Muscle regions of meridians warm needling method plus pricking Jing-Well points for blood-letting in the treatment of shoulder-hand syndrome after stroke

Tang Xiao-li (唐小丽), Pan Hai-yan (潘海燕)

Rehabilitation Medicine Department, Kaizhou District People’s Hospital, Chongqing Municipality, Chongqing 405400, China

Abstract

Keywords: Acupuncture Therapy; Warm Needling Therapy; Acupuncture-moxibustion Therapy; Pricking Therapy; Points,Jing-Well (Five Shu-Transmitting); Poststroke Syndrome; Shoulder-hand Syndrome; Blood Circulation

Apoplexy, also known as stroke, can be divided into hemorrhagic stroke and ischemic stroke. It is a common clinical cerebrovascular disease that seriously threatens human health. Shoulder-hand syndrome (SHS) is a common complication of stroke, also known as reflex sympathetic dystrophy syndrome, which often occurs 1-3 months after stroke. It is the upper limb neurological dysfunction caused by cerebral and myocardial blood circulation disorders[1]. The main manifestations of the disease are shoulder-hand pain, upper limb edema, skin redness, joint dislocation and limited mobility. Severe cases can lead to permanent hand and finger deformity,which not only brings pain to the patients, but also seriously affects the recovery of upper limb function and is not conducive to prognosis. It is an important subject to deepen the clinical study of SHS and explore simple,safe and effective treatment methods. Treatments of Western medicine are mainly based on comprehensive rehabilitation trainings consisting of Western medications and exercise therapy, to reduce muscle spasm and improve symptoms by moving shoulder-hand joints. However, due to problems such as slow effect,poor tolerance and compliance of the patients, some patients don’t respond well to the treatment. Chinese medicine treatment has a long history of post stroke rehabilitation. A variety of treatment protocols have been proven to have good effects in the rehabilitation process. In this study, we used muscle regions of meridians warm needling method plus pricking Jing-Well points for blood-letting treatment to treat patients with SHS, by selecting nail fold microcirculation,hemorrheology, calcitonin gene-related peptide (CGRP)and substance P (SP) as indicators, to explored and discuss the efficacy and mechanism.

1 Clinical Materials

1.1 Diagnostic criteria

1.1.1 Diagnostic criteria in Western medicine

Those who met the diagnostic criteria of acute cerebrovascular disease in the Guidelines and Consensus on Diagnosis and Treatment of Cerebrovascular Diseases in China (2016 Version)[2], with diagnosis of cerebral hemorrhage or cerebral infarction confirmed by CT or MRI. Those who met the diagnostic points of SHS in the Chinese Stroke Rehabilitation Treatment Guidelines(2011 Complete Edition)[3]: unilateral pain in the shoulder and hand; local skin flushing on the affected side and increased skin temperature; limited flexion of fingers on the affected side; excluding pain caused by peripheral vascular disease, trauma and infection.

1.1.2 Criteria for syndrome differentiation of traditional Chinese medicine (TCM)

Those who met the diagnostic criteria of apoplexy in theGuiding Principles for Clinical Study of New Chinese Medicines[4]and the diagnostic criteria of Bi-impediment syndrome in theInternal Medicine of Traditional Chinese Medicine[5]. The syndrome differentiation was syndrome of blockade of wind-phlegm-static blood. Primary manifestations: hemiplegia, shoulder pain; finger and wrist pain. Secondary manifestations: wry eye and mouth, inarticulateness, heavy joints, dizziness, pale complexion. Tongue and pulse manifestations: a dull pale tongue with white or greasy coating, and stringy slippery pulse. Diagnosis could be confirmed by meeting the primary manifestations plus two or more items of the secondary manifestations, and referring the tongue and pulse.

1.1.3 SHS staging criteria

Stage Ⅰ: Early stage, mostly occurred 1 week after stroke, manifested as unilateral shoulder pain, wrist and finger swelling; limb color and temperature changes,flexion limited, and passive flexion with severe pain;visible vasoconstriction disorders of various degrees, and bone decalcification of the affected limb could be seen in the imaging examination.

Stage Ⅱ: Later stage, generally lasted for 3-6 months.Increasing shoulder-hand pain and gradually restricted activity, lusterless skin, and imaging examination showed bone changes.

Stage Ⅲ: Sequelae stage. Significant muscle atrophy in upper limb and wrist of the affected side, fixed and flexed hand, deformed finger, pain and edema relieved or disappeared, shoulder joint mobility lost, and osteoporotic changes were seen in the imaging examination.

1.2 Inclusion criteria

Those who met the above diagnostic criteria of Western medicine and the syndrome of blockade of wind-phlegm-static blood for syndrome differentiation of TCM; who had entered the recovery period from stroke and had stable vital signs; whose SHS staging was at stage I, and the onset time was no more than 3 months;gender was not limited; aged 35-80 years; agreed to participate in this trial and signed informed consent.

1.3 Exclusion criteria

Those who had SHS caused by brain trauma or other diseases; who had a history of shoulder-neck pain caused by cervical spondylosis or scapulohumeral periarthritis;combined with malignant tumors, psychotic or severe diseases of other systems; those combined with coagulation disorders, skin allergy or leukemia unsuitable for acupuncture treatment; who were under other TCM therapies or received other treatments during the trial; women during pregnancy or lactation;who had joint pain or dyskinesia caused by peripheral neuropathy.

1.4 Statistical methods

All data were statistically analyzed by SPSS version 22.0 statistical software. Measurement data in normal distribution and having homogeneous variance were expressed as mean ± standard deviation (x±s). The pairedt-test was used for intra-group comparison. And the comparison between the groups was analyzed by independent samplet-test. Data in non-normal distribution and not meeting homogeneous variance were analyzed by nonparametric test. Counting data were processed by Chi-square test. Rank sum test was used for the comparison of ranked data.P<0.05 was considered to indicate a statistically significant difference.

1.5 General data

This study was reviewed and approved by the Ethics Committee of Kaizhou District People’s Hospital,Chongqing Municipality (Approval No. 20190179). A total of 72 patients with SHS were enrolled from Kaizhou District People’s Hospital, Chongqing Municipality,between November 2019 and December 2020. All the patients were randomly divided into an observation group and a control group by the random number table method, with 36 cases in each group. There were no significant differences in the data of gender, average age,average duration of disease, stroke type, hemiplegia site or National Institute of Health stroke scale (NIHSS) score between the two groups (allP>0.05), indicating that the two groups were comparable (Table 1).

Table 1. Comparison of baseline data between the two groups

2 Treatment Methods

Patients in both groups received the same conventional treatment for stroke.

2.1 Observation group

Patients in the observation group were additionally treated with the following treatment methods.

2.1.1 Rehabilitation exercise

Rehabilitation exercise included anti-spasm postures,inhibitory manipulation to reduce muscle tone, lifting exercise, and Bobath treatment, twice a day, 15 min for each item.

2.1.2 Muscle regions of meridians warm needling method

Acupoints: Neiguan (PC 6), Hegu (LI 4), Chize (LU 5),Jianyu (LI 15), Quchi (LI 11), Jiquan (HT 1), Shousanli(LI 10), Zusanli (ST 36), Weizhong (BL 40) and Ashi points on the affected side.

Methods:The physician held the distal part of the affected limb, and made the upper limb perform external rotation, internal rotation and abduction. During the process, the physician used thumb pulp to explore and An-press, Dian-digital An-press and Tui-push, searching for the pain points or cord-shaped tendon nodes around the shoulder, and other possible lesions along the courses of three yang meridians of hand and three yin meridians of hand, then marked them. The above acupoints, obvious pain points or nodal points of tendons were selected for acupuncture every time, and sterile acupuncture needles of 0.30 mm in diameter and 20-40 mm in length were used. When needling Jiquan(HT 1), the patient took a supine position, with arms and lower limbs naturally straightened. The physician perpendicularly punctured at 2 cun below the original acupoint location along the course of the Heart Meridian.The lifting-thrusting and twirling manipulation was performed to the extent that the patient had numbness and swelling feeling in the upper limb and could tolerate it. The needles were withdrawn after 30 s. Conventional acupuncture was performed at the other acupoints, and even reinforcing-reducing manipulation was performed after qi arrival. The moxa stick was ignited and stuck to the tail of the needle, and heat insulation paper was placed on the skin to avoid burns. The needles were retained for 30 min. The treatment was performed once a day, and 2 consecutive weeks of treatment constituted one treatment course. The results were observed after 2 courses of treatment (4 weeks), with 1 week of interval between the two courses.

2.1.3 Pricking Jing-Well points for blood-letting

Acupoints: Shaoshang (LU 11), Zhongchong (PC 9) and Shaochong (HT 9) as one group, and Shangyang (LI 1),Guanchong (TE 1) and Shaoze (SI 1) as the other group.

Methods:One group of acupoints were selected each time, and the two groups of acupoints were applied alternately. After disinfection with 75 % alcohol cotton balls, the physician used three-edged needle to prick the acupoints, and extruded 5-10 drops of blood, then pressed to stop bleeding with sterilized dry cotton balls.The treatment was performed once a day, 2 weeks as a treatment course. The results were observed after 2 courses of treatment (4 weeks), with 1 week of interval between the two courses.

2.2 Control group

Patients in the control group were additionally treated with the same rehabilitation training as in the observation group. The results were observed after 2 courses of treatment (4 weeks), with 1 week of interval between the two courses.

3 Observation of Results

3.1 Observation items

All items were assessed before and after treatment.

3.1.1 Primary efficacy indicators

Shoulder-hand syndrome scale (SHSS) was used to evaluate the severity of SHS, which included scores of sensation (pain), autonomic nerve (edema) and activities(external turn and rotation of the arm). The total score was 14 points, and the higher the score, the more severe the injury degree.

The simplified Fugl-Meyer assessment-upper extremity (FMA-UE) scale was used to evaluate the ability of upper limb activities. The total score was 66 points, and the higher the score, the better the ability of upper limb activity.

3.1.2 Secondary efficacy indictors

Visual analog scale (VAS) was used to evaluate the pain of shoulder joint. The total score of VAS was 10 points, and the higher the score, the more severe the pain.

Activities of daily living (ADL) was used to evaluate the ability of daily living, including 10 aspects, with a total score of 100 points. The higher the score, the better the living ability.

TCM syndrome score was used to evaluate the degree of symptoms in TCM, scoring 0-3 points as the degree of none, mild, moderate and severe. The higher the score,the more severe the symptoms.

The incidence of adverse reactions during treatment was recorded.

3.1.3 Indicators for mechanism discussion

The CSW-XW880 microcirculation detector (Shenzhen Coosway Optical Instrument Co., Ltd., China) was used to detect the nail fold microcirculation of the affected side,and the integral was calculated according to the principle of Tian’s weighted integral[6].

LBY-N6G hemorrheological instrument (Beijing Precil Instrument Co., Ltd., China) was used to detect hemorheology indicators, including whole blood viscosity (high-shear and low-shear), hematocrit and erythrocyte sedimentation rate (ESR). Four-milliliter fasting venous blood was taken, and was added with 0.2 mL heparin anticoagulant solution. Detection was conducted after centrifugal separation.

The levels of CGRP and serum SP were measured by radioimmunoassay. The immunohistochemistry kit was provided by Shanghai Caiyou Industrial Co., Ltd., China.

3.2 Criteria of curative efficacy

Basically cured: Pain and swelling of the shoulder and hand joints disappeared. The movements of the joints were not restricted. SHSS score and TCM syndrome score reduction ≥90%.

Markedly effective: Pain and swelling of the shoulder and hand joints were significantly improved. The movements of the joints were slightly restricted. SHSS score and TCM syndrome score reduction ≥70%, but<90%.

Effective: Pain and swelling of the shoulder and hand joints were improved. The movements of the joints were mildly restricted. There was no obvious muscle atrophy of the hand. SHSS score and TCM syndrome score reduction ≥30%, but <70%.

Invalid: Didn’t meet the above effective criteria.

3.3 Treatment results

3.3.1 Comparison of curative efficacy

The total effective rate of the observation group was 86.1%, higher than 63.9% of the control group (P<0.05),and the overall curative effect of the observation group was better than that of the control group (P<0.05),(Table 2).

3.3.2 Comparison of SHSS score

There were no statistical differences in each SHSS score and the total score between the two groups before treatment (allP>0.05). After treatment, the scores of pain, edema, external turn and rotation of arm and the total score in both groups decreased significantly (allP<0.05). And each score in the observation group was lower than that in the control group (allP<0.05),(Table 3).

3.3.3 Comparisons of FMA-UE, VAS, ADL and TCM syndrome scores

There were no statistical differences in the FMA-UE,VAS, ADL and TCM syndrome scores between the two groups before treatment (allP>0.05). Compared with the same group before treatment, the VAS score and TCM syndrome score in both groups decreased significantly after treatment (allP<0.05), and FMA-UE and ADL scores increased significantly (allP<0.05). The VAS score and TCM syndrome score in the observation group were lower than those in the control group, and the FMA-UE and ADL scores were higher than those in the control group after treatment (allP<0.05), (Table 4-Table 7).

3.3.4 Comparison of hemodynamic indicators

There were no statistical differences in the hemodynamic indicators between the two groups before treatment (allP>0.05). Compared with the same group before treatment, the whole blood viscosity (high-shear,low-shear) and the hematocrit in both groups decreased significantly after treatment (allP<0.05), and ESR increased significantly (allP<0.05). After treatment, the whole blood viscosity (high-shear, low-shear) and the hematocrit in the observation group were lower than those in the control group, and ESR was higher than that in the control group. And the differences between the two groups were statistically significant (allP<0.05),(Table 8-Table 11).

Table 2. Comparison of clinical efficacy between the two groups (case)

Table 3. Comparison of the SHSS score between the two groups ( x ±s, point)

Table 4. Comparison of the FMA-UE score between the two groups ( x ±s, point)

Table 5. Comparison of the VAS score between the two groups ( x ±s, point)

Table 7. Comparison of the TCM syndrome score between the two groups ( x ±s, point)

Table 8. Comparison of whole blood viscosity (high-shear) between the two groups ( x ±s, mPa·s)

Table 9. Comparison of whole blood viscosity (low-shear) between the two groups ( x ±s, mPa·s)

Table 10. Comparison of the hematocrit between the two groups ( x ±s, %)

Table 11. Comparison of ESR between the two groups ( x ±s, mm/h)

3.3.5 Comparison of nail fold microcirculation score

There was no statistical difference in each item of nail fold microcirculations between the two groups before treatment (allP>0.05). Compared with the same group before treatment, the scores of peritubular state, loop shape, blood flow and the total score in both groups decreased significantly (allP<0.05) after treatment. After treatment, each item in the observation group was lower than that in the control group, and the difference between the groups was statistically significant (allP<0.05), (Table 12).

3.3.6 Comparisons of the CGRP and SP levels

There were no statistical differences in the CGRP and SP levels between the two groups before treatment(bothP>0.05). Compared with the same group before treatment, the SP levels in both groups decreased significantly and CGRP increased significantly after treatment, and the intra-group differences were statistically significant (allP<0.05). After treatment, the SP level in the observation group was lower than that in the control group, and the CGRP level was higher than that in the control group. And the differences between the two groups were statistically significant (bothP<0.05), (Table 13 and Table 14).

3.3.7 Adverse reaction

No serious adverse reactions occurred in the two groups.

Table 12. Comparison of nail fold microcirculation score between the two groups ( x ±s, point)

Table 13. Comparison of the CGRP level between the two groups ( x ±s, ng/L)

Table 14. Comparison of the SP level between the two groups ( x ±s, ng/mL)

4 Discussion

SHS refers to a group of clinical syndromes. Pain and concurrent contracture caused by SHS after stroke will affect the rehabilitation process of the stroke. Generally,SHS affects only one limb, but it may also affect multiple limbs. If the disease is delayed or treated improperly, SHS can cause permanent deformity of the hand and finger.At present, the pathogenesis of SHS is not clear. Crossed nervous system dysfunction, shoulder-hand pump dysfunction, excessive flexion of wrist joint, local injury caused by changes in the structure and function of the shoulder joint, excessive external force, and hand injury on the affected side can all lead to SHS[7]. Nowadays,Western medicine has no specific treatment for SHS.Comprehensive rehabilitation is the main method currently adopted. If necessary, treatment methods such as local anesthesia, drugs and stellate ganglion block can be adopted.

Rehabilitation training has a good effect in clinical treatment by strengthening the muscle function of the affected upper limb, promoting venous return,improving edema, promoting the recovery of muscle pump function, and protecting joint function. However,some patients are prone to have negative emotions due to pain and swelling, affecting treatment compliance,and unable to complete rehabilitation exercise strictly according to the requirements, resulting in poor clinical results.

There is no specific disease name for SHS in TCM. It falls under the category of ‘Bi-impediment syndrome’ in modern Chinese medicine, which is considered to be the blockage of blood stasis and phlegm and fluid retention in the meridians, resulting in the blockage of meridian qi,and the malnutrition of joints and muscles, leading to the stiffness and heaviness of the joints, flaccidity and disability[8-9]. In addition, the vital qi is not restored after stroke but the pathogenic qi is retained. The deficiency of qi causes it unable to promote the circulation of blood and body fluid. Blood stasis and phlegm-turbidity gather in the affected limb, presenting with edema and pain.SHS is a syndrome of essential deficiency and superficial excess, that is, the deficiency of vital qi is the core, and pathogenic wind, fire, phlegm and stasis are the superficiality. Clinically, the treatment should be based on invigorating qi and activating blood circulation,dissipating phlegm and dredging collaterals. In this study,muscle regions of meridians warm needling method plus pricking Jing-Well points for blood-letting was applied in the observation group. The selected Neiguan (PC 6),Zusanli (ST 36), Hegu (LI 4), Chize (LU 5), Quchi (LI 11) and Jiquan (HT 1) were the basic points for stroke. Local acupoints around the joint, Jianyu (LI 15) and Shousanli(LI 10), were added. Among which, Jiquan (HT 1) is the initial point of the Heart Meridian. It is located in the center of the axillary fossa and covered by axillary hair,so that it is inconvenient to puncture this point.Therefore, lower Jiquan (HT 1) was selected in this study for the treatment, not only avoiding axillary hair and arteries, avoiding infection, but also following the principle of leaving acupoints without departing from meridians[10], which was more targeted for SHS.Meanwhile, it was assisted by other acupoints to unblock the meridians and collaterals, regulate qi and blood in the upper limb, and promote the recovery of joint function. In this study, muscle regions of meridians warm needling method was applied. Muscle regions of meridians needling method is acupuncture according to the running course of meridians[11]. And warm needling therapy is the combination of acupuncture and moxibustion, which has the effects of benefiting qi for activating blood circulation, and unblocking meridians and activating collaterals, so as to provoke meridian qi,regulate circulation of qi and blood, and relieve pain. It can also warm meridians for dispelling cold, eliminate blood stasis for resolving hard mass, and remove edema for relieving pain[12]. Jing-Well points are located at the end of the limbs, where qi of the twelve meridians starts.They are sensitive and have more obvious effects of dredging meridians and activating collaterals than other acupoints. Pricking Jing-Well points by three-edged needle has the effects of activating blood and unblocking collaterals, and clearing heat for tranquillizing mind.Modern study showed that pricking blood therapy had obvious effects in increasing cerebral blood flow,expanding blood vessels, improving vascular elasticity,and regulating muscle physiological functions[13].Therefore, pricking Jing-Well points for blood-letting method was applied in the observation group at the same time.

Results of this study confirmed that muscle regions of meridians warm needling method plus pricking Jing-Well points for blood-letting had more significant efficacy in treating post-stroke SHS than physical rehabilitation training, and had significant effects in improving edema,relieving pain, promoting the recovery of joints and improving the quality of life.

The central nervous system injury of patients after stroke has a certain degree of plasticity. Improving local blood supply of the affected limb, stimulating blood circulation in the brain and exciting the nerve cells that are still active in the lesion can compensate and reconstruct the neuronal function to the maximum extent[14]. Results of this study suggested that the scores of peritubular state, loop shape and blood flow and the total score after treatment in the observation group were lower than those in the control group. The whole blood viscosity (high-shear, low-shear) and the hematocrit in the observation group were lower than those in the control group, and ESR was higher than that in the control group. It indicated that compared with rehabilitation training, muscle regions of meridians warm needling method plus pricking Jing-Well points for blood-letting could better improve the blood viscosity,aggregation and coagulation status in SHS patients after stroke, promote microcirculation, and provide support for the combination of TCM therapy and modern rehabilitation technology.

Abnormal levels of neuromodulators play a significant role in the occurrence and development of SHS[15]. CGRP is a kind of bioactive polypeptide associated with pain,widely distributed in the central nervous system. It has the effects of relaxing blood vessels, repairing endothelial cells, improving lymphatic reflux, and relieving spasm. It is also closely related to bone metabolism. Swelling, spasm and bone changes in SHS patients are the results of wild involving of CGRP. SP is mainly located in sensory nerve fibers. It can stimulate the pain signal transduction of sensory nerve fibers,transmit noxious information at the spinal cord level, and play an important regulatory role in the generation of pain. Shoulder pain in SHS patients is the result of SP initiating neurogenic inflammatory response and aggravating the degree of ischemia and hypoxia damage.In this study, the CGRP level in the observation group after treatment was higher than that in the control group,and SP was lower than that in the control group,indicating that muscle regions of meridians warm needling method plus pricking Jing-Well points for bloodletting achieved the curative effect by regulating the CGRP and SP levels.

In summary, muscle regions of meridians warm needling method plus pricking Jing-Well points for bloodletting has a certain efficacy in treating SHS. It can promote the recovery of physical functions, improve the nail fold microcirculation and hemorrheology indicators,and regulate cytokine levels such as CGRP and SP. This method achieves the purpose of treating both manifestation and root cause of disease, and thus is worthy of clinical promotion.

Conflict of Interest

There is no potential conflict of interest in this article.

Acknowledgments

This work was supported by Traditional Chinese Medicine Science and Technology Project of Chongqing Health Bureau (重庆市卫生局中医药科技项目, No.2019BA00328).

Statement of Informed Consent

This study had been approved by the Medical Ethics Committee of Kaizhou District People’s Hospital,Chongqing Municipality (Approval No. 2019BA00328).Informed consent was obtained from all individual participants.

Received: 30 July 2020/Accepted: 12 October 2020