Acupuncture in Stroke Rehabilitation
Prof Barbro Johansson
Wallenberg Neuroscience Center, Lund, Sweden
Acupuncture and electroacupuncture stimulate skin and muscle afferents. Intracellular recordings of cortical neurons in primates as well as neuroimaging and neurophysiological studies in humans have shown that cortical sensorimotor representation areas can be modified by sensory stimulation. Experimental studies have demonstrated that acupuncture has circulatory and biochemical effects in common with physical exercise on the release of transmitters and peptides in the brain and spinal cord.1
Acupuncture has been used for the treatment of stroke patients in China from ancient times and is increasingly applied in stroke patients in western countries. Beneficial results have been reported in studies with different designs and treatments starting from 24 hours to 8 years after stroke onset. Although not generally accepted in the absence of convincing evidence of efficacy, the panel of the NIH Consensus Development Conference on Acupuncture stated in 1998 that: "There are other situations such as ...stroke rehabilitation ...where acupuncture may be useful as an adjunct treatment of an acceptable alternative or be included in a comprehensive management program".2 Few studies have been randomised and the use of control or sham groups have varied. An earlier study from my own department indicated a strikingly positive and lasting effect.3;4 However, although it was a randomised study, the effect of acupuncture was compared to controls with no alternative treatment.
The conclusion from a later randomised controlled multicentre trial was that there was no evidence for any specific effect of acupuncture.5 Three treatments were compared: acupuncture including electroacupuncture, low frequency high intensity TNS and subliminal high frequency low intensity TNS. It should be pointed out that even a subliminal stimulus (not perceived by the patient) may have an effect on the brain; furthermore, the simple fact of placing an electrode on the skin can lead to some brain activation. Thus the information to the patients was that all of them received one of three types of sensory stimulation.
The most likely explanation to the difference between the two studies is that the positive effect in our earlier study was due to expectation. We know that our thinking and our expectations have effects on the brain. Although it used to be believed that placebo effects are always transient, that might not be true and there is no theoretical reason why effects achieved by expectation could not be lasting.
Another point could be that during the time between the two studies a better general organisation of stroke care had positive effects that increased the outcome in all the three groups. Possible support for this interpretation is that the ADL improvement in all three groups was closer to the former acupuncture than to the former control group. However, another randomised study including a group with no sensory stimulation also failed to show any superiority of acupuncture.6
Current data on brain plasticity indicate that various types of sensory stimulation, training and activation can influence rehabilitation. Housing animals in an enriched environment after brain lesions interacts with various therapeutic interventions including drug treatment and transplantation. From experimental as well as clinical data methods combining sensory stimulation of various types and physical activity are likely to be most efficient.
Questions that have not been answered by our studies are whether acupuncture, low frequency TNS or other types are of value in specific subgroups of stroke patients. Studies with more homogenous patient populations combined with better evaluation methods may be more fruitful than multicentre studies to find such subgroups. There are some unavoidable problems with multicentre studies that will be discussed. However, to be able to generalise recommendations regarding acupuncture we need to show that the method works at more than one centre.
1. Andersson S, Lundeberg T. Acupuncture--from empiricism to science: functional background to acupuncture effects in pain and disease. Med Hypotheses 1995;45(3):271-81.
2. NIH Consensus Conference. Acupuncture. JAMA 1998;280(17):1518-24.
3. Johansson K, Lindgren I, Widner H, Wiklund I, Johansson BB. Can sensory stimulation improve the functional outcome in stroke patients? Neurology 1993;43(11):2189-92.
4. Magnusson M, Johansson K, Johansson BB. Sensory stimulation promotes normalization of postural control after stroke. Stroke 1994;25(6):1176-80.
5. Johansson BB, Haker E, von Arbin M, Britton M, Langstrom G, Terent A et al. Acupuncture and transcutaneous nerve stimulation in stroke rehabilitation: a randomized, controlled trial. Stroke 2001;32(3):707-13.
6.Gosman-Hedstrom G, Claesson L, Klingenstierna U, Carlsson J, Olausson B, Frizell M et al. Effects of acupuncture treatment on daily life activities and quality of life: a controlled, prospective, and randomized study of acute stroke patients. Stroke 1998;29(10):2100-8.>
Dr Johansson gained her MD and PhD at the University of Gothenburg, Sweden, and a Diploma of Tropical Medicine and Hygiene, London, 1964. She was visiting scientist, National Institutes of Health, USA, 1967-1968 and Professor of Neurology, Lund University 1981 - 1999.
Her present position is Senior Scientist, Division for Experimental Brain Research, Wallenberg Neuroscience Center. Lund, Sweden. Dr Johansson holds an EU appointment as senior scientist and adviser to the Slovak Academy of Sciences. Her research areas include clinical and experimental brain infarction; in particular how functional outcome can be influenced by postischaemic interventions such as environmental enrichment, sensory stimulation and neocortical transplantation; also possible mechanisms behind postischaemic brain plasticity. She has published more than 300 papers in international medical journals.
Dr Johansson was elected member of the Academia Europaea in 1994 and awarded the Sir Thomas Willis Award, by the American Stroke Council, 1999. She is an honorary member of the Swedish and Hungarian Stroke Associations and the World Federation of Neurology Research Group on Cerebrovascular Diseases.