Evaluation on Efficacy of Acupuncture with Cognitive Intervention on Motor Function and Activities of Daily Living in Patients with Stroke

CHENZeng-li(陈增力)，LIXin-jun(李新军)，SUNHui(孙慧)，WANGXin-min(王新民)，LIULong-long(刘龙龙)，GONGFa-tao(巩法桃)

The People's Hospital of Binzhou City, Binzhou 256610, China

ABSTRACT Objective:To observe clinical efficacy of acupuncture with cognitive training on motor function and activities of daily living (ADL) after ischemic stroke.Methods:A total of 68 patients with ischemic stroke in departments of neurology and rehabilitation medicine in Binzhou City People's Hospital of Shandong province from January 2015 to December 2019 were selected. They were randomly divided into the treatment group and the control group, with 34 cases in each group. The 2 groups were both given conventional medication and rehabilitation. The control group received cognitive training, while the treatment group was treated by acupuncture more. Fugl-Meyer Assessment Upper Extremity Scale(FMA-UE), Fugl-Meyer Assessment Lower Extremity Scale (FMA-LE), Modified Barthel Index (MBI) and Mini-mental State Examination (MMSE) were used to evaluate efficacy in the 2 groups respectively before the treatment, 2 months and 4 months after the treatment.Results:There was no statistically significant differences in FMA-UE, FMA-LE, MBI and MMSE scores between the 2 groups before the treatment(P＞0.05). The scores of FMA-UE, FMA-LE, MBI and MMSE in the 2 groups were significantly improved 2 months and 4 months after the treatment (P＜0.05). The efficacy in the treatment group was better than that in the control group.Conclusion:Acupuncture with cognitive training is beneficial to recovery of motor function and improvement of ADL after stroke. At the same time, it also confirms effectiveness of acupuncture on cognitive disorder.

KEYWORDS Acupuncture; Cognitive intervention; Motor function and ADL; Evaluation on efficacy

About 40% of patients after stroke have different degrees of cognitive disorder. According to incomplete statistics, cognitive disorder after stroke is 6-9 times more common than without stroke. And cognitive disorder seriously affects recovery of limb motor function and ADL in stroke hemiplegia[1]. What's more, it may develop into vascular dementia, which greatly reduces life quality of patients and brings heavy burden to families and society. Epidemiological statistics show that nearly 70% of stroke patients have motor, sensory and cognitive disorder, among which, 30% of the stroke patients suffer from cognitive disorder[2], and this tends to occur in younger people. It is found that acupuncture combined with cognitive rehabilitation training is conductive to recovery of motor function and improvement of ADL after stroke. Results and other details are reported as follows.

MATERIALS AND METHODS

General Materials

A total of 68 hemiplegic patients with ischemic stroke treated in departments of rehabilitation medicine and neurology of our hospital from January 2014 to December 2019 were selected and randomly divided into the treatment group (34 cases) and the control group (34 cases). There was no statistically significant difference between the 2 groups in general information such as gender, age,course of disease, lesion location and educational level (P＞0.05), as shown in Table 1.

Diagnostic Criteria

(1) Western medicine diagnosis refered to relevant diagnostic criteria inChina Guideline for Cerebrovascular Disease Prevention and Treatmentformulated during the 6th Chinese Academic Conference on Cerebrovascular Disease in 2005,combined with definite diagnosis of stroke with cognitive disorder by CT or MRI.

Table 1. Comparison on General Information of Patients in the 2 Groups

(2) Diagnostic criteria of traditional Chinese medicine (TCM) refered to syndrome differentiation and diagnostic criteria inStandard on Diagnosis and Efficacy Evaluation of Strokeformulated by Encephalopathy Emergency Cooperation Group of National Administration of Traditional Chinese Medicine in 1996[4], in which, the main symptoms are hemiplegia, unconsciousness, deviated mouth and tongue, dysphasia or aphasia, and hemiparesthesia,accompanied by bucking when drinking and ataxia.

Inclusion Criteria

(1) Ischemic stroke had been diagnosed by CT or MRI. (2) Patients showed clear consciousness,capable to cooperate and complete instructions. (3)Vital signs were stable. (4) Age was 45-70 years old.(5) Informed consent form had been signed.

Exclusion Criteria

(1) Patients showed unstable vital signs and unconsciousness. (2) Patients did not cooperate and dropped out. (3) Patients showed poor compliance,who did not receive treatment as required that unable to judge the efficacy. (4) Patients with diseases in heart, lung, liver, kidney and other important organs.

Therapeutic Methods

The patients in the 2 groups received routine medication and routine rehabilitation treatment.The control group received cognitive rehabilitation training, while the treatment group also received acupuncture on the treatment basis of the control group. Steps of the cognitive rehabilitation training were as follows. (1) Memory training. Pictures were given to patients and they were asked the number of the pictures and names. After a certain interval, the patients were recalled and asked their contents again. (2) Writing training. It was to let a patient copy a common paragraph (about 30-40 words). (3) Calculation training. Common addition and subtraction calculation within 100,from easy to difficult. (4) Attention and hand-eye coordination training. Methods of mission deleting and number games were repeatedly completed.(5) Comprehensive analysis ability training. They were asked to classify the same items. Patients were asked to participate actively in daily life activities and other guided training, and their families were required to guide them. The patients were trained 5 times a week, 5 times as a course of treatment, and each training lasted for about 40 min.Acupoints selected for acupuncture were as follows.(1) Main acupoints were Baihui (GV20), Sishencong(EX-HN1), Fengchi (GB20), Fengfu (GV16),Tianzhu (BL10), Wangu (GB12), Yuzhen (BL9),Shenting (GV24) and Benshen (GB13). When needling Fengfu (GV16), the head was tilted slightly forward and neck muscles were relaxed.The needle was slowly thrust towards the mandible 0.5-1 cun (寸). The needle tip could not be upward,so as not to pierce the foramen magnum and injure the medulla oblongata. The rest of the acupoints were given routine acupuncture. (2) Acupoints selection base on TCM syndrome differentiation.For liver-kidney deficiency, Sanyinjiao (SP6),Ganshu (BL18) and Shenshu (BL23) were selected.For Qi-blood deficiency, Qihai (CV6) and Geshu(BL17) were selected. For blood stasis blocking collaterals, Weizhong (BL40), Geshu (BL17)and Xuehai (SP10) were selected. For phlegmturbidity obstructing middle-jiao, Zhongwan(CV12) and Fenglong (ST40) were selected.(3) Acupoints selection according to symptoms.For upper extremity paralysis, Jiansanzhen Points,Quchi (LI11), Shousanli (LI10) and Hegu (LI4) were selected. For lower extremity paralysis, Huantiao(GB30), Fengshi (GB31), Weizhong (BL40),Zusanli (ST36), Kunlun (BL60) and Taichong (LR3)were selected. For dysphasia, Jinjin (EX-HN12)and Yuye (EX-HN13) were selected. For motor aphasia, lower 2/5 of motor area was selected. For nominal aphasia, speech area Ⅱ was selected. For sensory aphasia, speech area Ⅲ was selected. For dysphagia, Lianquan (CV23) was selected. After arrival of Qi (气), low frequency pulse therapeutic apparatus (G6805-Ⅱ) was connected, once per day,40 min for each time, and 6 days per week.

Observation Index

Motor function

Fugl-meyer Assessment (FMA) was applied.The full score of FMA Upper extremity (FMA-UE) was 66 points. FMA-UE score61 points was markedly effective, 34-60 points indicated improvement, and less than 33 points was ineffective. The full score of lower extremity assessment on motor function was 34 points.The higher the score, the better the motor function.

Activities of daily living

MBI was applied to assess 10 items, including dressing, washing, urination and defecation, moving,going upstairs and downstairs, etc.. Normal was 100 points. MBI60 points was good and the patient could basically take care of himself. 41-59 points was classified as moderate disability and needing help in life. 20-40 points was severe disability and obviously dependent on others in life. MBI20 points were completely disabled and completely dependent on others in life.

Cognitive function

MMSE was applied for assessment. The highest score was 30 points, and 27-30 points was normal. The MMSE score ＜ 27 points being diagnosed as cognitive disorder or not was also based on educational levels(illiteracy: MMSE ＞ 17 points, elementary school:MMSE ＞ 20 points, secondary school: MMSE ＞22 points, and university: MMSE ＞ 23 points)[5].Among them, MMSE9 points was severe disorder,10-20 points was moderate disorder, and 21-26 points was mild disorder.

Statistical analysis

Statistical software SPSS 19.0 was used for analysis. Measurement data were expressed by(), andt-test was used for comparison on them between the 2 groups. Enumeration data between the 2 groups were analyzed byχ2test.P＜0.05 indicated there is a statistically significant difference.

RESULT S

(1) There were no statistically significant differences between the 2 groups in terms of gender, age, course of disease, educational level,lesion location, etc. (P＞0.05), as shown in Table 1.

(2) There were no statistically significant differences in FMA-UE and FMA-LE scores between the 2 groups before the treatment (P＞0.05). There were statistically significant differences in FMA-UE and FMA-LE scores between the 2 groups in 2 months and 4 months after the treatment (P＜0.05).There was a statistically significant difference in different time points (P＜0.05). There was an interaction between efficacy and time in FMA-UE and FMA-LE scores, with a statistically significant difference (P＜0.05). After 2 months of the treatment and 4 months of the treatment, differences between the treatment group and the control group were statistically significant (P＜0.05), as shown in Table 2.

(3) There were no statistically significant difference in MBI and MMSE scores between the 2 groups before the treatment (P＞0.05). There were statistically significant differences in MBI and MMSE scores between the 2 groups in 2 months and 4 months after the treatment (P＜0.05). There was a statistically significant difference in different time points (P＜0.05). There was an interaction between efficacy and time in MBI and MMSE scores, with a statistically significant difference (P＜0.05). After 2 months of the treatment and 4 months of the treatment, differences between the treatment group and the control group were statistically significant(P＜0.05), as shown in Table 3.

DISCUSSION

Cognitive disorder after stroke is closely related to recovery of extremity motor function and improvement of ADL. The structural basisof cognition is the cerebral cortex, and cognition depends on normal function of the cerebral cortex.Any factors that affect the function and structure of the cerebral cortex can lead to cognitive disorder,while vasculopathy after stroke affects the cerebral cortex and subcortical regions[6]. The mechanism of cognitive rehabilitation training to improve patients'cognitive disorder is in the exploratory stage, but a large amount of clinical practice has proved that cognitive rehabilitation training can cause changes in the structure and function of the nervous system[7],promote establishment and functional reorganization of brain neural networks, establish new cognitive neural networks, and improve the cognitive function of patients[8]. The key to recovery after brain injury is axon regeneration and remodeling. When function of the executive site is damaged, a large number of neurons will be activated to promote nerve regeneration and germination in synaptic branches of healthy or undamaged brain tissue, and improve collateral circulation.

Table 2. Comparison on the Scores of FMA-UE and FMA-LE between the 2 Groups before and after the Treatment Point)

Table 2. Comparison on the Scores of FMA-UE and FMA-LE between the 2 Groups before and after the Treatment Point)

Note: a indicates F value.

Group Cases FMA-UE FMA-LE Before the Treatment 4 Months of the Treatment Treatment group 34 27.91±3.21 39.75±4.93a 48.97±9.48a 12.06±3.39 19.03±4.54a 27.41±4.36a Control group 34 28.21±3.35 29.87±4.88 38.94±9.78 11.93±3.51 15.32±4.23 20.18±4.25 F value FInteraction = 14.02, FBetween-group = 101.8, FTime = 51.24 FInteraction = 11.81, FBetween-group = 131.1, FTime = 38.26 P value PInteraction ＜ 0.05, PBetween-group ＜ 0.05, PTime ＜ 0.05 PInteraction ＜ 0.05, PBetween-group ＜ 0.05, PTime ＜ 0.05 2 Months of the Treatment 4 Months of the Treatment Before the Treatment 2 Months of the Treatment

Table 3. Comparison on the Scores of MBI and MMSE between the 2 Groups before and after the TreatmentPoint)

Table 3. Comparison on the Scores of MBI and MMSE between the 2 Groups before and after the TreatmentPoint)

Note: Compared with the control group, aP＜0.05

Group Cases MBI MMSE Before the Treatment 4 Months of the Treatment Treatment group 34 34.39±8.75 50.69±13.62a 68.56±13.63a 24.39±2.05 26.91±1.82a 28.46±2.63a Control group 34 35.38±11.74 43.79±13.33 51.34±14.45 24.33±1.95 25.19±1.73 26.03±1.85 F value FInteraction = 8.75, FBetween-group = 65.92, FTime = 18.71 FInteraction = 6.122, FBetween-group = 34.78, FTime = 24.45 P value PInteraction ＜ 0.05, PBetween-group ＜ 0.05, PTime ＜ 0.05 PInteraction ＜ 0.05, PBetween-group ＜ 0.05, PTime ＜ 0.05 2 Months of the Treatment 4 Months of the Treatment Before the Treatment 2 Months of the Treatment

The mechanism of acupuncture on motor function and cognitive disorder, and improving ADL after stroke can be discussed from the following two aspects. (1) Traditional medical theory. Motor dysfunction after stroke belongs to the category of "stroke hemiplegia" in TCM. Its pathogenesis is Yin-Yang (阴阳) disharmony, Qi-blood disorder,blood stasis and obstruction of meridians. Cognitive disorder belongs to the category of "dementia" in TCM. The pathological changes are in mental status and the disease location is in the brain, which is related to dysfunction of the heart, liver, spleen and kidney. The basic pathogenesis in TCM is"obstruction of orifices and concealment of spirit"and failure in vital activity.Inner Canon of Huangdi(《黄帝内经》) believes that the pathological basis of dementia is phlegm, dampness and blood stasis.Plain Questions(《素问》) records, "running upwards to the forehead, converging over the vertex and entering into the brain".Classic of Questioning(《难经》) records that "the governor channel starts from Huiyin (CV1), runs along the spine, goes up to Fengfu (GV16), and enters the brain", indicating that the governor channel is closely related to cognitive function. From perspectives of the relationship between the governor channel and the human brain, "the brain being the sea of marrow","kidney governing bones, generating marrow and connecting the brain" and "heart governing spirit", experience of previous people in selecting acupoints was summarized, in which Fengchi(GB20), Fengfu (GV16), Tianzhu (BL10), Wangu(GB12) and Yuzhen (BL9) function in resuscitation,regulating Qi (气) and blood, and nourishing brain marrow[9]. Shenting (GV24), Benshen (GB13) and Sishencong (EX-HN1) locate in the projection area of frontal and parietal lobes, which manages highlevel thinking and memory functions of the brain,and acupuncture in this area plays a protective role in the brain and improves the cognitive and memory functions[10]. Hegu (LI4) combined with Taichong(LR3) is also known as "Siguan Points". MA Bao-mei et al.[11]stimulated rats' Baihui (GV20) and Siguan Points by electroacupuncture, and it could reduce inflammatory injury of focal cerebral ischemiareperfusion in rats and promote recovery of nerve function. Jianyu (LI15), Quchi (LI11), Waiguan (SJ5)and Hegu (LI4) are key acupoints for treating upper limb paralysis and pain in arms. Practice has proved that in addition to modern rehabilitation treatment,acupuncture can obviously improve efficacy and shorten treatment time. Acupuncture plays a multi-faceted and multi-target role in rehabilitation of stroke[13]. In short, acupuncture treatment of stroke hemiplegia and cognitive disorder is not only to promote rehabilitation of various functional disorders, but also to play a dual role of treatment and prevention in benign regulation on metabolism.(2) Modern medical mechanism. In recent years,studies have shown that acupuncture can activate some nuclei in brain associated functional areas of the nervous system, so as to control release of relevant neurotransmitters to regulate target organs[15]. Cognitive disorder is an important factor affecting motor function recovery after stroke, and cognitive function intervention can promote the recovery of motor function in patients with stroke[16].External environmental stimuli on the brain promote reestablishment of stroke patients' brain function,and make damaged nerve cells to regenerate and establish a compensatory mechanism, which are able to correct movement and cognitive disorders after stroke[17]. CHEN Jian-wei et al.[18]found that cognitive function rehabilitation training not only improves cognitive function of patients, but also promotes recovery of motor function and improves ADL in stroke patients. Moreover, GUO Song-peng et al.[19]found that the mechanism of nerve function recovery may be related to the function of acupuncture provoking scattered low-energy brain tissue.

This study set 3 time points for observation,which were those before the treatment, 2 months after the treatment and 4 months after the treatment.The FMA-UE and FMA-LE scores in the 2 groups were compared, there were statistically significant differences after the treatment, compared with those before the treatment (P＜0.05), indicating that acupuncture with cognitive rehabilitation training has remarkable efficacy on recovery of motor function after stroke (shown in Table 2). The MBI and MMSE scores in the 2 groups before the treatment were compared to those after the treatment, and there were statistically significant differences (P＜0.05). According to results of meta-analysis, acupuncture can improve motor function disorder in patients after stroke,improving the quality of life and their independence[20].The above indicates that the combination of traditional acupuncture and modern rehabilitation has an advantage of strong complementarity, which is worthy of clinical application.