Acupuncture for treatment CVA And Bell palsy

By balgis MD MSc CM-FM Sp Ak

Cerebrovascular Disease• Most frequent of all neurological problems• Incidence: third leading cause of death in

U.S. – half a million people a year – one third will die from it

• Due to blood vessel pathology:– Lesions on walls of vessels leading to brain– Occlusions of vessel lumen by thrombus or

embolus– Vessel rupture– Alterations of blood quality

CV disease leads to two types of brain abnormalities :

1. Ischemia (with or without infarct)

2. Hemorrhage

Sudden weakness, paralysis, or numbness of the face, arm and the leg on one or both sides of the body

Loss of speech, or difficulty speaking or understanding speech

Dimness or loss of vision, particularly in only one eye

Unexplained dizziness (especially when associated with other neurologic symptoms) unsteadiness, or sudden falls

Sudden severe headache and/or loss of consciousness

Incidence

• Highest risk > 65 years of age• But about 1/3 (28%) are < 65 years

old• Tends to run in families• More often seen in females• More often seen in Blacks, perhaps

due to increased incidence of hypertension

Three types :• Global hypoperfusion – shock• Ischemia – thrombotic and embolic• Hemorrhagic

Risk Factors• Arterial hypertension• Heart disease

– Myocardial infarction or endocarditis– Atrial fibrillation

• Elevated plasma cholesterol• Diabetes mellitus• Oral contraceptives• Smoking• Polycythemia and thrombocythemia

Occlusive strokes

• Occurs with blockage of blood vessel by a thrombus or embolus

• May be temporary or permanent• Thrombotic stroke:

– 3 clinical types:•TIAs•Stroke-in-evolution•Completed stroke

Transient Ischemic Attacks• Last for only a few minutes, always

less than 24 hours• All neurological deficits resolve• Symptom of developing

thrombosis

Causes:

• Thrombus formation– Atherosclerosis– Arteritis– Hypertension

• Vasospasm• Other:

– Hypotension– Anemia– Polycythemia

Symptoms depend on location

• Anterior or middle cerebral arteries – contralateral monoparesis, hemiparesis, localized, tingling numbness in one arm, loss of right or left visual field or aphasia

Treatment

• Without Tx 80% have a recurrence in symptoms, and 1/3 go on to have a full stroke within 5 years

• Give anticoagulants prophylactically , usually ½ to 1 aspirin / day

Stroke-in-evolution

• Can have abrupt onset, but develop in a step-by-step fashion over minutes to hours, occasionally, from days to weeks

• Characteristic of thrombotic stroke or slow hemorrhage

Thrombotic CVA

• Involves permanent damage to brain due to ischemia, hypoxia and necrosis of neurons

• Most common form of CVA• Causes:

– Atherosclerosis assoc. with hypertension– Diabetes mellitus, and vascular disease– Trauma

• May take years to develop, often asymptomatic until major narrowing of arterial lumen

• Anything that lowers systemic B.P. will exacerbate symptoms (60 % during sleep)

• Area affected depends on artery and presence of anastomoses

• Area affected initially is greater than damage due to edema

• Infarcted tissue undergoes liquifaction necrosis

NIH Stroke Scale

What is Acupuncture?• Acupuncture is one of the oldest, most in

the world. Originating in China commonly used systems of healing some 3,000 years ago, only in the last three decades has it become popular in the United States.

• In 1993, the FDA estimated that Americans made up to 12 million visits per year to acupuncture practitioners and spent upwards of half a billion dollars on acupuncture treatments.

Acupuncture• Qi maintains

balance in the body.

• 16 meridians• 360 regular

acupoints• 40 commonly used

extra points• Acupoints

influence the physiology

Chinese Medicine Efficacy• Primary health care system for over 3000 years• NIH (National Institute of Health) stated in 1997

report acupuncture is effective in the treatment of:

– Nausea - Headache– Dental pain -Fibromyalgia– Addictions -Tennis Elbow– Asthma -Stroke Rehab– Osteoarthritis – Menstrual Cramps– Myofascial Pain – Carpal Tunnel Syndrome– Lower Back Pain

Chinese Medicine EfficacyThe 1997 National Institute of Health Consensus Conference on Acupuncture

stated;

– "The data in support of acupuncture are as strong as those for many accepted Western medical therapies.“

– "One of the advantages of acupuncture is that the incidence of adverse effects is substantially lower than that of many drugs or other accepted medical procedures used for the same conditions."

• In China and Japan, an acupuncturist is likely to start therapy as soon as possible after a stroke

• Acupuncture is done on a daily basis in China.• in Western countries, some acupuncturists with

experience in treating stroke with acupuncture believe treatment 3 times a week is optimal.

• Several different approaches have been used to treat stroke, demonstrating that acupuncture for this disorder remains a healthcare art: Traditional Chinese Yang meridian point therapy, Chinese scalp acupuncture,

• Dr. Yamamoto's YNSA Japanese scalp therapy, Korean Koryo Chim hand acupuncture, supplemental ear (auricular) acupuncture, and Xingnao KaiQiao (a newer therapy by Professor Shi Xuemin) are each advocated by a number of treatment centers in Oriental countries. One need not know in depth the approach of each, but it is important to know that more than one approach is available and used.

• Adding acupuncture to rehabilitation therapy obviously increases the cost; daily-to-3 times-weekly treatment is needed for 2-4 weeks or longer. Concern for added cost would perhaps disappear if the end result demonstrates more self-care and less dependence on family and health providers

Does acupuncture really work to help stroke victims improve?

• Many studies involving thousands of patients have been published in China and Japan, and 2 of 3 studies from Scandinavia, demonstrated significant help.

• These studies indicate that patients get well faster, perform better in self-care, require less nursing and rehabilitation therapy, and use less healthcare dollars.

Oriental Medicine Cost EffectivenessAcupuncture Treatment Results In Decreased

Days In Hospital Or Nursing Home

Half of 78 stroke patients receiving standard rehabilitative care were randomly chosen to receive adjunctive acupuncture treatment. Patients given acupuncture recovered faster and to a greater extent, spending 88 days/patient in hospital and nursing homes compared to 161 days/patient for standard care alone.

Cost savings: $26,000 per patient.Johansson K et al (1994), "Can sensory stimulation improve the functional outcome in

stroke patients?", Neurology 43:2189-2192.

Acupuncturetoday.Com• Acupuncture Study at Kansas

Hospital Shows Dramatic Improvement in Stroke Patients (Jan.2004)

Media outlets throughout Kansas have reported that an acupuncture study conducted on stroke patients at Wesley Rehabilitation Hospital in Wichita has produced improvements so dramatic, officials have decided to stop the study early so that they can offer the service to all stroke patients who qualify.

(continued)

Acupuncture Study at Kansas Hospital Shows Dramatic Improvement in Stroke Patients• In the study, which began two

years ago, 33 patients who had suffered their first stroke were randomly assigned to receive either acupuncture or traditional speech, occupational and physical therapy. Ninety percent of the patients in the acupuncture group improved so much that they were able to go home rather than another facility after leaving the hospital, compared to just 33 percent of patients in the traditional therapy group. Stroke patients who received acupuncture also showed more improvement in the ability to carry out tasks such as as dressing, bathing, grooming, walking and changing position.

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• Johansson et al (1993) 1 investigated the effectiveness of acupuncture as a supplement to physical therapy in recovery from stroke. 78 patients suffering from severe hemiparesis of the left or right side within ten days of stroke onset were randomly divided into a control group (n=40) who received daily physical therapy and a treatment group who additionally received two acupuncture treatments per week for ten weeks. Patients receiving acupuncture recovered faster and to a larger extent than controls with significant differences in measures of balance, mobility, quality of life index, and days spent in hospitals/nursing homes.

More Doctor Believing in Acupuncture,CM

Peran Akup pd CVA• Mekanisme kerja akupunktur melalui

efek lokal, segmental dan sentral shg timbul efek:

1. Meningkatkan aliran darah ke otak terutama ke daerah lesi

2. Memperbaiki kegiatan elektrik otak3. Memperbaiki mikrosirkulasi otak4. Meregulasi lemak darah5. Menghilangkan radikal bebas6. Mempengaruhi kadar katekolamin dan

endorfin

Shin et al • Mendapatkan bahwa akupunktur dapat

meningkatkan LPO (lipid peroksidase) dan TAX 2 darah , meningkatkan SOD ( Superoxide dismutase) dan PGI2

• Dg peningkatan aktifitas dari SOD mk kerusakan neuron akibat LPO dapat dihambat

• PGI2 dan TAX2 merupakan faktor penting dlm mempertahankan sirkulasi darah dan mencegah pembentukan trombus

Zheng et al• Akupunktur dapat mengurangi

kerusakan jaringan otak akibat iskemi melalui mekanisme regulasi neuromediator,RNA sel dan Genom dalam inti sel shg timbul perlindungan terhadap sel otak yg menghambat proses kerusakan jaringan.

Jun et al • EA dapat mengurangi jmlh

apoptosis pd daerah infrak dikorteks serebri, mengurangi neurotoksisitas dari asam amino yg dihasilkan oleh proses iskemi dan menghambat ekspresi c-fos serta memperkuat ekspresi dari protei bcl-2 yg dapat menghambat apoptosis

Terapi Akupunktur 1. Pada CVA ischemi terapi dianjurkan

sedini mungkin, sebaiknya dilakukan 48 jam setelah tanda vital stabil (WHO)

2. Pada CVA haemorhage umumnya dilakukan 3 minggu setelah serangan setelah sadar dan tanda vital terutama tekanan darahnya stabil, dimulai dengan rangsangan ringan dan scr bertahap rangsangan ditingkatkan

Titik2 yg digunakan untuk membangkitkan kesadaran

• Renzhong• Fengchi• Neiguan

Chen G.S. dan Erdmann W• Perangsangan titik renzhong (GV 26)

dapat meningkatkan PO2 scr cepat pd lobus frontalis korteks serebri.

• Diduga bahwa perangsangan pd titik renzhong menstimulasi sistem simpatis termasuk eksitasi dari reseptor betha pada pembuluh arteri serebral akan menyebabkan vasodilatasi shg terjadi peningkatan aliran darah kapiler

Rencana terapi1. Pada periode syok otak• Digunakan jarum halus • Bisa digunakan EA dg gel yg jarang• Sehari sekali selama 20-30 menit• satu seri terapi 10 kali• Istirahat 2 hari sebelum msk seri

kedua• Merangsang sisi yg sehat

Titik untuk Ekstremitas sup

1. Jianyu2. Quchi3. Waiguan4. Hegu5. Houxi

Titik untuk Ekstremitas inf1. Biguan2. Xuehai3. Yanglingquan4. Xianzhong5. Taichong

Rencana terapi2. Periode Spastik • Digunakan jarum halus • Bisa digunakan EA dg gel yg jarang• Sehari sekali selama 20-30 menit• satu seri terapi 10 kali• Istirahat 2 hari sebelum msk seri kedua• Merangsang otot antagonis dr otot yg

spastis, meredakan tonus tinggi otot yg spastik, memulihkan posisi tubuh shg menjadi normal

Titik untuk Ekstremitas sup1. Jianyu2. Jianliao3. Tianjing4. shousanli5. Waiguan6. Hegu7. zhongzhu8. Houxi

Titik untuk Ekstremitas inf1. Nei Biguan2. Xia Xuehai3. Yanglingquan4. Xiaxi

Rencana terapi3. Periode pemulihan

Saat ini dapat ditambahkan akupuktur kulit kepala untuk meningkatkan vaskularisasi dan merangsang hidup sel neurontitik yg digunakan fengchi, gongxue (lebar 2 jari tgk lurus dibawah fengchi), Shishencong

Bell's Palsy• Bell's Palsy is presumably due to an

inflammatory reaction in or around the facial nerve near the stylomastoid foramen

• Bell's palsy, also known as idiopathic facial paralysis because of its unclear etiology.

• It is the most common disease of the facial nerve that causes important functional, aesthetic, and psychosocial disturbances in the patients.

Bell's Palsy• Pada umumnya bersifat akut• Tiba tiba• biasanya disadari saat bangun

tidur• Pada anamnesa penderita sering

ada riwayat terkena angin waktu berkendaraan atau tidur dg jendela terbuka

Gejala pada sisi lumpuh • Akibat kelumpuhan serabut somatomotoris n

fasialis1. Dahi tidak dapat dikerutkan 2. Mata tidak dapat menutup (lagopthalmus) 3. Dalam usaha menutup mata bola mata

kerap berputar keatas ( bell’s phenomen)4. Lipat nasolabial jadi datar5. Mulut tidak bisa diangkat baik scr spontan

maupun atas perintah6. Sudut mulut tertarik ke arah sisi yg sehat, • gangguan perasaan pengecapan pd 2/3

anterior lidah ( sisi kelainan) akibat kelumpuhan serabut viscerosensoris n facialis

Terapi akupunktur pd bell’s palsy• Merangsang otot wajah yg lumpuh

baik dg titik lokal maupun titik jauh• Titik akup yg sering digunakan:1. Yifeng 6. Yingxiang2. Xiaguan 7. Zanzhu3. Yangbai 8. Quanliao4. Sibai 9. Sizhukong5. Dichang 10. Hegu

• Rangsangan penjaruman atau dengan EA

• Setiap kali dirangsang 5-6 buah titik

• 3 kali perminggu

INTRODUCTION

• A 56-year-old white female presented with a 3-month history of severe right facial pain, weakness, and paralysis. This patient was referred to an otolaryngologist and a neurologist at Johns Hopkins, but did not achieve symptomatic relief.

PRESENTING COMPLAINT •      The patient's right facial paralysis developed

overnight. Associated symptoms included pain in her face, difficulty speaking clearly, aud hypersensitivity to sound in the right ear. She was unable to close her right eyelid, and experienced difficulty with drinking and mastication. She was evaluated and treated by an otolaryngologist, and placed on a steroid taper and acyclovir; symptomatic improvement in facial muscle strength did not occur. Her facial disfigurement and difficulty speaking impacted on her occupation (restaurant owner and operator). She developed mild depression and a secluded behavior.

MEDICATIONS

• Prednisolone, Premarin, Acyclovir, DHEA, vitamins, minerals, and a natural Synthroid substitute.

•  DIAGNOSTIC TESTS Autoimmune and serology were

negative. Lyme titer was negative. Thyroid function tests indicated that she was euthyroid with a slightly decreased TSH level.

• REVIEW OF SYSTEMS Neck pain, lower back pain, joint pain, depression, right facial pain and sensitivity to sounds in the right ear, with difficulty speaking clearly.

TREATMENT • Chinese medicine attributes this condition to Wind

and Cold of external origin which invade the meridians traversing the face and disrupt the flow of Qi and Blood, preventing the vessels and muscles from receiving the necessary nourishment.

• Treatment is directed toward spreading the Qi through the meridians of the face (1).

• The patient was treated with an integrated approach of acupuncture models. Points from a neuroanatomical model, or for classical indications, were included at each treatment and primarily used unilaterally. Other points utilized the energetic approach, and were treated bilaterally.

• The following acupuncture points were used without electrical stimulation.

• The local points were treated only on the right side, while the distal points were needled bilaterally.

• The principal points included GB 20 (Fengchi), GB 14 (Yangbai), ST 4 (Dicang), ST 2 (Sibai), and LI 4 (Hegu).

• The supplemental points included GV 26 (Renzhong), M-HN 18 [Jiachengjiang] (1), M-HN 9 (Taiyang), ST 7 (Ziagnuan), ST 36 (Zusanli), ST 44 (Neiting), and LI 19 (Heliao).

PATIENT RESPONSE •  The patient was initially graded with a House-

Brackmann grade 5 paralysis in the right facial muscles (4).

• After 10 acupuncture treatments over a 4-week period:1. She showed significant motion in her forehead and had

total closure of her eye with maximal effort. However, with normal effort, she had 1 to 2 mm of scleral fill with good protection of her cornea.

2. She also had good buccal movement and increased movement in the muscles supplied by the mandibular branch of her facial nerve.

• After a total of 15 acupuncture treatments over an 8-week period, she exhibited normal upper division motion and intact tone in the lower division, with only a mild decrease in motor strength in this division. Her strength was graded at approximately a House-Brackmann 2. She had full eye closure, and intact conjunctivae with slight ectropion.

• According to Liu (1995), when acupuncture was initiated within three days post-onset in 684 cases of facial nerve paralysis, 100 percent of the patients were cured or there was a marked improvement (5).

• Other studies (Gao, Chen, 1991) revealed that 80% of cases that were treated at more than 2 months post-onset, and 83 percent of severe cases, were cured or had excellent effect (6).

• Treatment, as with this patient, may include numerous diagnostic procedures, different classes of medications, lifestyle alterations, and still, continued suffering. Acupuncture may often lead to significant clinical improvement (7).

• Abstract: Background Bell’s palsy involves acute facial paralysis due to inflammation of the facial nerve. Acupuncture and moxibustion (acu-moxi) is beneficial in treating facial palsy. In order to verify the efficacy of acu-moxi on Bell’s palsy, a randomized single-blind, multicenter clinical trial was performed.

• Methods A total of 480 patients from four clinical centers were involved in this trial, of whom 439 completed the trial and 41 did not. All patients were randomly assigned to either the control group or to one of two treatment groups. The control group was treated with prednisone, vitamin B1, vitamin B12, and dibazole; the treatment groups were treated either with acu-moxi alone or in combination with prednisone, Vitamin B1, vitamin B12, and dibazole. Symptoms and signs, the House-Brackmann scale, and facial disability index (FDI) scores were assessed and determined both pre- and post-treatment to evaluate the effectiveness of the treatment methods.

• Results The characteristics of the control and two treatment groups were comparable without statistically significant differences before treatment. There were significant differences between the control and treatment groups after treatment (χ2=15.265, P=0.018). According to evaluations based on the House-Brackmann scale and FDI scores, the effectiveness of treatment in the two treatment groups was better than in the control group and was most effective in patients receiving acu-moxi treatment alone (Z=-2.827, P=0.005). Conclusion The efficacy of acu-moxi treatment for Bell’s palsy is verified scientifically.

• Treatment group 1 was given acu-moxi treatment. The acupuncture points used were Dicang (ST4), Jiache (ST6), Hegu (LI4), Yangbai (GB14), Xiaguan (ST7), and Yifeng (SJ17) on the affected side, and Hegu (LI4) bilaterally. ［ 1 ］ Filiform needles (1-1.5 cun, 0.32 mm) were used with moderate stimulation to get an acupuncture sensation, and the needles were retained for 30 minutes. Hanging moxibustion was applied for five minutes at each point, once a day, five times a week, for a total of four weeks.

• The House-Brackmann scale is specifically designed to evaluate the results of the treatment of facial paralysis disorders.［ 7 ］ Facial nerve function is graded by the House-Brackmann scale into 6 grades: Ⅰ, Normal; Ⅱ, Mild dysfunction; Ⅲ, Moderate dysfunction; Ⅳ, Moderately severe dysfunction; Ⅴ, Severe dysfunction and Ⅵ, Total paralysis. The House-Brackmann scale is generally accepted as effective in evaluating facial nerve function.

Clinical observation on treatment of acupuncture for different stages of Bell's palsy• ObJECTIVE: To observe the therapeutic effects of

acupuncture for treatment of different stages of Bell's palsy, and explore the best intervention period.

• METHODS: Forty cases of Bell's palsy patients were divided into three groups according to their onset time: an active stage group, a resting stage group and a recovery stage group. All three groups were treated with acupuncture. Fengchi (GB 20), Dicang (ST 4), Jiache (ST 6), Qianzheng (Extra), Sibai (ST 2), Yangbai (GB 14) on the affected side and Hegu (LI 4) on the healthy side were selected as main points. Dazhui (GV 14), Chengjiang (CV 24), Shuigou (GV 26) and Cuanzhu (BL 2), Yuyao (EX-HN 4), Yifeng (TE 17), Tinghui (GB 2), Quanliao (SI 18), Xiaguan (ST 7), Yingxiang (LI 20) on the affected side were selected as adjuvant points.

• RESULTS: (1) Acupuncture was effective for the Bell's palsy in active stage, resting stage and recovery stage (all P<0. 01); (2) The obvious effective rate of acupuncture for treatment of Bell's palsy in the active stage group was obviously superior to those of resting stage group and recovery stage (both P<0. 01). (3) There was no significant difference of the obvious effective rate between the resting stage group and the recovery stage group (P>0. 05).

• CONCLUSION: Acupuncture has a good therapeutic effect for treatment of Bell's palsy, and the therapeutic effect is most obvious with intervention of treatment in the active stage.