Advertisement

Electroacupuncture for Poststroke Spasticity: A Systematic Review and Meta-Analysis

  • Author Footnotes
    ∗ Cai and Zhang contributed equally to this work.
    Yiyi Cai
    Footnotes
    ∗ Cai and Zhang contributed equally to this work.
    Affiliations
    China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia

    Guangdong Provincial Hospital of Chinese Medicine (The Second Affiliated Hospital of Guangzhou University of Chinese Medicine), Guangdong Provincial Academy of Chinese Medical Sciences, and The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
    Search for articles by this author
  • Author Footnotes
    ∗ Cai and Zhang contributed equally to this work.
    Claire Shuiqing Zhang
    Footnotes
    ∗ Cai and Zhang contributed equally to this work.
    Affiliations
    China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
    Search for articles by this author
  • Shaonan Liu
    Affiliations
    Guangdong Provincial Hospital of Chinese Medicine (The Second Affiliated Hospital of Guangzhou University of Chinese Medicine), Guangdong Provincial Academy of Chinese Medical Sciences, and The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
    Search for articles by this author
  • Zehuai Wen
    Affiliations
    Guangdong Provincial Hospital of Chinese Medicine (The Second Affiliated Hospital of Guangzhou University of Chinese Medicine), Guangdong Provincial Academy of Chinese Medical Sciences, and The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
    Search for articles by this author
  • Anthony Lin Zhang
    Affiliations
    China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
    Search for articles by this author
  • Xinfeng Guo
    Affiliations
    Guangdong Provincial Hospital of Chinese Medicine (The Second Affiliated Hospital of Guangzhou University of Chinese Medicine), Guangdong Provincial Academy of Chinese Medical Sciences, and The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
    Search for articles by this author
  • Chuanjian Lu
    Affiliations
    China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia

    Guangdong Provincial Hospital of Chinese Medicine (The Second Affiliated Hospital of Guangzhou University of Chinese Medicine), Guangdong Provincial Academy of Chinese Medical Sciences, and The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
    Search for articles by this author
  • Charlie Changli Xue
    Correspondence
    Corresponding author Charlie Changli Xue, PhD, School of Health and Biomedical Sciences, RMIT University, PO Box 71, Bundoora, VIC 3083, Australia.
    Affiliations
    China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia

    Guangdong Provincial Hospital of Chinese Medicine (The Second Affiliated Hospital of Guangzhou University of Chinese Medicine), Guangdong Provincial Academy of Chinese Medical Sciences, and The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
    Search for articles by this author
  • Author Footnotes
    ∗ Cai and Zhang contributed equally to this work.
Published:April 25, 2017DOI:https://doi.org/10.1016/j.apmr.2017.03.023

      Abstract

      Objective

      To evaluate the effects and safety of electroacupuncture (EA) for stroke patients with spasticity.

      Data Sources

      Five English databases (PubMed, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine Database) and 4 Chinese databases (Chinese Biomedical Database, Chinese National Knowledge Infrastructure, Chongqing VIP Database, Wanfang Database) were searched from their inception to September 2016.

      Study Selection

      Randomized controlled trials were included if they measured spasticity with the Modified Ashworth Scale (MAS) in stroke patients and investigated the add-on effects of electroacupuncture to routine pharmacotherapy and rehabilitation therapies.

      Data Extraction

      Information on patients, study design, treatment details and outcomes assessing spasticity severity, motor function, and activities of daily living was extracted.

      Data Synthesis

      In total, 22 trials involving 1425 participants met the search criteria and were included. The estimated add-on effects of EA to reduce spasticity in the upper limbs as measured by the MAS (standardized mean difference [SMD]=−.57; 95% confidence interval [CI], −.84 to −.29), and to improve overall motor function as measured by the Fugl-Meyer Assessment of Sensorimotor Recovery (mean difference [MD]=10.60; 95% CI, 8.67–12.53) were significant. Significant add-on effects of EA were also shown for spasticity in the lower limbs, lower-limb motor function, and activities of daily living ([SMD=−.88; 95% CI, −1.42 to −.35;], [MD=4.42; 95% CI, .06–8.78], and [MD=6.85; 95% CI, 3.64–10.05], respectively), although with high heterogeneity. For upper-limb motor function, no significant add-on effects of EA were found.

      Conclusions

      EA combined with conventional routine care has the potential of reducing spasticity in the upper and lower limbs and improving overall and lower extremity motor function and activities of daily living for patients with spasticity, within 180 days poststroke. Further studies of high methodological and reporting quality are needed to confirm the effects and safety of EA, and to explore the adequate and optimal protocol of EA for poststroke spasticity, incorporating a group of comprehensive outcome measures in different populations.

      Keywords

      List of abbreviations:

      BI (Barthel Index), CI (confidence interval), EA (electroacupuncture), FMA (Fugl-Meyer Assessment of Sensorimotor Recovery), MAS (Modified Ashworth Scale), MD (mean difference), MDD (minimum detectable difference), RC (routine care), SMD (standardized mean difference)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

      1. World Health Organization. Global status report on noncommunicable diseases 2014. Available at: http://apps.who.int/iris/bitstream/10665/148114/1/9789241564854_eng.pdf. Accessed January 20, 2016.

        • Watkins C.L.
        • Leathley M.J.
        • Gregson J.M.
        • Moore A.P.
        • Smith T.L.
        • Sharma A.K.
        Prevalence of spasticity post stroke.
        Clin Rehabil. 2002; 16: 515-522
        • Zorowitz R.D.
        • Gillard P.J.
        • Brainin M.
        Poststroke spasticity: sequelae and burden on stroke survivors and caregivers.
        Neurology. 2013; 80: S45-S52
        • Kwah L.K.
        • Harvey L.A.
        • Diong J.H.
        • Herbert R.D.
        Half of the adults who present to hospital with stroke develop at least one contracture within six months: an observational study.
        J Physiother. 2012; 58: 41-47
        • Bravo-Esteban E.
        • Taylor J.
        • Abian-Vicen J.
        • et al.
        Impact of specific symptoms of spasticity on voluntary lower limb muscle function, gait and daily activities during subacute and chronic spinal cord injury.
        NeuroRehabilitation. 2013; 33: 531-543
        • Gillard P.J.
        • Sucharew H.
        • Kleindorfer D.
        • et al.
        The negative impact of spasticity on the health-related quality of life of stroke survivors: a longitudinal cohort study.
        Health Qual Life Outcomes. 2015; 13: 159
        • Martin A.
        • Abogunrin S.
        • Kurth H.
        • Dinet J.
        Epidemiological, humanistic, and economic burden of illness of lower limb spasticity in adults: a systematic review.
        Neuropsychiatr Dis Treat. 2014; 10: 111-121
        • Milinis K.
        • Young C.A.
        • Trajectories of Outcome in Neurological Conditions (TONiC) study
        Systematic review of the influence of spasticity on quality of life in adults with chronic neurological conditions.
        Disabil Rehabil. 2016; 38: 1431-1441
        • European Stroke Organisation (ESO) Executive Committee
        • ESO Writing Committee
        Guidelines for management of ischaemic stroke and transient ischaemic attack 2008.
        Cerebrovasc Dis. 2008; 25: 457-507
        • Australian National Stroke Foundation
        Clinical guidelines for stroke management 2010.
        (Available at:) (Accessed May 22, 2016)
        • Miller E.L.
        • Murray L.
        • Richards L.
        • et al.
        Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: a scientific statement from the American Heart Association.
        Stroke. 2010; 41: 2402-2448
        • Smith L.N.
        • James R.
        • Barber M.
        • Ramsay S.
        • Gillespie D.
        • Chung C.
        Rehabilitation of patients with stroke: summary of SIGN guidance.
        BMJ. 2010; 340: c2845
        • Stroke Foundation of New Zealand and New Zealand Guidelines Group
        Clinical guidelines for stroke management.
        Stroke Foundation of New Zealand, Wellington2010
      2. Chinese Society of Neurology and Stroke Prevention Project Committee of National Health and Family Planning Commission in China. [China post-stroke rehabilitation guideline].
        Chin J Rehabil Theory Pract. 2012; 18 ([Chinese]): 18
      3. National Institute for Health and Care Excellence. Stroke rehabilitation in adults clinical guideline 2013. Available at: https://www.nice.org.uk/guidance/cg162. Accessed January 20, 2016.

        • Bensmail D.
        • Quera Salva M.A.
        • Roche N.
        • et al.
        Effect of intrathecal baclofen on sleep and respiratory function in patients with spasticity.
        Neurology. 2006; 67: 1432-1436
        • Bensmail D.
        • Ward A.B.
        • Wissel J.
        • et al.
        Cost-effectiveness modeling of intrathecal baclofen therapy versus other interventions for disabling spasticity.
        Neurorehabil Neural Repair. 2009; 23: 546-552
        • Harned M.E.
        • Salles S.S.
        • Grider J.S.
        An introduction to trialing intrathecal baclofen in patients with hemiparetic spasticity: a description of 3 cases.
        Pain Physician. 2011; 14: 483-489
        • Sze K.H.
        • Wong E.
        • Or K.H.
        • Lum C.M.
        • Woo J.
        Factors predicting stroke disability at discharge: a study of 793 Chinese.
        Arch Phys Med Rehabil. 2000; 81: 876-880
        • Nair K.P.
        • Marsden J.
        The management of spasticity in adults.
        BMJ. 2014; 349: g4737
        • Wu P.
        • Mills E.
        • Moher D.
        • Seely D.
        Acupuncture in poststroke rehabilitation: a systematic review and meta-analysis of randomized trials.
        Stroke. 2010; 41: e171-e179
        • Fan L.B.
        • Liu S.Z.
        • Wang Z.T.
        • et al.
        Application of electro-acupuncture plus movement therapy in recovering neurologic function of patients with spastic hemiplegia.
        Shanghai J Acupunct Moxibustion. 2015; 34: 3
        • Lim S.M.
        • Yoo J.
        • Lee E.
        • Kim H.J.
        • Shin S.
        Acupuncture for spasticity after stroke: a systematic review and meta-analysis of randomized controlled trials.
        Evid Based Complement Alternat Med. 2015; 2015: 870398
        • Liu A.J.
        • Li J.H.
        • Li H.Q.
        • et al.
        Electroacupuncture for acute ischemic stroke: a meta-analysis of randomized controlled trials.
        Am J Chin Med. 2015; 43: 1541-1566
        • Mukherjee M.
        • McPeak L.K.
        • Redford J.B.
        • Sun C.
        • Liu W.
        The effect of electro-acupuncture on spasticity of the wrist joint in chronic stroke survivors.
        Arch Phys Med Rehabil. 2007; 88: 159-166
        • Park S.W.
        • Yi S.H.
        • Lee J.A.
        • Hwang P.W.
        • Yoo H.C.
        • Kang K.S.
        Acupuncture for the treatment of spasticity after stroke: a meta-analysis of randomized controlled trials.
        J Altern Complement Med. 2014; 20: 672-682
        • Qi Y.
        • Fu L.
        • Xiong J.
        • Wang Z.
        • Mou J.
        • Lu Y.
        Systematic evaluation of acupuncture for treatment of post-stroke spastic paralysis.
        Chin Acupunct Moxibustion. 2009; 29: 6
        • Yu M.
        • Zhang H.
        [The effects of electro-acupuncture combined with rehabilitation exercises for spasticity in hemiplegia patients].
        Chin Gen Pract. 2007; 10 ([Chinese]): 2
        • Liu M.
        • Li Z.H.
        • Ma H.
        Clinical evaluation of electric acupuncture at antagonistic muscle acupoints combined with rehabilitation training for the treatment of apoplexy spastic paralysis.
        J Clin Acupunct Moxibustion. 2016; 32: 3
        • Cheng P.
        • Jin H.M.
        • Zheng J.
        • Liu Z.G.
        Clinical research on transcranial direct current stimulation and electrical acupuncture therapy for upper limb spasticity after stroke.
        Chin Arch Tradit Chin Med. 2015; 33: 4
        • Zhang S.
        • Lei M.
        • Xiao Y.
        • Zou L.
        [A clinical research on the effects of electro-acupuncture combined with Bobath therapy for post-stroke spasticity].
        Chin J Public Health. 2015; 31 ([Chinese]): 2
        • Huang R.L.
        • Xia Q.
        • Zhu Z.J.
        • Yuan H.
        • Chen R.Q.
        • Xiao H.B.
        [A clinical research on the effects of acupuncture combined with rehabilitation for post-stroke spasticity].
        J Anhui Univ Chin Med. 2016; 35 ([Chinese]): 4
        • Yao G.
        • Zeng K.
        • Zhou F.
        [Applying electro-acupuncture to acupoints in antagonistic muscles combined with physical therapies for post-stroke muscle spasticity].
        Chin Manipulation Rehabil Med. 2012; 3 ([Chinese]): 1
        • Yang D.
        • Lin X.
        • Yu Z.
        [The effects of acupuncture combined with Bobath therapy for post-stroke spasticity and motor function].
        Liaoning J Tradit Chin Med. 2007; 34 ([Chinese]): 2
        • Yan W.
        • Huo W.
        • Yao B.
        • Yin J.
        [The effects of electro-acupuncture combined with physical therapies for muscle spasticity after cerebral infarction].
        Chin J Phys Med Rehabil. 2010; 32 ([Chinese]): 3
        • Xue Q.
        • Li S.
        • Huo G.
        [The effects of acupuncture therapy to balance muscle tones for hemiplegia patients with spasticity in motor function rehabilitation].
        Jiangsu J Tradit Chin Med. 2008; 40 ([Chinese]): 2
        • Xing X.
        • Yang B.
        • Li F.
        • et al.
        [Acupuncture and moxibustion combined with rehabilitation treatment of 30 cases of spastic hemiplegia after ischemic stroke] [Article in Chinese].
        Liaoning J Tradit Chin Med. 2015; 42: 3
        • Wu W.
        [The effects of acupuncture combined with rehabilitation therapies for strephenopodia in hemiplegia side after stroke].
        Shanghai J Acupunct Moxibustion. 2011; 30 ([Chinese]): 3
        • Wu B.
        • Gao W.
        • Yang X.
        • et al.
        [Electro-acupuncture combined with rehabilitation therapies for post-stroke spasticity in 30 hemiplegia patients].
        J Clin Acupunct Moxibustion. 2008; 24 ([Chinese]): 2
        • Wang G.
        • Guan Y.
        • Ma X.
        [The clinical observation on acupuncture combined with oral medications for stroke survivors with increased muscle tone].
        Acta Chin Med Pharmacol. 2007; 35 ([Chinese]): 2
        • Lu J.
        [Clinical observation on needling combined with rehabilitation treatment of foot-drop for post-stroke patients] [Article in Chinese].
        Fujian University of Traditional Chinese Medicine, Fuzhou: Minhou2003
        • Lu J.
        • Tu W.
        • Zhang D.
        • et al.
        Effects of acupuncture on different acupoints in combination with rehabilitation on hemiplegic muscle spasticity in hemiplegia patients.
        Chin Acupunct Moxibustion. 2010; 30: 5
        • Lu F.
        [The combination of acupuncture Bobath therapy tendon junction of spastic paralysis after stroke clinical efficacy] [Article in Chinese].
        Heilongjiang University of Chinese Medicine, Harbin: Xiangfang2011
        • Li L.
        • Yang W.
        • Hu F.
        • et al.
        [Clinical effect of electric acupuncture and baclofen on recovery of spasticity] [Article in Chinese].
        Chin J Rehabil. 2007; 22: 2
        • Li H.
        • Yue G.
        • Liu D.
        • et al.
        [Electro-acupuncture combined with rehabilitation therapies for 30 cases with post-stroke foot drop].
        Yunnan J Tradit Chin Med Materia Medica. 2011; 32 ([Chinese]): 2
        • Guo J.
        [The study of acupuncture for early stage of post-stroke rehabilitation].
        ([Chinese]) Beijing University of Chinese Medicine, Beijing: Chaoyang District2003
        • Guo J.
        • Yang L.
        • Lu H.
        [An observational study on acupuncture for motor dysfunction of upper limbs after cerebral infarction].
        Guang Ming Zhong Yi. 2015; 30 ([Chinese]): 2
        • Cai H.
        • Liao R.
        • Zhang Y.
        • et al.
        [Neurodevelopment treatment combined with acupuncture for 30 cases at the stage of spasticity after stroke].
        Hunan J Tradit Chin Med. 2011; 27 ([Chinese]): 2
        • Page S.J.
        • Fulk G.D.
        • Boyne P.
        Clinically important differences for the upper-extremity Fugl-Meyer scale in people with minimal to moderate impairment due to chronic stroke.
        Phys Ther. 2012; 92: 791-798
        • Wagner J.M.
        • Rhodes J.A.
        • Patten C.
        Reproducibility and minimal detectable change of three-dimensional kinematic analysis of reaching tasks in people with hemiparesis after stroke.
        Phys Ther. 2008; 88: 652-663
        • Hsieh Y.W.
        • Wang C.H.
        • Wu S.C.
        • Chen P.C.
        • Sheu C.F.
        • Hsieh C.L.
        Establishing the minimal clinically important difference of the Barthel Index in stroke patients.
        Neurorehabil Neural Repair. 2007; 21: 233-238
        • McMakin C.R.
        • Oschman J.L.
        Visceral and somatic disorders: tissue softening with frequency-specific microcurrent.
        J Altern Complement Med. 2013; 19: 170-177
        • Zhao W.
        • Wang C.
        • Li Z.
        • et al.
        Efficacy and safety of transcutaneous electrical acupoint stimulation to treat muscle spasticity following brain injury: a double-blinded, multicenter, randomized controlled trial.
        PLoS One. 2015; 10: e0116976
        • World Health Organization
        WHO international standard terminologies on traditional medicine in the western Pacific region.
        Office of Publications, World Health Organization, Geneva2007
        • White A.
        • Cummings M.
        • Barlas P.
        • et al.
        Defining an adequate dose of acupuncture using a neurophysiological approach—a narrative review of the literature.
        Acupunct Med. 2008; 26: 111-120
        • Deare J.C.
        • Zheng Z.
        • Xue C.C.
        • et al.
        Acupuncture for treating fibromyalgia.
        Cochrane Database Syst Rev. 2013; : CD007070
        • Thibaut A.
        • Chatelle C.
        • Ziegler E.
        • Bruno M.A.
        • Laureys S.
        • Gosseries O.
        Spasticity after stroke: physiology, assessment and treatment.
        Brain Inj. 2013; 27: 1093-1105
        • Fleuren J.F.
        • Voerman G.E.
        • Erren-Wolters C.V.
        • et al.
        Stop using the Ashworth Scale for the assessment of spasticity.
        J Neurol Neurosurg Psychiatry. 2010; 81: 46-52
        • Cousins E.
        • Ward A.B.
        • Roffe C.
        • Rimington L.D.
        • Pandyan A.D.
        Quantitative measurement of poststroke spasticity and response to treatment with botulinum toxin: a 2-patient case report.
        Phys Ther. 2009; 89: 688-697
        • Lindsay C.
        • Helliwell B.
        • Harding P.
        • et al.
        A prospective observational study investigating the time course of arm recovery and the development of spasticity and contractures following stroke.
        Physiotherapy. 2015; 101: e887-e888
        • Zhao J.G.
        • Cao C.H.
        • Liu C.Z.
        • et al.
        Effect of acupuncture treatment on spastic states of stroke patients.
        J Neurol Sci. 2009; 276: 143-147
        • Dincer F.
        • Linde K.
        Sham interventions in randomized clinical trials of acupuncture—a review.
        Complement Ther Med. 2003; 11: 235-242
        • Koog Y.H.
        Effect of placebo acupuncture over no-treatment: a simple model incorporating the placebo and nocebo effects.
        Complement Ther Med. 2016; 24: 69-72
        • Wong E.L.
        • Leung P.C.
        • Zhang L.
        Placebo acupuncture in an acupuncture clinical trial. How good is the blinding effect?.
        J Acupunct Meridian Stud. 2015; 8: 40-43
        • Zhu D.
        • Gao Y.
        • Chang J.
        • Kong J.
        Placebo acupuncture devices: considerations for acupuncture research.
        Evid Based Complement Alternat Med. 2013; 2013: 628907
        • Pildal J.
        • Hrobjartsson A.
        • Jorgensen K.J.
        • Hilden J.
        • Altman D.G.
        • Gotzsche P.C.
        Impact of allocation concealment on conclusions drawn from meta-analyses of randomized trials.
        Int J Epidemiol. 2007; 36: 847-857
        • Hrobjartsson A.
        • Emanuelsson F.
        • Skou Thomsen A.S.
        • Hilden J.
        • Brorson S.
        Bias due to lack of patient blinding in clinical trials. A systematic review of trials randomizing patients to blind and nonblind sub-studies.
        Int J Epidemiol. 2014; 43: 1272-1283
        • Schulz K.F.
        • Altman D.G.
        • Moher D.
        CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials.
        Int J Surg. 2011; 9: 672-677
        • MacPherson H.
        • Altman D.G.
        • Hammerschlag R.
        • et al.
        Revised STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA): extending the CONSORT statement.
        PLoS Med. 2010; 7: e1000261
        • Ada L.
        • O'Dwyer N.
        • O'Neill E.
        Relation between spasticity, weakness and contracture of the elbow flexors and upper limb activity after stroke: an observational study.
        Disabil Rehabil. 2006; 28: 891-897
        • Botte M.J.
        • Nickel V.L.
        • Akeson W.H.
        Spasticity and contracture. Physiologic aspects of formation.
        Clin Orthop Related Res. 1988; : 7-18