Acupuncture for treatment CVA And Bell palsy

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Acupuncture for treatment CVA And Bell palsy

• By balgis MD MSc CM-FM Sp Ak

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Cerebrovascular Disease

• Most frequent of all neurological problems
• Incidence third leading cause of death in U.S.
  half a million people a year one third will die
  from it
• Due to blood vessel pathology
• Lesions on walls of vessels leading to brain
• Occlusions of vessel lumen by thrombus or embolus
• Vessel rupture
• Alterations of blood quality

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• CV disease leads to two types of brain
  abnormalities
• Ischemia (with or without infarct)
• Hemorrhage

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Stroke Warning Signs
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Incidence

• Highest risk gt 65 years of age
• But about 1/3 (28) are lt 65 years old
• Tends to run in families
• More often seen in females
• More often seen in Blacks, perhaps due to
  increased incidence of hypertension

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Three types

• Global hypoperfusion shock
• Ischemia thrombotic and embolic
• Hemorrhagic

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Risk Factors

• Arterial hypertension
• Heart disease
• Myocardial infarction or endocarditis
• Atrial fibrillation
• Elevated plasma cholesterol
• Diabetes mellitus
• Oral contraceptives
• Smoking
• Polycythemia and thrombocythemia

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Occlusive strokes

• Occurs with blockage of blood vessel by a
  thrombus or embolus
• May be temporary or permanent
• Thrombotic stroke
• 3 clinical types
• TIAs
• Stroke-in-evolution
• Completed stroke

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Transient Ischemic Attacks

• Last for only a few minutes, always less than 24
  hours
• All neurological deficits resolve
• Symptom of developing thrombosis

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Causes

• Thrombus formation
• Atherosclerosis
• Arteritis
• Hypertension
• Vasospasm
• Other
• Hypotension
• Anemia
• Polycythemia

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Symptoms depend on location

• Anterior or middle cerebral arteries
  contralateral monoparesis, hemiparesis,
  localized, tingling numbness in one arm, loss of
  right or left visual field or aphasia

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Treatment

• Without Tx 80 have a recurrence in symptoms, and
  1/3 go on to have a full stroke within 5 years
• Give anticoagulants prophylactically , usually ½
  to 1 aspirin / day

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Stroke-in-evolution

• Can have abrupt onset, but develop in a
  step-by-step fashion over minutes to hours,
  occasionally, from days to weeks
• Characteristic of thrombotic stroke or slow
  hemorrhage

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Thrombotic CVA

• Involves permanent damage to brain due to
  ischemia, hypoxia and necrosis of neurons
• Most common form of CVA
• Causes
• Atherosclerosis assoc. with hypertension
• Diabetes mellitus, and vascular disease
• Trauma

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• May take years to develop, often asymptomatic
  until major narrowing of arterial lumen
• Anything that lowers systemic B.P. will
  exacerbate symptoms (60 during sleep)
• Area affected depends on artery and presence of
  anastomoses
• Area affected initially is greater than damage
  due to edema
• Infarcted tissue undergoes liquifaction necrosis

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NIH Stroke Scale
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What is Acupuncture?

• Acupuncture is one of the oldest, most in the
  world. Originating in China commonly used systems
  of healing some 3,000 years ago, only in the last
  three decades has it become popular in the United
  States.
• In 1993, the FDA estimated that Americans made
  up to 12 million visits per year to acupuncture
  practitioners and spent upwards of half a billion
  dollars on acupuncture treatments.

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Acupuncture

• Qi maintains balance in the body.
• 16 meridians
• 360 regular acupoints
• 40 commonly used extra points
• Acupoints influence the physiology

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Chinese Medicine Efficacy

• Primary health care system for over 3000 years
• NIH (National Institute of Health) stated in 1997
  report acupuncture is effective in the treatment
  of
• Nausea - Headache
• Dental pain -Fibromyalgia
• Addictions -Tennis Elbow
• Asthma -Stroke Rehab
• Osteoarthritis
• Menstrual Cramps
• Myofascial Pain
• Carpal Tunnel Syndrome
• Lower Back Pain

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Chinese Medicine Efficacy

• The 1997 National Institute of Health Consensus
  Conference on Acupuncture stated
• "The data in support of acupuncture are as strong
  as those for many accepted Western medical
  therapies.
• "One of the advantages of acupuncture is that the
  incidence of adverse effects is substantially
  lower than that of many drugs or other accepted
  medical procedures used for the same conditions."
  

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• In China and Japan, an acupuncturist is likely to
  start therapy as soon as possible after a stroke
• Acupuncture is done on a daily basis in China.
• in Western countries, some acupuncturists with
  experience in treating stroke with acupuncture
  believe treatment 3 times a week is optimal.
• Several different approaches have been used to
  treat stroke, demonstrating that acupuncture for
  this disorder remains a healthcare art
  Traditional Chinese Yang meridian point therapy,
  Chinese scalp acupuncture,

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• Dr. Yamamoto's YNSA Japanese scalp therapy,
  Korean Koryo Chim hand acupuncture, supplemental
  ear (auricular) acupuncture, and Xingnao KaiQiao
  (a newer therapy by Professor Shi Xuemin) are
  each advocated by a number of treatment centers
  in Oriental countries. One need not know in depth
  the approach of each, but it is important to know
  that more than one approach is available and
  used.
• Adding acupuncture to rehabilitation therapy
  obviously increases the cost daily-to-3
  times-weekly treatment is needed for 2-4 weeks or
  longer. Concern for added cost would perhaps
  disappear if the end result demonstrates more
  self-care and less dependence on family and
  health providers

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Does acupuncture really work to help stroke
victims improve?

• Many studies involving thousands of patients have
  been published in China and Japan, and 2 of 3
  studies from Scandinavia, demonstrated
  significant help.
• These studies indicate that patients get well
  faster, perform better in self-care, require less
  nursing and rehabilitation therapy, and use less
  healthcare dollars.

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Oriental Medicine Cost Effectiveness

• Acupuncture Treatment Results In Decreased Days
  In Hospital Or Nursing Home
• Half of 78 stroke patients receiving standard
  rehabilitative care were randomly chosen to
  receive adjunctive acupuncture treatment.
  Patients given acupuncture recovered faster and
  to a greater extent, spending 88 days/patient in
  hospital and nursing homes compared to 161
  days/patient for standard care alone.
• Cost savings 26,000 per patient.
• Johansson K et al (1994), "Can sensory
  stimulation improve the functional outcome in
  stroke patients?", Neurology 432189-2192.

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Acupuncturetoday.Com

• Acupuncture Study at Kansas Hospital Shows
  Dramatic Improvement in Stroke Patients
  (Jan.2004)
• Media outlets throughout Kansas have reported
  that an acupuncture study conducted on stroke
  patients at Wesley Rehabilitation Hospital in
  Wichita has produced improvements so dramatic,
  officials have decided to stop the study early so
  that they can offer the service to all stroke
  patients who qualify.
• (continued)

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Acupuncture Study at Kansas Hospital Shows
Dramatic Improvement in Stroke Patients

• In the study, which began two years ago, 33
  patients who had suffered their first stroke were
  randomly assigned to receive either acupuncture
  or traditional speech, occupational and physical
  therapy. Ninety percent of the patients in the
  acupuncture group improved so much that they were
  able to go home rather than another facility
  after leaving the hospital, compared to just 33
  percent of patients in the traditional therapy
  group. Stroke patients who received acupuncture
  also showed more improvement in the ability to
  carry out tasks such as as dressing, bathing,
  grooming, walking and changing position.

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• Johansson et al (1993) 1 investigated the
  effectiveness of acupuncture as a supplement to
  physical therapy in recovery from stroke. 78
  patients suffering from severe hemiparesis of the
  left or right side within ten days of stroke
  onset were randomly divided into a control group
  (n40) who received daily physical therapy and a
  treatment group who additionally received two
  acupuncture treatments per week for ten weeks.
  Patients receiving acupuncture recovered faster
  and to a larger extent than controls with
  significant differences in measures of balance,
  mobility, quality of life index, and days spent
  in hospitals/nursing homes.

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More Doctor Believing in Acupuncture,CM
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Peran Akup pd CVA

• Mekanisme kerja akupunktur melalui efek lokal,
  segmental dan sentral shg timbul efek
• Meningkatkan aliran darah ke otak terutama ke
  daerah lesi
• Memperbaiki kegiatan elektrik otak
• Memperbaiki mikrosirkulasi otak
• Meregulasi lemak darah
• Menghilangkan radikal bebas
• Mempengaruhi kadar katekolamin dan endorfin

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Shin et al

• Mendapatkan bahwa akupunktur dapat meningkatkan
  LPO (lipid peroksidase) dan TAX 2 darah ,
  meningkatkan SOD ( Superoxide dismutase) dan PGI2
• Dg peningkatan aktifitas dari SOD mk kerusakan
  neuron akibat LPO dapat dihambat
• PGI2 dan TAX2 merupakan faktor penting dlm
  mempertahankan sirkulasi darah dan mencegah
  pembentukan trombus

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Zheng et al

• Akupunktur dapat mengurangi kerusakan jaringan
  otak akibat iskemi melalui mekanisme regulasi
  neuromediator,RNA sel dan Genom dalam inti sel
  shg timbul perlindungan terhadap sel otak yg
  menghambat proses kerusakan jaringan.

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Jun et al

• EA dapat mengurangi jmlh apoptosis pd daerah
  infrak dikorteks serebri, mengurangi
  neurotoksisitas dari asam amino yg dihasilkan
  oleh proses iskemi dan menghambat ekspresi c-fos
  serta memperkuat ekspresi dari protei bcl-2 yg
  dapat menghambat apoptosis

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Terapi Akupunktur

1. Pada CVA ischemi terapi dianjurkan sedini
   mungkin, sebaiknya dilakukan 48 jam setelah tanda
   vital stabil (WHO)
2. Pada CVA haemorhage umumnya dilakukan 3 minggu
   setelah serangan setelah sadar dan tanda vital
   terutama tekanan darahnya stabil, dimulai dengan
   rangsangan ringan dan scr bertahap rangsangan
   ditingkatkan

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Titik2 yg digunakan untuk membangkitkan kesadaran

• Renzhong
• Fengchi
• Neiguan

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Chen G.S. dan Erdmann W

• Perangsangan titik renzhong (GV 26) dapat
  meningkatkan PO2 scr cepat pd lobus frontalis
  korteks serebri.
• Diduga bahwa perangsangan pd titik renzhong
  menstimulasi sistem simpatis termasuk eksitasi
  dari reseptor betha pada pembuluh arteri serebral
  akan menyebabkan vasodilatasi shg terjadi
  peningkatan aliran darah kapiler

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Rencana terapi

• Pada periode syok otak
• Digunakan jarum halus
• Bisa digunakan EA dg gel yg jarang
• Sehari sekali selama 20-30 menit
• satu seri terapi 10 kali
• Istirahat 2 hari sebelum msk seri kedua
• Merangsang sisi yg sehat

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Titik untuk Ekstremitas sup

• Jianyu
• Quchi
• Waiguan
• Hegu
• Houxi

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Titik untuk Ekstremitas inf

1. Biguan
2. Xuehai
3. Yanglingquan
4. Xianzhong
5. Taichong

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Rencana terapi

• 2. Periode Spastik
• Digunakan jarum halus
• Bisa digunakan EA dg gel yg jarang
• Sehari sekali selama 20-30 menit
• satu seri terapi 10 kali
• Istirahat 2 hari sebelum msk seri kedua
• Merangsang otot antagonis dr otot yg spastis,
  meredakan tonus tinggi otot yg spastik,
  memulihkan posisi tubuh shg menjadi normal

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Titik untuk Ekstremitas sup

1. Jianyu
2. Jianliao
3. Tianjing
4. shousanli
5. Waiguan
6. Hegu
7. zhongzhu
8. Houxi

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Titik untuk Ekstremitas inf

• Nei Biguan
• Xia Xuehai
• Yanglingquan
• Xiaxi

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Rencana terapi

• 3. Periode pemulihan
• Saat ini dapat ditambahkan akupuktur kulit
  kepala untuk meningkatkan vaskularisasi dan
  merangsang hidup sel neuron
• titik yg digunakan fengchi, gongxue (lebar 2
  jari tgk lurus dibawah fengchi), Shishencong

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Bell's Palsy

• Bell's Palsy is presumably due to an inflammatory
  reaction in or around the facial nerve near the
  stylomastoid foramen
• Bell's palsy, also known as idiopathic facial
  paralysis because of its unclear etiology.
• It is the most common disease of the facial nerve
  that causes important functional, aesthetic, and
  psychosocial disturbances in the patients.

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Bell's Palsy

• Pada umumnya bersifat akut
• Tiba tiba
• biasanya disadari saat bangun tidur
• Pada anamnesa penderita sering ada riwayat
  terkena angin waktu berkendaraan atau tidur dg
  jendela terbuka

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Gejala pada sisi lumpuh

• Akibat kelumpuhan serabut somatomotoris n
  fasialis
• Dahi tidak dapat dikerutkan
• Mata tidak dapat menutup (lagopthalmus)
• Dalam usaha menutup mata bola mata kerap
  berputar keatas ( bells phenomen)
• Lipat nasolabial jadi datar
• Mulut tidak bisa diangkat baik scr spontan maupun
  atas perintah
• Sudut mulut tertarik ke arah sisi yg sehat,
• gangguan perasaan pengecapan pd 2/3 anterior
  lidah ( sisi kelainan) akibat kelumpuhan serabut
  viscerosensoris n facialis

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Terapi akupunktur pd bells palsy

• Merangsang otot wajah yg lumpuh baik dg titik
  lokal maupun titik jauh
• Titik akup yg sering digunakan
• Yifeng 6. Yingxiang
• Xiaguan 7. Zanzhu
• Yangbai 8. Quanliao
• Sibai 9. Sizhukong
• Dichang 10. Hegu

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• Rangsangan penjaruman atau dengan EA
• Setiap kali dirangsang 5-6 buah titik
• 3 kali perminggu

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INTRODUCTION

• A 56-year-old white female presented with a
  3-month history of severe right facial pain,
  weakness, and paralysis. This patient was
  referred to an otolaryngologist and a neurologist
  at Johns Hopkins, but did not achieve symptomatic
  relief.

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PRESENTING COMPLAINT

•      The patient's right facial paralysis
  developed overnight. Associated symptoms included
  pain in her face, difficulty speaking clearly,
  aud hypersensitivity to sound in the right ear.
  She was unable to close her right eyelid, and
  experienced difficulty with drinking and
  mastication. She was evaluated and treated by an
  otolaryngologist, and placed on a steroid taper
  and acyclovir symptomatic improvement in facial
  muscle strength did not occur. Her facial
  disfigurement and difficulty speaking impacted on
  her occupation (restaurant owner and operator).
  She developed mild depression and a secluded
  behavior.

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MEDICATIONS

• Prednisolone, Premarin, Acyclovir, DHEA,
  vitamins, minerals, and a natural Synthroid
  substitute.

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•  DIAGNOSTIC TESTS
• Autoimmune and serology were negative. Lyme
  titer was negative. Thyroid function tests
  indicated that she was euthyroid with a slightly
  decreased TSH level.
• REVIEW OF SYSTEMS Neck pain, lower back pain,
  joint pain, depression, right facial pain and
  sensitivity to sounds in the right ear, with
  difficulty speaking clearly.

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TREATMENT

• Chinese medicine attributes this condition to
  Wind and Cold of external origin which invade the
  meridians traversing the face and disrupt the
  flow of Qi and Blood, preventing the vessels and
  muscles from receiving the necessary nourishment.
  
• Treatment is directed toward spreading the Qi
  through the meridians of the face (1).
• The patient was treated with an integrated
  approach of acupuncture models. Points from a
  neuroanatomical model, or for classical
  indications, were included at each treatment and
  primarily used unilaterally. Other points
  utilized the energetic approach, and were treated
  bilaterally.

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• The following acupuncture points were used
  without electrical stimulation.
• The local points were treated only on the right
  side, while the distal points were needled
  bilaterally.
• The principal points included GB 20 (Fengchi), GB
  14 (Yangbai), ST 4 (Dicang), ST 2 (Sibai), and LI
  4 (Hegu).
• The supplemental points included GV 26
  (Renzhong), M-HN 18 Jiachengjiang (1), M-HN 9
  (Taiyang), ST 7 (Ziagnuan), ST 36 (Zusanli), ST
  44 (Neiting), and LI 19 (Heliao).

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PATIENT RESPONSE

•  The patient was initially graded with a
  House-Brackmann grade 5 paralysis in the right
  facial muscles (4).
• After 10 acupuncture treatments over a 4-week
  period
• She showed significant motion in her forehead and
  had total closure of her eye with maximal effort.
  However, with normal effort, she had 1 to 2 mm of
  scleral fill with good protection of her cornea.
• She also had good buccal movement and increased
  movement in the muscles supplied by the
  mandibular branch of her facial nerve.
• After a total of 15 acupuncture treatments over
  an 8-week period, she exhibited normal upper
  division motion and intact tone in the lower
  division, with only a mild decrease in motor
  strength in this division. Her strength was
  graded at approximately a House-Brackmann 2. She
  had full eye closure, and intact conjunctivae
  with slight ectropion.

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• According to Liu (1995), when acupuncture was
  initiated within three days post-onset in 684
  cases of facial nerve paralysis, 100 percent of
  the patients were cured or there was a marked
  improvement (5).
• Other studies (Gao, Chen, 1991) revealed that
  80 of cases that were treated at more than 2
  months post-onset, and 83 percent of severe
  cases, were cured or had excellent effect (6).
• Treatment, as with this patient, may include
  numerous diagnostic procedures, different classes
  of medications, lifestyle alterations, and still,
  continued suffering. Acupuncture may often lead
  to significant clinical improvement (7).

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• Abstract Background Bells palsy involves acute
  facial paralysis due to inflammation of the
  facial nerve. Acupuncture and moxibustion
  (acu-moxi) is beneficial in treating facial
  palsy. In order to verify the efficacy of
  acu-moxi on Bells palsy, a randomized
  single-blind, multicenter clinical trial was
  performed.
• Methods A total of 480 patients from four
  clinical centers were involved in this trial, of
  whom 439 completed the trial and 41 did not. All
  patients were randomly assigned to either the
  control group or to one of two treatment groups.
  The control group was treated with prednisone,
  vitamin B1, vitamin B12, and dibazole the
  treatment groups were treated either with
  acu-moxi alone or in combination with prednisone,
  Vitamin B1, vitamin B12, and dibazole. Symptoms
  and signs, the House-Brackmann scale, and facial
  disability index (FDI) scores were assessed and
  determined both pre- and post-treatment to
  evaluate the effectiveness of the treatment
  methods.

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• Results The characteristics of the control and
  two treatment groups were comparable without
  statistically significant differences before
  treatment. There were significant differences
  between the control and treatment groups after
  treatment (?215.265, P0.018). According to
  evaluations based on the House-Brackmann scale
  and FDI scores, the effectiveness of treatment in
  the two treatment groups was better than in the
  control group and was most effective in patients
  receiving acu-moxi treatment alone (Z-2.827,
  P0.005). Conclusion The efficacy of acu-moxi
  treatment for Bells palsy is verified
  scientifically.

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• Treatment group 1 was given acu-moxi treatment.
  The acupuncture points used were Dicang (ST4),
  Jiache (ST6), Hegu (LI4), Yangbai (GB14), Xiaguan
  (ST7), and Yifeng (SJ17) on the affected side,
  and Hegu (LI4) bilaterally.1 Filiform needles
  (1-1.5 cun, 0.32 mm) were used with moderate
  stimulation to get an acupuncture sensation, and
  the needles were retained for 30 minutes. Hanging
  moxibustion was applied for five minutes at each
  point, once a day, five times a week, for a total
  of four weeks.

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• The House-Brackmann scale is specifically
  designed to evaluate the results of the treatment
  of facial paralysis disorders.7 Facial nerve
  function is graded by the House-Brackmann scale
  into 6 grades ?, Normal ?, Mild dysfunction ?,
  Moderate dysfunction ?, Moderately severe
  dysfunction ?, Severe dysfunction and ?, Total
  paralysis. The House-Brackmann scale is generally
  accepted as effective in evaluating facial nerve
  function.

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Clinical observation on treatment of acupuncture
for different stages of Bell's palsy

• ObJECTIVE To observe the therapeutic effects of
  acupuncture for treatment of different stages of
  Bell's palsy, and explore the best intervention
  period.
• METHODS Forty cases of Bell's palsy patients
  were divided into three groups according to their
  onset time an active stage group, a resting
  stage group and a recovery stage group.
• All three groups were treated with acupuncture.
  Fengchi (GB 20), Dicang (ST 4), Jiache (ST 6),
  Qianzheng (Extra), Sibai (ST 2), Yangbai (GB 14)
  on the affected side and Hegu (LI 4) on the
  healthy side were selected as main points. Dazhui
  (GV 14), Chengjiang (CV 24), Shuigou (GV 26) and
  Cuanzhu (BL 2), Yuyao (EX-HN 4), Yifeng (TE 17),
  Tinghui (GB 2), Quanliao (SI 18), Xiaguan (ST 7),
  Yingxiang (LI 20) on the affected side were
  selected as adjuvant points.

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• RESULTS (1) Acupuncture was effective for the
  Bell's palsy in active stage, resting stage and
  recovery stage (all Plt0. 01) (2) The obvious
  effective rate of acupuncture for treatment of
  Bell's palsy in the active stage group was
  obviously superior to those of resting stage
  group and recovery stage (both Plt0. 01). (3)
  There was no significant difference of the
  obvious effective rate between the resting stage
  group and the recovery stage group (Pgt0. 05).
• CONCLUSION Acupuncture has a good therapeutic
  effect for treatment of Bell's palsy, and the
  therapeutic effect is most obvious with
  intervention of treatment in the active stage.