Recent empirical evidence suggests that stimulating acupressure points with electrical stimulation has a positive effect on the function of patients with cerebral vascular accidents (CVA).  Acupressure therapy or acupuncture as its most commonly referred has been around for thousands of years.  Acupuncture originated in China and is most commonly associated with traditional Chinese medicine (TCM). Different types of acupuncture (Classical Chinese, Japanese, Tibetan, Vietnamese and Korean acupuncture) are practiced and taught throughout the world.  According to traditional Chinese medical theory, acupuncture points are situated on meridians along which qi, the vital energy, flows. There is no known anatomical or histological basis for the existence of acupuncture points or meridians. Acupuncture has been subject of active scientific research since only the 20^thcentury and its effects therefore are still not well understood by traditional Western medicine.  Nevertheless, emerging clinical evidence seem to imply this technique is effective for a variety of conditions raging to pain, tone reduction and even function.  Although there is research to prove the clinical use of stimulating acupressure points with electrical stimulation to improve functional outcomes on CVA patients, its physiological rational is very poorly understood.

Many studies point out to the functional benefits of acupuncture on CVA patients.  In a randomized controlled clinical trial published in 1993, Han - Hwa Hu et al showed that a small sample of acute / ischemic CVA patients treated with acupressure had better ADL scores on a Barthel Index (BI) at 3 month and 12 month post treatment when compared to the control group.  The BI covers relevant ADL variables that are sensitive in detecting small but real changes in functional levels (1).  A study by Johansson et al published in Neurology that same year proved that a bout of electro acupuncture therapy twice a week for 10 weeks substantially improved BI scores as well as balance and mobility in patients with severe hemi paresis of the left or right side within 10 days of stroke onset.  Moreover, the improvements were significantly better than those patients receiving conventional modes of physical and occupational therapy.  Nevertheless, the difference to the control group diminished with time and was lost at 1 - year follow up (2).  On another randomized control trial, Magnusson et al demonstrated that acute hemi paretic patients receiving electro acupressure therapy had better postural control and balance at the end of treatment than a control group receiving conventional modes of physical and occupational therapy.  Significantly more patients of the treatment group than of the control group maintained stance during perturbation.  And among patients capable of maintaining stance during perturbation, the control patients were characterized by significant divergence from normal values in two of the three characteristic parameters of dynamic postural control (i.e. swiftness and stiffness) (3).  Moreover, in a study conducted by Pei Jian et al on acute phase cerebral infarction subjects with hemi paresis, showed that motor functions and ADL's were significantly improved in the electro acupuncture group as compared with the control group receiving clinical treatment and therapeutic exercises.  The experimenters used the Brunnstrom - Fugl - Meyer and BI scores to measure outcomes (4).  Functional outcomes are not as promising however when examining the electro acupuncture studies for patients with chronic strokes.  In a randomized controlled sham trial, Wayne et al showed that over 10 weeks of electro acupressure therapy did not improve UE function or quality of life with chronic stroke symptoms.  It's worth mentioning that a subset of subjects in this study that were treated with electro acupressure, significantly improved UE spasticity as measure by the Ashworth scale and ROM compared with the sham control group (5).

As we can appreciate from the review of the literature above, acupuncture seems to have a positive effect on motor function however its underlying neurophysiology remains unknown.  One theory suggests that electro acupuncture increases blood circulation by decreasing blood viscosity, hematocrit and fibrinogen at the brain tissue level (1,2).  Moreover, some theories suggests that the technique promotes faster recovery through the promotion of damaged, but not dead, neurons in the border zone between infarct and surrounding brain tissue while others may also suggest that it stimulates alternative compensatory neural pathways in the brain (2).  In the muscle and skin, acupuncture may increase the blood flow through mechanisms thought to involve the sympathetic nervous system and neuropeptides.  According to Johansen et al, electrical stimulation of acupuncture points activates multiple efferent pathways that can lad to altered activity in numerous neural systems (2).  Studies on functional reorganization after stroke using positron emission tomography suggest considerable reorganization within the brain, including metabolic activation of contralateral and frontal areas.  Acupuncture may enhance the functional plasticity of the brain but this will require further testing (2).  It is also possible that acupuncture and other forms of sensory stimulation may activate multiple neuronal pathways at the spinal cord level leading to enhance neuronal activity during gait and balance recovery strategies.  According to Wayne, "...it is conceivable that the application of sensory stimulation might furnish spinal neurons with input that promotes remodeling or restoration of the coordinated motor function of the affected limbs." 

Effectively stimulating acupressure points with electrical stimulation modalities such as TENS or PENS in patients with acute and ischemic strokes can be a good adjunct treatment to increase function during rehabilitation.  Just like with anything else in therapy, this type of treatment should be followed with other proven techniques such as NDT, PRE, and functional / therapeutic exercise.  Until next time!

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References

1.  Hu HH, et al. A randomized controlled trial on the treatment for acute partial ischemic stroke with acupuncture.  Neuroepidemiology. 1993; 13:106-113.

2.  Johansson K, Lindgren I, et al.  Can sensory stimulation improve the functional outcome in stroke patients? Neurology. 1993; 43:2189-2192.

3.  Magnusson M, Johansson K, et al. Sensory stimulation promotes normalization of postural control after stroke.  Stroke. 1994; 25: 1176-1180.

4.  Jian P, Lijuan S, et al. The effect of electroacupuncture on motor function recovery in patients with acute cerebral infarction: A randomized controlled trial. J Trad Chin Med. 2001; 4: 270 - 272.

5.  Wayne PM, Krebs DE, et al.  Acupuncture for upper extremity rehabilitation in chronic stroke: A randomized sham - controlled study. Arch Phys Med Rehabil. 2005; 86(12): 2248 - 2255.