Evaluation of the Curative Effect of "Xingnao Kaiqiao"Acupuncture Based on Brunnstrom Staging on Upper Limb and Hand Motor Function in the Recovery Period after Stroke

CHEN Zeng-li (陈增力), WANG Xin-min (王新民), CAO Ying-ying (曹莹莹),LIU Long-long (刘龙龙), LI Xin-ying (李新营), GONG Fa-tao (巩法桃)

Department of Rehabilitation Medicine, Binzhou People's Hospital of Shandong Province, Binzhou 256600, China

ABSTRA CT Objective:To observe the effects of Xingnao Kaiqiao acupuncture (醒脑开窍针) on the motor function of upper limb and hand in the recovery period after stroke.Methods:Seventy-six cases of hemiplegia patients with ischemic stroke were divided into the treatment group and the control group (n=38 in each). Based on the Brunnstrom's stage of Xingnao Kaiqiao acupuncture combined with rehabilitation training was used in the treatment group, and the control group was given rehabilitation training. Fugl-Meyer Assessment of the upper extremity (FMA-UE), Action Research Arm Test (ARAT) and Simple Test for Evaluating hand Function (STEF) were adopted separately to compare scores before treatment and 8 weeks after treatment.Results:The difference was not statistically significant in the two groups of patients for comparison of FMA-UE, ARAT and STEF scores before treatment (P＞0.05). The difference was statistically significant in the two groups of score comparison of FMA-UE, ARAT and STEF after treatment(P＜0.05).Conclusion:The Xingnao Kaiqiao acupuncture has its unique advantages in improving recovery of motor function of upper limb and hand in recovery period after stroke.

KEYWORDS Brunnstrom stage; Xingnao Kaiqiao acupuncture; Recovery period of cerebral ischemic stroke; Motor function of upper limb and hand

In recent years, with the continuous deepening of evidence-based medicine research, it has become a research hotspot to explore safe, scientific, and effective assessment and treatment to improve upper limb and hand dysfunction after stroke.Xie Jia-hong and others systematically evaluated the safety and effectiveness of Xingnao Kaiqiao acupuncture in the treatment of ischemic stroke[1],which has obvious curative effect and good safety in improving activities of daily living, neurological deficits and limb motor function. Different degrees of limb dysfunction are often left after a stroke. The upper limbs and hand function recover more slowly than the lower limbs. According to statistics, about 65% of post-stroke patients have upper limb and hand dysfunction and affect ADL[2]. 55%-75% of surviving stroke patients have left limb dysfunction,of which hand dysfunction accounts for 80%[3]. The upper limbs and hands play an important role in daily life[4]. After stroke, the upper limbs and hand dysfunction seriously affect the patient's life activity ability and quality of life. The clinical effect of using the Xingnao Kaiqiao acupuncture and compulsory exercise therapy on the recovery of upper limb and hand function after ischemic stroke was observed.The results were reported as follows.

MATERIALS AND METHODS

Clinical Data

General information

A total of 76 patients with hemiplegia during recovery from ischemic stroke who were hospitalized in the Department of Neurology or Rehabilitation Medicine of our hospital from June 2014 to August 2019 and met the selection criteria were selected as the research objects, and this study was discussed and approved by the medical ethics committee of Binzhou People's Hospital(No. 252). The enrolled patients were randomly divided into the treatment group (Xingnao Kaiqiao acupuncture plus rehabilitation training group) and the control group (rehabilitation training group),with 38 cases in each group. There were 38 cases in the treatment group, 21 males and 17 females,aged 43-70 (54.1±4.8) years old, and the course of disease was 3-6 (2.3±0.4) months. There were 38 cases in the control group, 23 males and 15 females,aged 41-69 (52.8±4.2) years old, and the course of illness was 3-7 (2.2±0.5) months. There was no statistically significant difference between the 2 groups in general data such as gender, age, course of disease and lesion location (P＞0.05).

Diagnostic criteria

The diagnostic criteria adopted in theGuidelines for the Prevention and Treatment of Cerebrovascular Diseases in Chinaformulated in 2005 by the Fourth National Conference on Cerebrovascular Diseases in China, and confirmed by CT or MRI. The patients are the first onset.

Inclusion criteria

① Meet the above diagnostic criteria; ② No speech and cognitive dysfunction; ③ With a certain understanding ability, able to cooperate to complete instructions; ④ Impact side shoulder joint active flexion and abduction＞90°, external rotation＞45°,elbow joint flexion and extension＞ 20°, forearm pronation and supination45°, wrist joint dorsal extension＞10°, thumb metacarpophalangeal joint extension＞10°extension can be repeated more than 3 times within 1 min; ⑤ Age 36-70 years old; ⑥ Brunnstrom Ⅲ-Ⅴ stage, the Brunnstrom classification of upper limbs and hands is above grade Ⅲ, and more than 3 months after stroke, with the symptoms of one upper limb dyskinesia; ⑦ Sign informed consent.

Exclusion criteria

① Patients with shoulder-hand syndrome after stroke; ② Severe cognitive impairment or severe depression; ③ Patients with other comorbidities with restricted activities.

Treatment Methods

Both groups were given basic treatment,including medications for blood pressure, blood lipids, and blood sugar control, and the same rehabilitation training. According to Brunnstrom's theory of 6 stages, the main symptoms of stage III-V are significantly increased muscle tension,and some fingers with spasms. The treatment is mainly to suppress muscle tension and promote separation movement. The main points in the treatment group were Fengfu (DU16), Tianzhu(BL10), Sishencong (EX-HN1), Baihui (DU20),Renzhong, Fengchi (GB20) (bilateral), Jiquan (HT1)(affected side), Chize (LU5) (affected side), Neiguan(PC6) (bilateral), Hegu (LI4), Houxi (SI3) (affected side), Baxie (EX-UE9), Laogong (PC8) (affected side). Combined acupoints: internal rotation of upper limbs to correct internal rotation (0.5 inches from Shousanli (LI10), inner edge of the ulna,affected side). The elbow joint cannot be flexed to take the biceps muscle abdomen (two points).The elbow joint cannot be straightened to take the triceps muscle abdomen (two points). Acupuncture operation: use disposable filiform needles(specifications: 0.25×25 mm, 0.25×50 mm,Suzhou Medical Products Factory Co., Ltd.),acupuncturing of Fengfu point 35 mm in the direction of the nose, local soreness, direct puncture 25 mm straight from the margin of Tianzhu point, soreness can spread to the top of the head. Sishencong and the skin are pierced forward, backward, left and right towards Baihui at an angle of 15°-30°. Neiguan avoids the median nerve, and acupuncture depth is 17-22 mm, performing lifting-thrusting and twirling.Renzhong: puncture upward obliquely 8-10 mm,performing lifting-thrusting and twirling, taking the patient's eyeball moistness as the degree, to achieve the effect index required by measurement. Jiquan:straight puncture 20-25 mm, performing liftingthrusting, and take the twitch of the affected limb as the degree. Chize: flex the elbow and puncture straight 15-22 mm, performing lifting-thrusting and twirling to make the patient's forearm slightly move.Fengchi: needle to the laryngeal knot, insert the needle 25-30 mm, perform twirling. Hegu: insert the needle 23-30 mm, performing lifting-thrusting and twirling to Houxi point to make the patient's index finger twitch. Baxie: performing lifting-thrusting and twirling to Laogong point, 1 time/day, 30-40 min per time, 6 days a week, a total of 8 weeks.

Rehabilitation training adopts compulsory exercise therapy: ① Splints and slings to fix the uninvolved upper limbs were applied. The daily fixation time of uninhibited upper limbs is not less than 90% of the waking time. ② Wearing splints and slings should be based on the patient's functional impairment. Including: shoulder joint rotation,forearm pronation and supination, wrist flexion and extension training, muscle strength training, thumb and forefinger pinch training, etc. ③ The exercise function obtained during the training was applied in daily life and the daily life training of the affected upper limb (Eating, holding things, brushing teeth,opening doors, making phone calls, etc.) was record.At least 2-3 kinds of training with corresponding functional defects every day (such as holding water cups, inserting wholes, holding balls, using chopsticks, writing, playing chess, etc.). Patients when they reach the required action goals were encouraged. The intensive training time gradually increased from 1 h to 2 h, and practiced for 6 days a week. At other times outside the treatment room, daily actions under the supervision of family members were completed. The daily practice time is not less than 2 hours for 8 consecutive weeks.

Observation Indicators

Upper limb motor function

The Fugl-Meyer upper limb function assessment method (FMA-UE) is used to assess the upper limb motor function score. The content includes 4 parts, and 33 items, using a 3-level score(0-2 points). Each joint of the upper limbs and their 5 functions: flexion, coordination, joint mobility,stability and coordination are separately evaluated[5].

Hand functions

Adopt ① Action Research Arm Test (ARTA)includes 4 items: grasping (6 items), grip (6 items),pinching (6 items) and gross movements (3 items),a total of 19 items, each item is scored by a 4-level score: 0 points means unable to complete the action,3 points means normal completion of the action. The total score is 57 points, and the evaluation time is about 10 minutes[6]. ② Simple Test for Evaluating Hand Function (STEF): Test the completion of 10 actions of fingers, such as flexion, extension, grasping,and holding. The difficulty is in the order of big ball,small ball, big square, etc. The score is based on the time required to complete the work activity, divided into 11 levels, each with a score of 0-10 points.The shorter the completion of the work activity, the higher the score. Under double-blind conditions,the two groups were evaluated for upper limb motor dysfunction and upper limb mobility limitation before treatment and 8 weeks after treatment.

Statistical Analysis

The statistical software version SPSS19.0 was used for analysis and processing. All scoring data were expressed as (). The data used t-test. The comparison between the two groups before and after treatment used paired datat-test. Independent samplettest was used for comparison between the two groups.P＜0.05 indicates that the difference is statistically significant.

RESULTS

Comparison of FMA-UE before and after Treatment in the Two Groups of Patients

There was no significant difference in FMA-UE and ARAT scores between the two groups before treatment (P＞0.05). FMA-UE score in the treatment group after treatment (55.69±5.62) was significantly higher than (42.59±5.33) in the control group(t=10.426,P＜0.01). Comparing the scores of the upper limb movement study scale after treatment in the two groups, the ARAT score in the treatment group (45.19±10.62) was significantly higher than(32.08±10.32) the control group (t=5.455,P＜0.01).Shown as Table 1.

Comparison of STEF of the 2 Groups Before and After Treatment

There was no significant difference in the STEF scores between two groups before treatment(P＞0.05). The STEF score in the treatment group after treatment (65.09±4.61) was significantly higher than (52.51±4.63) the control group(t=11.856,P＜0.01). Shown as Table 2.

DISCUSSION

Aim at the basic pathogenesis of stroke of blood stasis, liver wind, phlegm turbidity and other blinding the mind and leading to "blocking of orifice and concealment of the mind, spirit not leading thebreath", the Xingnao Kaiqiao acupuncture method is put forward as the treatment principles and methods.The method is mainly "rejuvenating the brain and opening orifice, nourishing the liver and kidney",and "unblocking the meridians" as a supplement.The selection of points is mainly based on the Yin Meridian and the Governor Meridian[7]. It mainly emphasizes acupuncture manipulative measurement norms, which is different from traditional acupuncture methods and acupoints selection[8], breaking the previous acupuncture thinking of "mainly Yang meridian, supplemented by Yin meridian".

Table 1. Comparison of FMA-UE and ARAT Scores before and after Treatment Between the Two Groups Point)

Group Cases FMA-UE score ARAT score Before treatment After treatment Before treatment After treatment The treatment group 38 28.99±5.52 55.69±5.62 23.89±9.32 45.19±10.62 The control group 38 29.04±5.66 42.59±5.33 24.18±9.69 32.08±10.32 t value 10.426 5.455 P value ＜0.01 ＜0.01

Table 2. STEF Scores before and after Treatment in the Two GroupsPoint)

Table 2. STEF Scores before and after Treatment in the Two GroupsPoint)

Group Cases Before treatment After treatment The treatment group 38 42.09±3.32 65.09±4.61 The control group 38 41.70±3.44 52.51±4.63 t value 11.856 P value ＜0.01

The treatment of acupuncture for stroke is multi-faceted and multi-targeted, and the selection of different acupoints at the right time will help patients with stroke to recover completely[9]. A number of clinical and basic experimental studies by Shi Xuemin have confirmed that Xingnao Kaiqiao acupuncture can effectively improve cerebral hemodynamics, slow down cell apoptosis, and is superior to traditional acupuncture in improving cerebral circulation,protecting brain cells, and improving brain function[10].The acupuncture has increased from qualitative replenishment and reduction to a quantitative level, and the operability of acupuncture therapy has been standardized[11]. The basic concept of constraint-induced movement therapy (CIMT) is to repetitively train the upper limbs on the affected side by restricting movement of the uninhibited limb. The personalized rehabilitation training programs are developed for upper limb motor dysfunction, emphasizing the active participation of patients. Through repeated mandatory plastic training, the plasticity of the brain and the plasticity of the synapses is changed, so as to maximize the recovery of the brain cortical function. It will obtain effective exercise components in the treatment process and use it in daily life.

Modern medicine believes that hand motor functions are fine movements, which are distributed in the cerebral cortex projection area. There are more single synapses between the α motor neurons that innervate the hand muscles and the corticospinal tract. This is also the reason for slower recovery of hand function after stroke[12]. Experiments have confirmed that acupuncture therapy helps to enhance the transmission of information from the affected limb to the brain cells, facilitates the low center of the spinal cord, excites α motor neurons, helps to realize the functional reorganization of the central nervous system, and promotes the production of limb separation and movement, so as to improve limb motor function[13]. A large number of studies have shown that active muscle weakness is an important factor that causes upper extremity dysfunction in stroke patients, leading to muscle weakness including motor neuron autonomous activation disorder, functional motor unit reduction,etc.[14]. Xingnao Kaiqiao acupuncture improves the plasticity of neuronal activity and the state of neurological deficits and regulates the stabilization of the cytoskeleton after cerebral ischemia-reperfusion injury, thereby improving the plasticity of neurons and protecting neurons[15].

Modern medicine shows that the structure and function of the brain are plastic. The undamaged cortex or under the cortex can undergo functional reorganization, and the damaged cortical area can be restored and remodeled and reorganized after effective treatment. FMA-UE has good reliability(ICC=0.92) and validity. The validity of ARAT has been verified at home and abroad. Muscle denervation or prolonged immobilization after stroke is prone to muscle atrophy. It is currently believed that muscle atrophy after stroke includes denervated muscular atrophy and disuse muscular atrophy.Its spasticity can aggravate muscle atrophy[16]. In this study, for the Xingnao Kaiqiao acupuncture method combined with CIMT therapy after 8 weeks of treatment, FMA-UE, ARAT, STEF in the treatment group scores were significantly higher than the control group (P＜0.01). It is suggested that the therapy can improve the motor function of upper limbs and hands in patients with stroke recovery period, help remodel the nerve function of the central nervous system,and significantly delay the process of compensatory changes in skeletal muscle after stroke.

Xingnao Kaiqiao acupuncture promotes the enhancement of muscle strength, relieves the degree of muscle spasm, helps the blood circulation of the brain and peripheral tissues, and enhances the reactivity of the nerves[17]. GAO Xiao-ying et al.[18]believes that this method repairs vascular neurons in the ischemic penumbra by adjusting blood rheology, and maximizing the internal environment of the body, which can reduce the NIHSS score of stroke and improve the related scores such as BI and ADL. Xingnao Kaiqiao acupuncture with CIMT in the treatment of stroke upper extremity and hand movement dysfunction can not only reflect the TCM perspective of syndrome differentiation and treatment, but also highlight the modern thinking of integration of traditional Chinese and Western medicine. On the one hand, Xingnao Kaiqiao combined with CIMT confirmed extensive activation of the ipsilateral and contralateral cerebral cortex before and after treatment by fMRI[19]. On the other hand, it regulates the body's neural reflexes,accelerates the remodeling of brain function, and helps the recovery of upper limb and hand function after stroke.