Ask an expert - neuro and psycho logical - stroke

12 questions

This is a very good question. It is the received wisdom inside the profession that treatment should be started as soon as possible after a stroke, and that the potential for change and improvement diminishes over time. This is driven in part by the fact that in China it is not at all unusual for someone to start having treatment on the day of a stroke, the logic being that the energy of the body has been disturbed and the sooner that it is corrected, the less likely the disturbance is to be 'set' in the system. 

We have some sympathy with this view. There have been several books published in the last couple of decades which have explored the possibility that once an energetic pattern has become established it is no longer seen as a pathological factor but becomes the essence of the person. This means that someone can in a rather peculiar way become invested in the post-illness state as their reality, with the attendant difficulty in getting things to change. If you talk to people who teach the Alexander Technique you find the same model; once the body has  a set pattern it takes a long time to re-train it.

However, our clinical experience with post-stroke patients is rather more mixed than this. Whilst we have always warned patients who come in many months or years after the initial stroke that progress may be slow or in some cases non-existent, we have found that some people do have a marked and immediate response to treatment, often in direct proportion to their underlying constitutional health. A person who was strong and energetically in good shape before the CVA often has a greater power to recover.

There has been a mountain of research into this area, as you can see from the rather long review paper which we have on our website

 https://www.acupuncture.org.uk/arrc/public-review-papers/stroke-and-acupuncture-the-evidence-for-effectiveness.html


but which may be a little technical for many readers. It has long been our hope that the evidence will reach a critical mass where we can argue a case for early intervention within the NHS with acupuncture treatment, if for no other reason than the fact that increasing the speed of recovery would save the NHS millions of pounds in rehabilitation costs. We have some hope that familiarity with the Chinese system will encourage some trials in the UK.

As far as your brother is concerned, however, it is rather difficult to say what might be possible without a face to face assessment. What you and he will find, however, is that most of our members are very happy to give up a little time without charge to prospective patients to see whether acupuncture treatment would be a good option. Most of us are very frank about someone's chances because the disappointment of achieving nothing or very little is just as palpable by the practitioner as the patient. We get it wrong - some people we think we can't help recover amazingly and we think we can help don't. In the main, however, we tend to recognise those people for whom acupuncture is well worth a try.

The crucial thing is to try to set measurable outcomes so that improvements are not just a matter of feeling better in oneself, good as this is, but visible through verifiable markers - better range of movement, greater endurance in in walking, and so on. This avoids the problem of running up a large bill without really getting anything back. If it isn't working after five to ten sessions it is better to draw a line unless there are secondary improvements which render the treatment worthwhile.

The use of acupuncture treatment to help after stroke is now becoming more greatly accepted, and as you can see from our review paper

https://www.acupuncture.org.uk/arrc/public-review-papers/stroke-and-acupuncture-the-evidence-for-effectiveness.html There has been considerable interest because in China it is not uncommon for people to begin  a course of acupuncture treatment within hours of a stroke in order to remobilise the energy of the body as quickly as possible.

The paper doesn't make much mention of dysphagia, though, and for that we have had to look at wider evidence sources. The best summary is here

https://www.ncbi.nlm.nih.gov/pubmed/23000511.

A systematic review is a means of aggregating the results of many different trials and is seen as a very effective way of building up a wider picture than a small trial can offer. The results are encouraging, although as always there is criticism of the design studies and methodological rigour of many of the tests. This is usually to do with the fact that most studies are performed in China and are less concerned with whether acupuncture works - 2500 years of history says it does - than with what works better. We are still held to account for whether it works at all, which requires a very strict and not entirely appropriate trial design.

There was one rather interesting study published in  2016 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4810993/ which looks really encouraging but the technique describes pharyngeal acupuncture, and we doubt that you will find many UK practitioners either trained in this technique or willing to do it. There are also a growing number of practitioners using scalp acupuncture, for which there are two or three main systems, and great claims are made for their success in treating neurological problems, but here the research is very thin. If you can find someone who works with this method near where you live it may be worth having a chat with them.

We always advise prospective patients to visit a BAcC member local to them for a chat. Everyone is unique and different, and with cases like stroke recovery there are so many confounding factors that it is always best to find a way of getting a face to face assessment. There are no magic formulae to apply, but there are often signs which a practitioner can use to assess how well someone is likely to respond. This is invaluable for offering a prognosis.

From a Chinese medicine perspective there are many ways of regarding functional disturbances, and given the general agreement about what causes a stroke in energetic terms it is sometimes possible to track the functional disturbances which flow from this to the problems with swallowing in a way which offers direct treatment possibilities.

We are always cautious, however; the longer a symptom has been in place the more difficult it can be to move, a view shared with conventional medicine in looking at post-stroke recovery. If the problem arises from a head injury rather than an infarct, though, there may be good reasons to believe that acupuncture treatment may be able to help, however long after the injury a person is treated.

 

Q:  My father suffered from brain stroke 5 yrs ago. He is getting physiotherapy but his left hand is still not working. Can he have acupuncture therapy for this? Does this procedure have any side effects?

A: We are sorry to hear of your father's continuing problems.

Let's deal with the easy answer first. There are very few side effects from acupuncture, and the vast majority are transient. We put together a safety website with the two leading medical acupuncture organisations (www.acupuncturesafety.org.uk)  which quotes a number of research studies. These show that acupuncture ranks as one of the safest therapies around. There are occasionally minor reactions to treatment, like headaches or tiredness, and very rarely an injury caused by the needles, but when you consider that there are over 4 million treatments being given each year the number of these is remarkably low.

The other side of your question is more difficult to answer. We have on the BAcC website a very thorough review paper

 http://www.acupuncture.org.uk/arrc/public-review-papers/stroke-and-acupuncture-the-evidence-for-effectiveness.html

as well as a simpler factsheet

http://www.acupuncture.org.uk/a-to-z-of-conditions/a-to-z-of-conditions/3894-stroke.html

which are both very encouraging about the use of acupuncture for the after effects of stroke. In China, however, it is common practice to start treatment on the day of the stroke itself and to treat daily or more to try to restore the 'lost' functions as quickly as possible. The received wisdom is that if the treatment is delayed it becomes progressively more difficult to achieve the same level of result and the final outcome may not be as good. This is paralleled by some treatments in the west, where drug intervention on the day may work when a gap means it won't. The fact that your father is now five years on from his stroke suggests that where he is now may not improve a great deal.

However, there's no point in being unduly pessimistic. All of us have taken on cases like this and managed to achieve a great deal more than we expected. The great strength of Chinese medicine is that it treats the individual, not the condition, and there is always a chance that if someone's baseline constitution is strong they may be able to achieve quite a great deal of improvement. Full restoration of function would be a stretch, but some gain may be possible.

The best advice, which we invariably give, is to visit a local BAcC member with your father to get a face to face assessment of what may be possible. Most of our colleagues are more than happy to give up a little time without charge to see whether acupuncture treatment may be of benefit.  

 

Q:  My sister aged 31 had brain haemorrhage and paralysis on 30th March, 2016 (9:00 AM). She was 7 weeks pregnant that time thru IVF. Due to large infarcts in right brain, doctors went for craniotomy same day at 11:30 PM and she had 28 stitches in head.

After staying 6 days unconscious, and 22 days in ICU, she was brought home after 1 month from hospital. Now at home, her baby is normally growing and double marker test is fine. She is taking all foods from mouth directly, no support and no tubes.

But, she has no movement in her left hand and leg. Physiotherapy is going on. She is speaking well, brain working fine, memory is sharp.

Could acupuncture can help with  her paralysis?

A: We are really sorry to hear of your sister's problems; that must have been a terrible shock to all of you. It's good that she has made the recovery she has so far, and that the baby is well.

The nearest equivalent research that we have which can offer some positive hope of a good outcome is research into the use of acupuncture treatment in the recovery from stroke. On our website there is a rather dense review paper

http://www.acupuncture.org.uk/arrc/public-review-papers/stroke-and-acupuncture-the-evidence-for-effectiveness.html

which goes through in great detail the various papers which show encouraging possibilities for the use of acupuncture treatment. It used to be the case, and is still likely to be, that acupuncture treatment was commenced on the day of a stroke itself. The Chinese medicine understanding of what is happening in a stroke or CVA is given the generic term 'wind stroke' and is seen as a disruption of the flow of energy in the channels caused by an uncontrolled upsurge in the head. The treatment strategy is very straightforward; restore proper flow in the channels or meridians on the affected side as soon as possible. Treatment would often involve a course of daily or even twice daily sessions for several weeks to try to restore energy flow as quickly as possible before the post-stroke pattern is established as a norm.

This always raises questions in the West, where if someone is lucky acupuncture treatment might be possible four to six weeks after the CVA itself, of whether a late start hinders the chance of recovery. We would have to be honest and say that the later start would possibly slow down progress, but not stop it. The received wisdom is that within the first year there is always something that can be done, but this is not a precise judgement. This expert has seen good changes in someone two years down the line and treated others within the year to no effect. It really is a matter of the individual circumstances and the strength of someone's constitutional energy. At 31 your sister has a better chance than many.

The confounding factor is the pregnancy. Generally we all try to treat with as little intervention as possible during the pregnancy, and there is now a solid strand of postgraduate training in acupuncture for pregnancy, fertility and childbirth that we are on the verge of defining what would constitute expert practice and the ability to define oneself as a specialist. It would be ideal if any practitioner your sister saw had this training. However, the issue here is what may have caused the infarct. From a Chinese medicine perspective there are a number of possibilities, the treatment of which alongside the pregnancy and the post-stroke recovery might call for a level of expertise and experience which not all of our members might feel that they have. You may have to ask around a little to see who might be the best person to see. We tend to be a very honest bunch, and we direct people to those colleagues who we think will be best for the patient's needs.

We hope that your sister finds acupuncture treatment beneficial, if she decides to go ahead with it, and that the rest of her pregnancy is trouble-free and rewarded with a happy outcome.

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