Acupuncture treatment in post-stroke patients. Neural plasticity and neurogenesis in adult brain.
Karavis Miltiades, MD, FICAE, med.Ac. Consultant in Physical Medicine and Rehabilitation (PRM physician) President of Hellenic Medical Acupuncture Association Director of Acupuncture Department, Filoktitis Medical Rehabilitation Center According to National Stroke Associations, USA, stroke is one of the leading causes of long term adult disability, affecting 800.000 adults each year in US. Worldwide, 33 million people suffer from stroke (prevalence 2010) and is the second leading cause of death (11,13% of all deaths) above the age of 60 years. It is the leading cause of disability. Most stroke survivors will live with residual impairments that will diminish independence and quality of life. That is why the most important phase of recovery is rehabilitation. Rehabilitation of stroke survivors actually start in the hospital, as soon as possible, usually when patient’s vital signs are stable, within 3-5 days from the event. Acute and sub-acute rehabilitation units provide individualized inpatient programs. The long term goals are to improve function and relearn skills that are lost due to stroke. Despite the standard recovery methods available, no two identical recovery results can be obtained for patients who survived a cerebrovascular accident (CVA). Beside the conventional rehabilitation program, in our center we offer also acupuncture, electroacupuncture and scalp acupuncture, according to rehabilitation phase and goals. There are many issues that make it difficult to conduct a research in order to investigate the efficiency and effectiveness of acupuncture on post-stroke rehabilitation. Series of clinical researches in recent years have shown that acupuncture, as an ancient technique of peripheral sensory stimulation, regulates cerebral microcirculation, cerebral hemodynamics, brain metabolism, focal neuronal activity and function of specific brain regions. It seems that acupuncture enhances the capacity of adult brain to replace, in a quicker way, some of the lost neurons after stroke injury, promoting proliferation, migration and differentiation of neural stem cells. Animal studies (CMAO model) support also the hypothesis that acupuncture, as a form of sensory stimulation (sensory-dependent neural plasticity), inhibits post-ischemic inflammation, reduces peri-lessional edema, promotes neurogenesis and angiogenesis through the increase of neurotrophine and BDGF concentration. Clinically, there are some reports (small sampled, low quality studies) and reviews showing that acupuncture improves motor function and balance, upper and lower limb spasticity, self-care ability and quality of life. Furthermore, acupuncture is claimed to be effective in insomnia, anxiety and post-stroke depression. Finally, some acupuncture points show a specificity on cognitive function (memory, attention, concentration, vocational ability) and their use are considered of great importance on stroke rehabilitation. These are the reasons why we decided to include acupuncture as a commonly used technique in our stroke rehabilitation unit, at Filoktitis Rehabilitation center in Athens. Given the former, in Filoktitis Rehabilitation Centre, Athens-Greece, we conducted (starting from 2011) a preliminary study regarding the effect of TCM acupuncture and electro-acupuncture, on short and long term outcome, in a cohort of 160 patients (86 men (54%) and 74 women (46%), mean age±SD 41.1 ± 16.6 years). The main objective of this preliminary study was to assess the effect of an additional (acupuncture) intervention, in parallel with a routine stroke pharmacological treatment and rehabilitation program, in a sample of subjects with a wide spectrum of neurological conditions, but especially on stroke patients. Based on data provided by our experience and the present preliminary study, we aim to assess the effect of electro-acupuncture, TCM acupuncture or a combination of both on a bigger cohort of patients and their short and long term outcomes. The main objectives of this study were the assessment of treatment strategies concerning plasticity of the nervous system, amendment of rehabilitation and improvement of short and long term functional and physical outcomes. The design of the present research project (The Filoktitis Research Project) is multidimensional. Basically in order to evaluate baseline characteristics and treatment outcomes in evidence based medicine, we had to use valid and reliable tools. The majority of the scales and questionnaires used in rehabilitation medicine are not validated in Greek language for Greek speaking patients, assessors and clinicians. One of our objectives is to formally translate, adapt and validate key scales and questionnaires in Greek language such as, UK FIM+FAM and modified Ashworth Scale. Furthermore, we aim to assess the test-retest reliability of the scales by examining the inter-rater and intra-rater reliability. Finally, in a randomized-controlled design we aim to evaluate the effect of TCM (combined or not with electro-acupuncture) in big cohort of patients in our rehabilitation Centre. In the present topic we will review the latest data about neural plasticity and neurogenesis in adult brain, animal models and animal studies that confirm experience-based rehabilitation techniques. Finally we will present in detail the most important acupuncture points, TCM techniques and electroacupuncture parameters that we use in our inpatient and outpatient facility. Furthermore, we will share with you the challenges and problems we face in our daily routine by using acupuncture in stroke survivors.