, but the mechanism is unclear.

AIMS

The aim of this study was to investigate whether acupuncture could protect cognitive function against cerebral multi-infarction (CMi) induced oxidative stress by inhibiting the activation of NF-κB and its target gene p53.

METHODS

An animal model of CMi was established by injecting homologous blood emboli into the right internal carotid artery of male Wistar rats. After 2 weeks of acupuncture treatment, cognitive function was detected by novel object recognition. Electron spin resonance and Fluo-3 fuorescence imaging were used to test the generation of ROS and intracellular calcium accumulation, respectively. Expression of NF-κB and p53 was examined by Western blot analysis and immunofluorescence.

RESULTS

CMi induced spatial learning and memory impairment, overproduction of intracellular hydroxyl radicals, and elevations of Ca²⁺, which were ameliorated by verum acupuncture treatment. Acupuncture inhibited activation of NF-κB and its downstream target gene p53.

CONCLUSION

These findings suggest that acupuncture could protect cognitive function against oxidative stress induced by CMi, which is partially associated with suppression of NF-κB-p53 activation.

Acupuncture combined Bobath approach for limbs paralysis after hypertensive intracerebral hemorrhage: A protocol for a systematic review

BACKGROUND

Previous studies have reported that acupuncture combined Bobath approach (BA) can be used to treat limbs paralysis (LP) after hypertensive intracerebral hemorrhage (HICH) effectively. However, no systematic review has explored its effectiveness and safety for LP following HICH. In this systematic review, we aim to assess the effectiveness and safety of acupuncture plus BA for the treatment of LP following HICH.

METHODS

The following 7 databases will be searched from their inception to the February 1, 2019: Cochrane Central Register of Controlled Trials, EMBASE, PUBMED, the Cumulative Index to Nursing and Allied Health Literature, the Allied and Complementary Medicine Database, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure without any language restrictions. The randomized controlled trials (RCTs) of acupuncture plus BA that evaluate the effectiveness and safety for LP after HICH will be included. The methodological quality of all included studies will be assessed by using Cochrane risk of bias tool. Two authors will independently perform study selection, data extraction, and methodological quality evaluation. Any disagreements occurred between 2 authors will be resolved by a third author involved through discussion. Data will be pooled and analyzed by using RevMan 5.3 Software.

RESULTS

This review will evaluate the effectiveness and safety of acupuncture combined BA for LP following HICH. The primary outcome is limbs function. The secondary outcomes are muscle strength, muscle tone, and quality of life, as well as the adverse events.

CONCLUSION

The results of this study will summarize the latest evidence of acupuncture combined BA for LP following HICH.

Structural Changes Induced by Acupuncture in the Recovering Brain after Ischemic Stroke

The aim of this study was to observe the grey matter (GM) tissue changes of ischemic stroke patients, to explore the therapy responses and possible mechanism of acupuncture. 21 stroke patients were randomly assigned to receive either acupuncture plus conventional (Group A) or only conventional (Group B) treatments for 4 weeks. All patients in both groups accepted resting-state functional magnetic resonance (fMRI) scan before and after treatment, and the voxel-based morphometry (VBM) analysis was performed to detect the cerebral grey structure changes. The modified Barthel index (MBI) was used to evaluate the therapeutic effect. Compared with the patients in Group B, the patients in Group A exhibited a more significant enhancement of the changes degree of MBI from pre- to post-treatment intervention. VBM analyses found that after treatment the patients in Group A showed extensive changes in GMV. In Group A, the left frontal lobe, precentral gyrus, superior parietal gyrus, anterior cingulate cortex, and middle temporal gyrus significantly increased, and the right frontal gyrus, inferior parietal gyrus, and middle cingulate cortex decreased (P < 0.05, corrected). In addition, left anterior cingulate cortex and left middle temporal gyrus are positively related to the increase in MBI score (P < 0.05, corrected). In Group B, right precentral gyrus and right inferior frontal gyrus increased (P < 0.05, corrected). In conclusion, acupuncture can evoke pronounced structural reorganization in the frontal areas and the network of DMN areas, which may be the potential therapy target and the potential mechanism where acupuncture improved the motor and cognition recovery.

The effect and biomechanical mechanisms of intradermal needle for post-stroke hemiplegia recovery: Study protocol for a randomized controlled pilot trial

The incidence of stroke has increased significantly in recent years. Post-stroke hemiplegia is a common stroke complication with long-term negative consequences. Several studies have suggested that acupuncture could be an effective intervention for the rehabilitation of post-stroke hemiplegia. Intradermal needling is a kind of acupuncture which is widely used in clinical settings. This study attempts to investigate the biomechanical effects of intradermal needle for post-stroke hemiplegia recovery.This proposed study is a single-centered, prospective, single-blinded (patient-assessor-blinded), randomized clinical pilot trial involving 40 patients with post-stroke hemiplegia. Patients will be randomized to an experimental group or control group in a 1:1 ratio. All of them will receive conventional rehabilitation therapies. Patients in the experimental group will be treated with intradermal needle, whereas patients in the control group will receive sham intradermal needle. The primary outcome measures will be biomechanically validated from the parameters of RSSCAN gait system: plantar pressure distribution, step length, and stride. The scores of clinical scales such as National Institutes of Health Stroke Scale, Fugl-Meyer Assessment, Berg Balance Scale, Barthel Index, and Stroke-specific Quality of Life Scale will be assessed as secondary outcome measures. All assessments will be conducted at baseline, 4 weeks after intervention and at the end of 3 months' follow-up.The purpose of this study is to explore the potential effect and biomechanical mechanisms of intradermal needle for post-stroke hemiplegia recovery, as well as to provide a basis for future larger clinical studies.

Acupuncture for acute stroke

BACKGROUND

Sensory stimulation via acupuncture has been reported to alter activities of numerous neural systems by activating multiple efferent pathways. Acupuncture, one of the main physical therapies in Traditional Chinese Medicine, has been widely used to treat patients with stroke for over hundreds of years. This is the first update of the Cochrane Review originally published in 2005.

OBJECTIVES

To assess whether acupuncture could reduce the proportion of people with death or dependency, while improving quality of life, after acute ischemic or hemorrhagic stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group trials register (last searched on February 2, 2017), the Cochrane Central Register of Controlled Trials Ovid (CENTRAL Ovid; 2017, Issue 2) in the Cochrane Library, MEDLINE Ovid (1946 to February 2017), Embase Ovid (1974 to February 2017), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) EBSCO (1982 to February 2017), the Allied and Complementary Medicine Database (AMED; 1985 to February 2017), China Academic Journal Network Publishing Database (1998 to February 2017), and the VIP database (VIP Chinese Science Journal Evaluation Reports; 1989 to February 2017). We also identified relevant trials in the Chinese Clinical Trial Registry (last searched on Feburuary 20, 2017), the World Health Organization (WHO) International Clinical Trials Registry Platform (last searched on April 30, 2017), and Clinicaltrials.gov (last searched on April 30, 2017). In addition, we handsearched the reference lists of systematic reviews and relevant clinical trials.

SELECTION CRITERIA

We sought randomized clinical trials (RCTs) of acupuncture started within 30 days from stroke onset compared with placebo or sham acupuncture or open control (no placebo) in people with acute ischemic or hemorrhagic stroke, or both. Needling into the skin was required for acupuncture. Comparisons were made versus (1) all controls (open control or sham acupuncture), and (2) sham acupuncture controls.

DATA COLLECTION AND ANALYSIS

Two review authors applied the inclusion criteria, assessed trial quality and risk of bias, and extracted data independently. We contacted study authors to ask for missing data. We assessed the quality of the evidence by using the GRADE approach. We defined the primary outcome as death or dependency at the end of follow-up .

MAIN RESULTS

We included in this updated review 33 RCTs with 3946 participants. Twenty new trials with 2780 participants had been completed since the previous review. Outcome data were available for up to 22 trials (2865 participants) that compared acupuncture with any control (open control or sham acupuncture) but for only six trials (668 participants) that compared acupuncture with sham acupuncture control. We downgraded the evidence to low or very low quality because of risk of bias in included studies, inconsistency in the acupuncture intervention and outcome measures, and imprecision in effect estimates.When compared with any control (11 trials with 1582 participants), findings of lower odds of death or dependency at the end of follow-up and over the long term (≥ three months) in the acupuncture group were uncertain (odds ratio [OR] 0.61, 95% confidence interval [CI] 0.46 to 0.79; very low-quality evidence; and OR 0.67, 95% CI 0.53 to 0.85; eight trials with 1436 participants; very low-quality evidence, respectively) and were not confirmed by trials comparing acupuncture with sham acupuncture (OR 0.71, 95% CI 0.43 to 1.18; low-quality evidence; and OR 0.67, 95% CI 0.40 to 1.12; low-quality evidence, respectively).In trials comparing acupuncture with any control, findings that acupuncture was associated with increases in the global neurological deficit score and in the motor function score were uncertain (standardized mean difference [SMD] 0.84, 95% CI 0.36 to 1.32; 12 trials with 1086 participants; very low-quality evidence; and SMD 1.08, 95% CI 0.45 to 1.71; 11 trials with 895 participants; very low-quality evidence). These findings were not confirmed in trials comparing acupuncture with sham acupuncture (SMD 0.01, 95% CI -0.55 to 0.57; low-quality evidence; and SMD 0.10, 95% CI -0.38 to 0.17; low-quality evidence, respectively).Trials comparing acupuncture with any control have reported little or no difference in death or institutional care at the end of follow-up (OR 0.78, 95% CI 0.54 to 1.12; five trials with 1120 participants; low-quality evidence), death within the first two weeks (OR 0.91, 95% CI 0.33 to 2.55; 18 trials with 1612 participants; low-quality evidence), or death at the end of follow-up (OR 1.08, 95% CI 0.74 to 1.58; 22 trials with 2865 participants; low-quality evidence).The incidence of adverse events (eg, pain, dizziness, faint) in the acupuncture arms of open and sham control trials was 6.2% (64/1037 participants), and 1.4% of these (14/1037 participants) discontinued acupuncture. When acupuncture was compared with sham acupuncture, findings for adverse events were uncertain (OR 0.58, 95% CI 0.29 to 1.16; five trials with 576 participants; low-quality evidence).

AUTHORS' CONCLUSIONS

This updated review indicates that apparently improved outcomes with acupuncture in acute stroke are confounded by the risk of bias related to use of open controls. Adverse events related to acupuncture were reported to be minor and usually did not result in stopping treatment. Future studies are needed to confirm or refute any effects of acupuncture in acute stroke. Trials should clearly report the method of randomization, concealment of allocation, and whether blinding of participants, personnel, and outcome assessors was achieved, while paying close attention to the effects of acupuncture on long-term functional outcomes.

Electroacupuncture brain protection during ischemic stroke: A role for the parasympathetic nervous system

The demand for using parasympathetic activation for stroke therapy is unmet. In the current study, we investigated whether the neuroprotection provided by electroacupuncture (EA) in an experimental stroke model was associated with activation of the parasympathetic nervous system (PNS). The results showed that parasympathetic dysfunction (PD), performed as unilateral vagotomy combined with peripheral atropine, attenuated both the functional benefits of EA and its effects in improving cerebral perfusion, reducing infarct volume, and hindering apoptosis, neuronal and peripheral inflammation, and oxidative stress. Most importantly, EA rats showed a dramatically less reduction in the mRNA level of choline acetyltransferase, five subtypes of muscarinic receptors and α7nAChR, suggesting the inhibition of the impairment of the central cholinergic system; EA also activated dorsal motor nucleus of the vagus, the largest source of parasympathetic pre-ganglionic neurons in the lower brainstem (detected by c-fos immunohistochemistry), and PD suppressed these changes. These findings indicated EA may serve as an alternative modality of PNS activation for stroke therapy.