Ask an expert - neuro and psycho logical - stroke

14 questions

Q:  I'm trying to find help with my (central post-stroke pain syndrome) I've had for 28 years after a stroke hemorrhage in 1990. I have tried everything from oramorph , Trans cranial magnetic stimulation, deep brain stimulation, spinal cord stimulation HF10 and other interventions all with no benefit so would acupuncture help?

A:  We have to be honest and say that if all of the other therapies you have tried over the last 28 years have failed to effect a change it would be a very considerable surprise if acupuncture treatment suddenly proved to be the answer. However, we are not entirely sure what the CVA has caused by way of continuing symptoms under the generic title of CPSP, and there are aspects of post stroke treatment where the blockages which arise at the time of the event will stay blocked until someone clears them. We do occasionally hear of people having dramatic changes twenty or thirty years after a problem began but this is quite a rare event, and we would never use examples like that as the basis for a recommendation.

We have gathered a considerable amount of information about the treatment of strokes in a rather dense review paper which can be found here

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

but the short answer to questions about efficacy is that in China acupuncture treatment, when used, commences almost immediately before the system has become 'fixed' in a state of disrepair, and the evidence suggests that this maximises the chances of regaining residual function quickly. The longer people wait for acupuncture treatment, the less well it seems to work and the less overall effect it seems to have.

Pain management is something for which acupuncture has developed something of a reputation since Nixon's visit to China in the 1970s and the sight of people having operations under acupuncture anaethesia. This led to a proliferation of trials and because neurotransmitter levels are easily measured a great deal of good evidence about the use of acupuncture to stimulate their release. Many Pain Management clinics base their work on this. The central question is how much relief and how sustainable, and it may be a matter of weighing up the cost and inconvenience against the amount of relief treatment can offer, it indeed it does work a little. 

The best advice that we can give is that you visit a local BAcC member to seek their view in a brief face to face assessment of what may be possible, depending in the exact presentation it is that you need help with. We also think that cranial osteopathy might be another pathway which might offer some potential for change, but we don't have a central referral point to which we can direct you. Many osteopaths use cranial techniques, but some spend a great deal of time on this work and are often the local 'go to' people for difficult cases. we would hope that any you might contact direct you to the most

Q. i'm trying to find help with my (central post-stroke pain syndrome) I've had for 28 years after a stroke hemorrhage in 1990.
i have tried everything from oramorph , Trans cranial magnetic stimulation, deep brain stimulation, spinal cord stimulation HF10 and other interventions all with no benefit so would acupuncture help?

A. We have to be honest and say that if all of the other therapies you have tried over the last 28 years have failed to effect a change it would be a very considerable surprise if acupuncture treatment suddenly proved to be the answer. However, we are not entirely sure what the CVA has caused by way of continuing symptoms under the generic title of CPSP, and there are aspects of post stroke treatment where the blockages which arise at the time of the event will stay blocked until someone clears them. We do occasionally hear of people having dramatic changes twenty or thirty years after a problem began but this is quite a rare event, and we would never use examples like that as the basis for a recommendation.

We have gathered a considerable amount of information about the treatment of strokes in a rather dense review paper which can be found here

https://www.acupuncture.org.uk/arrc/public-review-papers/stroke-and-acupuncture-the-evidence-for-effectiveness.html
but the short answer to questions about efficacy is that in China acupuncture treatment, when used, commences almost immediately before the system has become 'fixed' in a state of disrepair, and the evidence suggests that this maximises the chances of regaining residual function quickly. The longer people wait for acupuncture treatment, the less well it seems to work and the less overall effect it seems to have.

Pain management is something for which acupuncture has developed something of a reputation since Nixon's visit to China in the 1970s and the sight of people having operations under acupuncture anaethesia. This led to a proliferation of trials and because neurotransmitter levels are easily measured a great deal of good evidence about the use of acupuncture to stimulate their release. Many Pain Management clinics base their work on this. The central question is how much relief and how sustainable, and it may be a matter of weighing up the cost and inconvenience against the amount of relief treatment can offer, it indeed it does work a little.

The best advice that we can give is that you visit a local BAcC member to seek their view in a brief face to face assessment of what may be possible, depending in the exact presentation it is that you need help with. We also think that cranial osteopathy might be another pathway which might offer some potential for change, but we don't have a central referral point to which we can direct you. Many osteopaths use cranial techniques, but some spend a great deal of time on this work and are often the local 'go to' people for difficult cases. we would hope that any you might contact direct you to the most experienced, just as we imagine that our members might have a local 'hero' to whom they send the more challenging cases.

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.

 

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