A stroke is defined as a syndrome of rapidly developing clinical signs of focal (or global) disturbance of cerebral function, with symptoms lasting 24 hours or longer, or leading to death, with no apparent cause other than that of vascular origin [1]. The damage to the brain tissue is caused by thrombosis, embolus or haemorrhage. This leads to hemiplegia or some form of hemiparesis. The description of the stroke or cerebrovascular accident (CVA) as ‘right’ or ‘left’ can be misleading as the resulting paralysis is usually on the side opposite to the brain lesion. This also assumes, incorrectly, that all the adverse effects will be unilateral.

This definition includes subarachnoid haemorrhage but excludes transient ischaemic attack (TIA), subdural haematoma and haemorrhage or infarction caused by infection or tumour. TIA is defined as a neurological deficit due to cerebrovascular disease that lasts less than 24 hours. Hemiplegia is defined as the paralysis of muscles on the side of the body opposite to the area of cerebral damage.

Incidence

An estimated 150 000 people have a stroke in the UK each year, with over 67 000 deaths due to stroke, making stroke the most common cause of death in England and Wales after heart disease and cancer [2].

Stroke has a greater disability impact than any other disease, with many thousands of people living with moderate to severe disabilities as a result [3].

The direct cost of stroke to the NHS is estimated to be £2.8 billion and the cost to the wider economy is £1.8 billion. The informal care cost is around £2.4 billion, with the total costs of stroke predicted to rise in real terms by 30% between 1991 and 2010. Stroke patients occupy around 20% of all acute hospital beds and 25% of long-term beds [4].

It is thought that there has been an overall reduction in the numbers of strokes in the UK. Work undertaken in the Oxford region has shown that, as a result of the use of preventive medicines, including drugs that lower blood pressure and cholesterol and those that thin the blood, together with the reduction in heavy smoking, the incidence of stroke has dropped by 40% [5]. The current decline in incidence and case fatality may also be due to dietary changes and the emphasis on the treatment of hypertension [6]. There is a possibility that the predisposition to stroke runs in families, although this is likely to be linked to hypertension as the risk factor [7].

Stroke is a devastating condition for both patients and carers, with a high mortality rate throughout the first year after the lesion: 30% at 3 weeks, 40% at 6 months and 50% at 1 year [8]. Morbidity is high, with 12% estimated to be in long-term care 1 year after the event [9]. The risk of recurrence is also high: 7% for at least 5 years after the initial stroke and 15 times the stroke risk for the general population [10]. The figures suggest that each health district can expect 550 patients to present with stroke each year and each general practitioner can expect to see four or five new cases a year and be caring for 12 survivors, of whom seven or eight will be disabled [11]. Stroke is therefore a major financial burden to the NHS and consumes more than 4% of total NHS expenditure and more than 7% of community health and social care resources [12].

Risk factors

There are many health factors which appear to predispose a patient to stroke. Age is the most important factor [13], but in general raised blood pressure [14], smoking [15] and alcohol consumption [16] are associated with a greater risk of occlusive and haemorrhagic stroke. Diabetes mellitus is associated only with occlusive stroke. Other factors that may be important are obesity, poor diet, febrile illness, oral contraception, taking hormone replacement therapy and, in some cases, wide seasonal variation in temperature, although this can be either extreme cold or heat [17]. It has also been suggested that the seasonal availability of vitamin C may be a factor [18], although with the wide variety of non-seasonal foods now available this may not be an issue in industrial nations.

Diagnosis

Differentiation from other diseases

Medical treatment

Acute

Most patients with stroke are admitted to hospital, although some, those with generally less severe symptoms, remain at home for their nursing and subsequent rehabilitation. In practice it is difficult to be certain how many people are not admitted to hospital because they are not routinely recorded.

A welcome innovation has been a widespread advertising campaign to alert the public to the first signs of stroke [24], emphasizing that stroke should be recognized as a medical emergency requiring fast admission and specialist management. Patients who have suffered a stroke remain at increased risk of a further incident: therefore secondary prevention is part of treatment.

Measurement of the underlying structural changes within the brain has only recently become routine. Now the idea of cell death or apoptosis is better understood, it is becoming clear that there are two types of damage. Firstly, the focus of the stroke, where the cells are deprived of oxygen, for whatever reason, and subsequently die, and, secondly, the so-called penumbra or area surrounding the focal point, where the cells are damaged by pressure from temporarily swollen tissues but may not necessarily be destroyed. Since the penumbra has the potential to be reperfused there is a limited time period for interventions to be effective before the cells die. It would be desirable to increase the blood supply to the penumbra without increasing the haemorrhage.

Considerable research has been undertaken to investigate drug treatment in the immediate aftermath of stroke. Drugs such as aspirin and heparin seem to have some purpose in preventing further damage immediately after the stroke but two recent major studies have not entirely supported their use.

The International Stroke Trial investigated 19 435 patients within 48 hours of acute stroke and randomized them between two different doses of heparin or placebo [25]. The design also randomized patients to receive daily aspirin or no aspirin. The researchers used a 2×2 factorial design with patients randomized to one of four possible groups: heparin and aspirin, aspirin or heparin alone or no treatment. Treatment lasted 14 days or until discharge, if sooner.

The results from the International Stroke Trial study showed that there was no overall benefit in mortality or limitation of brain damage from the use of heparin; indeed, there was a slightly higher – 9 per 1000 – rate of haemorrhagic strokes and more deaths within 14 days. Neither heparin regimen gave any clinical advantage at 6 months. There was no interaction between heparin and aspirin in the main outcomes.

The other major study, the Chinese Acute Stroke Trial [26], randomized 20 000 patients to daily low-dose aspirin or a placebo, also within 48 hours of the stroke. Treatment lasted 4 weeks. The Chinese Acute Stroke Trial study showed that aspirin started in the acute stage was associated with small benefits. The difference in death rates between the aspirin and control groups was only 0.5%. Combining the data from these two very large trials detects a small treatment effect for aspirin, thus supporting the early prescribing of aspirin, as long as continuing haemorrhage has been excluded. As aspirin is prescribed in any case for long-term prevention it becomes imperative that CT scans take place routinely very soon after stroke.

Thrombolytic drugs have also been investigated, particularly tissue plasminogen activator (tPA, alteplase) given within just 3 hours of an acute ischaemic stroke. The most recent Cochrane review [27] balances the increase in deaths within the first to seventh days and deaths at final follow-up with the reduction in disability in the survivors. It suggests that intravenous recombinant tPA may be the best method of delivery but is cautious about recommending general use.

However the current advice given to physicians [28] is that thrombolytics may be given but haemorrhage must definitely be excluded and that the patient should be in a specialist centre with appropriate experience and expertise.

Subacute

The most important first step is an assessment of disability. Swallowing, management of dysphagia and nutrition will be checked, along with bowel and bladder function. Immediate complications will be prevented by careful monitoring of temperature, dehydration and risk of pressure sores. Possible areas of impairment and also social context need to be assessed before full rehabilitation is started.

Spasticity is a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes. It commonly leads to muscle shortening and joint contractures. Signs of change in muscle tone are observable within a few days of the initial brain damage. A relatively new drug used to combat spasticity is botulinum toxin (BTX or BoNT). A number of trials among stroke patients have shown a significant decrease in muscle tone. The effects of the BTX were shown to decrease after 3 months, but if the patients were regaining control of their muscles, that could be seen as an advantage. Several studies have shown a good effect in stroke rehabilitation situations [29–31]. The trial by Lai et al. [31] shows that an increased effect is gained by serial splinting to maintain the increase in range of movement gained by the relaxing muscle spasm. It would be interesting to compare that with the muscle-relaxing effect of acupuncture, either in place of, or used with, BTX.

Management and rehabilitation

Input is necessary from a range of health professionals in addition to the medical team. Physiotherapists, speech and language therapists and occupational therapists are all important members of the team and need to understand what each can contribute. Social services and community health staff will also join the team to enable the ultimate easy discharge of the patient into the community.

Correct positioning of stroke patients is a widely advocated strategy to prevent the development of abnormal muscle tone, contractures, pain, skin breakdown and respiratory complications. Since this and the other supportive treatments require a constant team effort, it has been demonstrated that patients in specialist stroke units are likely to do better [32].

Rehabilitation should be a long-term process with a seamless transition from acute to community services. Training in the skills of independent living may be necessary for up to a year after the stroke, but is rarely available in the straitened circumstances prevailing throughout the NHS.

Prognosis

Body structure and function, activity and participation

The effect of stroke, or indeed any neurological condition, is described in varying ways. The International Classification of Functioning, Disability and Health (ICF) suggests that an individual’s disability and resultant function is a result of the interactions between his or her health condition and contextual factors such as the physical environment or social attitudes [33]. A full description is included in this chapter, although it applies equally to the others.

ICF highlights the relationship between problems with body structure and function and the individual’s level of activity and participation (Table 6.1).

Table 6.1 Definitions of major International Classification of Functioning, Disability and Health categories

Category	World Health Organization definition (33)
Body structure	Anatomical parts of the body such as organs, limbs and their components
Body function	Physiological functions of body systems, including psychological functions
Activity	The execution of a task or action by an individual
Participation	Involvement in a life situation

ICF goes on to identify three levels of functioning of the human: at the body level, at the whole-person level and within society in general.

Disability involves functional difficulties in one or more of these levels and may include the following:

• Impairment refers to problems in body function or structure resulting from the health condition; in the example of stroke, impairments might include paralysis, sensory loss, visual disturbance, pain, cognitive impairment, speech problems or impairment of consciousness.

• Activity limitations are difficulties an individual may have in carrying out activities and might include an inability to walk to the toilet or the inability to drive.

• Participation restrictions refer to problems the individual may have when involved in day-to-day life situations.

Contextual factors also contribute to the overall disability. External environmental factors might include steps into the person’s home limiting access or uneven footpaths en route to the local shops posing a risk of tripping. Personal factors might include the individual’s personal coping style and past experience as well as educational and social background.

Disability is often measured in terms of the ability to carry out activities of daily living (ADL) using scales such as the Barthel ADL Index. The main emphasis in stroke research has been on the domains of physical activity and self-care but it is useful to remember that the World Health Organization definition of disability is much broader than this.

The relationships between impairments and activity or participation restriction are not fixed. Individuals with very severe impairment may participate fully within their local community with an appropriate level of support. Another individual with relatively mild impairment may be severely restricted in activity and participation, possibly due to substantial impact of contextual factors. This highlights the complexity of carrying out research in the stroke population.

Effects of stroke

The primary effect of stroke is impairment of muscle function caused by motor and/or sensory deficits commonly affecting the face, arm and leg on the contralateral side. This will result in the characteristic hemiparesis or hemiplegia leading to physical disability of a temporary or permanent nature.

Unfortunately there are many other possible effects, depending on the site of the brain lesion and the quality of the poststroke care. Among them are:

• dysphagia or dysphasia

• incontinence

• infections, urine or respiratory

• cognitive impairment

• mood changes

• pressure sores

• deep-vein thrombosis

• pulmonary embolus

• pain, particularly in the shoulder

• falls and fractures.

Depending on the site of the lesion there may be varying degrees of speech loss or swallowing difficulties and there is a real danger of food aspiration in the acute stage of stroke. Most patients with moderate to severe stroke are incontinent at admission, and many are discharged still incontinent. Both urinary and faecal incontinence are common in the early stages and need urgent management in order to prevent these problems delaying the patients’ eventual rehabilitation. Urinary incontinence directly after stroke is an indicator of poor prognosis for both survival and functional recovery [34]. Care must be taken to prevent infection.

Anxiety is an equally common problem accompanied by feelings of fear and apprehension with physical symptoms such as breathlessness, palpitations and trembling. The specific causes of anxiety after stroke are not known; it may simply be a product of the sudden physical disability or may more closely resemble an anxiety disorder and require antidepressive drug treatment. Anxiety after stroke has certainly been shown to be associated with increased severity of depressive symptoms and greater functional impairment [35].

Long periods of inactivity produce a danger of skin breakdown and the possibility of pressure sores is increased if the patient is also incontinent. The lack of voluntary movement also increases the risk of deep-vein thrombosis and pulmonary embolus. Early mobilization after stroke has been shown both to cut rates of poststroke depression by 50% and also to be cost-effective [36, 37]. This has implications for early acupuncture treatment of this condition. The link between exercise and general feeling of well-being and mood elevation is well documented in healthy subjects [38], and the chemical action of acupuncture has often been compared to that of exercise [39].

A further complication of recovery is spastic hypertonia associated with exaggerated deep tendon reflexes. This is often associated with central nervous system disorders due to lesions in the brain that affect descending tracts normally inhibiting spinal reflex pathways. The resulting excessive muscle tone can cause many problems, including loss of free movement, difficulties performing daily activities and pain [40]. It may also cause the limb to become ‘frozen’ or fixed in an uncomfortable position.

Pain is most common in the affected shoulder. It is to be hoped that it is less often present now that much emphasis is placed on correct positioning of the paralysed limbs [41]. Unfortunately the initial loss of muscle tone in the hemiplegic arm often results in damage to the capsule with subsequent pain. Use of functional electrical stimulation can help prevent this unpleasant complication [42].

Falls are not uncommon in elderly patients even if they have not suffered a stroke. Paretic limbs become osteopenic or less dense and since the stroke patient is likely to fall to the affected side, poststroke fractures are a frequent complication in the process of rehabilitation. Fear of falling can be damaging too, leading to reduction in possible mobility and social withdrawal.

Patterns of recovery

The aim of all treatment should be independence in self-care within a year after the stroke. This is achieved in a range between 60% [43] and 83% [44] of surviving patients, both measured at 1 year after stroke. However the same data suggest that between 16 and 31% may be institutionalized by the end of the year.

Recovery of rolling, sitting balance, transfers and walking among patients referred for rehabilitation seems to follow a relatively predictable pattern over the first 8 weeks [45]. The majority of muscle recovery occurs within the first 3 months after the stroke with subsequent recovery taking place at a slower pace [46]. Some useful recovery still occurs between the sixth and twelfth months. In the hemiplegic hand it is thought that if there is no active hand grip after 3 weeks there is unlikely to be much improvement [47].

The accepted wisdom within the physiotherapy profession is that there is little to be gained from the rehabilitation process as late as 2 years after the stroke, but there may be unused potential for physical improvement in the period before this cut-off, depending on previous access to treatment. Overall recovery is thought to be adversely affected by the patients’ age [48]. This assumes that there may be co-pathology, including mobility problems such as osteoarthritis.

Recurrence

One in five strokes is a recurrent stroke and a patient who has had one stroke is at 10-fold increased risk of another [49]. Despite similar neurological impairments, patients with recurrence on the opposite side to their original episode tend to have markedly more severe functional disability after completed rehabilitation than patients with an ipsilateral recurrence, implying that functional ability to compensate is decreased. These figures serve to underline the importance of a prophylactic dose of aspirin or even acupuncture.

Stroke and physiotherapy

Current physiotherapy

Physiotherapists are an important part of the hospital rehabilitation team and, working alongside the occupational therapists, are particularly concerned with regaining functional movement in the paralysed limbs. In order to achieve this many of the primary movement patterns need to be relearned by the patient. Progress is often hindered by the state of the muscle tissue, which may exhibit weakness, spasticity or no tone at all, remaining flaccid. Progress can also be inhibited by the development of contractures and resulting pain produced by poor postural positioning in the bed and chair. This will also be made worse by early, incorrect attempts at movement.

The modalities used by the physiotherapist are many and varied, based essentially on the retraining of physical movement and incorporating forms of biofeedback to retrain balance and proprioception [50], functional electrical stimulation [51], gait retraining and treadmill training [52]. Transcutaneous electrical nerve stimulation (TENS) has also been used successfully [53], usually utilizing acupuncture points. Approaches to treatment vary but may also include techniques drawn from the Bobath approach, movement science and, on occasion, proprioceptive neuromuscular facilitation. Research has failed to identify substantial differences between the different approaches but a clear finding is the need for intensive training [54]. More research on the individual components of rehabilitation is still required.

Spontaneous neurological recovery is considered by many to be responsible for most of the functional recovery after stroke but in a critical review Kwakkel et al. suggested that simple biological variability may encourage rehabilitation-induced effects and that comprehensive functional therapy incorporating elements of intensive and task-specific strategies may ultimately produce the best effects [55].

Application of acupuncture

Physiotherapists working in neurological rehabilitation units are in close daily contact with their patients and, as acupuncture appears to be an effective intervention in the stroke recovery process, are ideally placed to use it.

Prevention of stroke by traditional Chinese medicine (TCM) acupuncture depends on meticulous TCM diagnosis and is both complicated and unproven, but the type of acupuncture applied after stroke to combat the paralysis is not complex and is well within the capacity of any physiotherapist with basic acupuncture training. The state of current research is confused but indicates possible applications [56].

Neurological basis

The specific neurological changes that could benefit a stroke patient are described in detail in Chapter 4. However the demonstrable physiological effects of acupuncture in stroke are as follows.

Changes in cerebral circulation

Given the pathology of stroke, it is clear that an acupuncture intervention that could maintain peripheral circulation to the cerebral hemispheres when the central supply is compromised would be useful acute therapy [57].

Of course, since the same conditions would apply as with aspirin or thrombolytic drugs, it must be ascertained that there is no continuing haemorrhage.

Changes in blood composition, velocity and general circulation

Changes in blood flow and velocity, noted by Yuan et al. [57] and Litscher et al. [58], could be helpful in preventing further emboli and aiding with reperfusion of temporarily damaged brain tissue. Indeed, these changes may mirror the actions of tPA or aspirin and could be considered as an alternative if the acupuncture could be administered quickly enough.

Effects on muscle tissue

A general increase in blood flow could be beneficial to recovering muscle tissue, particularly that which has been damaged by long-term disuse. One of the main perceived problems with rehabilitation is the increase in muscle tone and acupuncture has been shown to have a potentially useful decreasing effect [55, 59, 60]. In a good-quality trial, but with small numbers, clinically relevant changes in spasticity were observed to be comparable to those produced by botulinum toxin injections [61].

More work is needed on this aspect of acupuncture and stroke. A more general effect on muscle tissue, leading to an increase in muscle strength in healthy subjects, has been demonstrated, although only in small studies [62, 63]. In a larger study carried out in the UK, the Motricity Index was used to measure muscle strength recovery in stroke patients and the researchers found that acupuncture appeared to produce a boost for this in the early stages of recovery [64].

The use of electroacupuncture raises a further set of questions for the researcher but does seem to be effective in some situations, for example in poststroke shoulder subluxation, where electroacupuncture has been shown to have a useful effect if applied in the early stages [65] (Figure 6.1).

Figure 6.1 • Electroacupuncture applied in stroke (TE 5 and LI 10).

Using electroacupuncture, Shen et al. [66] showed that the combination of electroacupuncture and exercise therapy improved limb function in the hemiplegic patient, and, additionally, that the therapeutic effect of exercise was increased if it was given after the acupuncture.

A paper in Chinese suggests that scalp acupuncture, a form of electroacupuncture, (see Chapter 12: Figure 6.2), works better if used in combination with exercise therapy in stroke rehabilitation [67].

Figure 6.2 • Scalp acupuncture in stroke, motor line.

Effects on mood

Acupuncture is associated with improvements in mood and energy, due in part to the observed increase in serotonin and endorphins. This evidence has been around for some time [68] but the positive psychological effects are coming under closer scrutiny now [69]. Since it has been suggested that depression and anxiety after stroke are associated with increased severity of depressive symptoms and greater functional impairment [35], this alternative to drug therapy may be very acceptable and will assist with patient compliance with taxing exercise programmes [70].

Effects on energy levels

There is a lot of anecdotal evidence linking acupuncture with an increase in energy level but little hard research, particularly in the field of neurology. However, an interesting study by Molassiotis et al., working with oncology patients, showed a significant decrease in fatigue after the application of acupuncture [71]. Given the known effect of the acupuncture stimulus on the limbic system it is not unreasonable to assume that this would be the case. A similar effect was detected in the Hopwood trial of acupuncture in stroke patients with just subsignificant results on the Nottingham Health Profile scale for emotional reaction and energy levels, in favour of the acupuncture group at 24 weeks after their stroke [64].

A Canadian project to create guidelines for 13 types of physical rehabilitation interventions used in the management of adult patients (>18 years of age) presenting with hemiplegia or hemiparesis following a single clinically identifiable ischaemic or haemorrhagic CVA was developed in 2006 [72]. This group identified and synthesized evidence from comparative controlled trials. The group then formed an expert panel which developed a set of criteria for grading the strength of the evidence and the recommendation. Patient-important outcomes were determined through consensus, provided that these outcomes were assessed with a valid and reliable outcome scale.

The Ottawa Panel developed 147 positive recommendations of clinical benefit concerning the use of different types of physical rehabilitation interventions involved after stroke. Among those listed were therapeutic exercise, task-oriented training, biofeedback, gait training, balance training, treatment of shoulder subluxation, electrical stimulation, TENS, therapeutic ultrasound and acupuncture [72].

Table 6.2 offers a summary of the symptoms that are likely to be present to a greater or lesser degree in most stroke patients. Obviously one of the characteristics is the unilateral nature of the impairment but otherwise these symptoms are common throughout this group of neurological conditions.

Table 6.2 Symptom picture for stroke

Symptom	Characteristic presentation	Stroke
Decreased mobility	Hemiparesis or hemiplegia
Fatigue	Lack of energy
Respiratory problems	Weak cough	X
Muscle spasm	Increased tone
Contractures	Stiffness and rigidity leading to deformity
Autonomic changes	Slowing circulation
Cognition/mood	Emotional lability, poststroke depression
Communication	Sometimes hampered by facial palsy (loss of speech with right cerebrovascular accident)
Bladder problems	Occasional	X
Visual problems	Hemianopia, single-sided visual neglect

X, usually absent; , common, , very frequent.

Links to TCM

TCM recognized the effects of stroke and categorized the symptoms over 2000 years ago (Table 6.3). Before the Tang and Song dynasties, the pathomechanism of stroke was seen as the result of some internal deficiency followed by a Pathogenic attack. Later the condition was considered to be primarily a result of internal Wind. Contemporary Chinese TCM doctors now view this disease as deficiency of upright Qi leading to an internal stirring of Liver Wind. Onset is also related to disorders involving the Yin and Yang of the Heart and Liver, Spleen and Kidney, in their Zang Fu sense.

Table 6.3 Traditional Chinese medicine (TCM) effects of stroke

The risk factors of diet, obesity, high blood pressure and a sedentary occupation have been acknowledged in the sizeable literature dealing with stroke treatment using both herbs and acupuncture [73–75]. The very fact that this type of treatment has been reported as clinically successful for so long underlines the need for more rigorous research in this field.

TCM treatment depends on the perceived cause of the stroke. A lot of treatment may be undertaken to prevent stroke ever happening, with the deficiency of Yin in both Liver and Kidney being tackled along with support for the Spleen and advice on diet and lifestyle.

Physiotherapists are rarely in a position to prevent this kind of neurological catastrophe but are very much concerned with the treatment and rehabilitation of the patient after it has occurred. The consensus of opinion in TCM terms seems to be that an energetic policy, stimulating the points of the Yang meridians, is most successful. The aim is to move the stagnation of Qi and Blood. Electroacupuncture is often added, as is scalp acupuncture. It is useful to stimulate both Spleen and Stomach in order to aid and regulate digestion and points for Kidney and Liver are sometimes added to prevent recurrence.

Simple acupuncture formula for windstroke sequelae

Upper-limb points

GB 20 Fengchi, LI 15 Jianyu, LI 11 Quchi, LI 10 Shousanli, LI 4 Hegu, TE 5 Waiguan.

Lower-limb points

GB 31 Fengshi, ST 31 Biguan, ST 36 Zusanli, SP 10 Xuehai, GB 39 Xuanzhong, GB 43 Xiaxi, LR 3 Taichong.

The resulting paralysis may not affect both limbs, so the points used to free the channels should only be used where necessary. The points selected to support the major Zang Fu organs should be used in all cases.

Some authorities recommend the use of points on the unaffected limb, some use them bilaterally but there seems to be no clear guide as to which is better. From the point of view of a stimulus to the nervous system to prevent stroke-side neglect, it seems logical to treat only the affected side. It also seems logical to add electroacupuncture using a current of 2 Hz in order to produce a muscle twitch. However bilateral treatment makes sense too; stimulation of both dorsal horns will maximize the effect. TCM sometimes advises starting with the unaffected side and progressing to both sides [76].

The TCM approach to the physical sequelae of stroke is to mobilize the Qi in the affected limbs but in modern texts the selection of points, although still based on syndrome differentiation, follows a more segmental pattern, recognizable to Western medical acupuncture practitioners.

The TCM differentiation of stroke offers four patterns, similar to those in the West:

1. a mild stroke involving only the superficial channels and collaterals (Zhong Luo)

2. a more serious incident involving the channels themselves and resulting in recognizable hemiplegia (Zhong Jing)

3. stroke involving the bowels or ‘tense’ stroke (Zhong Fu). The patient loses consciousness and on regaining it may show hemiplegia and changes in continence or constipation

4. a severe form of stroke is that involving the viscera (Zhong Zang), where the patient is unconscious and comatose with open mouth, and loose lips failing to contain the saliva.

It is the Zhong Jing type that is most likely to be treated by physiotherapists and, if the Zhong Fu and Zhong Zang survive they will show the same one-sided paralysis of the limbs and sometimes the face [77].

The fundamental causative factors are thought to be linked to the Wei and Feng syndromes (see Chapter 1).

Syndromes identified in stroke

As with most neurological conditions the state or balance of all the body system is seen to be disturbed and the following syndromes are often found within the umbrella classification of ‘poststroke’. Table 6.4 offers collections of acupoints which can be used if the symptoms fit.

Table 6.4 Common syndromes in stroke

Syndrome	Main points	Comments
Attack on the channels with external Pathogens still retained in the body	LI 4 Hegu TE 5 Waiguan ST 8 Touwei GB 20 Fengchi

Early treatment, first 10 days only Deficiency of Yin with an excess of Yang, Liver/GallBladder fire flaring upward

Cooling points Liver/Kidney Yin Xu together with generalized Yin and Yang Xu

Supporting Kidney energy Spleen/Kidney Yang Xu with Phlegm and stasis in the channels

Kid 3 could be added Qi and Blood Xu with malnourishment of the sinews and vessels

Plus local points where weakness is marked Underlying Blood stasis

More general, powerful moving points

The energy that is present in the body is all that is available so this treatment can sometimes be very slow and should not be undertaken if the patient is very weak or if the results of the brain lesion are severe.

Acupuncture is rarely used in isolation in TCM. Specific Chinese herbal medicine will also be prescribed to invigorate blood and transform stasis. Table 6.5 offers a more eclectic selection of points, mostly chosen on the basis of myotomes and muscle innervation or useful Yang meridians.

Table 6.5 Acupuncture points used in stroke

Problem	Acupoints	Comments
Paralysis of the extensor groups of the Upper Limb (Yang aspect)	GB 21 Jianjing LI 15 Jianyu LI 11 Quchi TE 5 Waiguan Baxie (Extras) GB 10 Fubai	Chinese texts also suggest LI 17 Tianding but this is awkward to needle and most relevant with loss of voice
Paralysis of the flexor groups of the Upper Limb (Yin aspect)	LU 10 Yuji PE 8 Laogong HR 8 Shaofu Baxie (Extras)	PE 8 is not easy to needle, but suggested for ‘trembling’ of the hand Although not strictly Yin in aspect, the Baxie points are useful in hemiplegia
Paralysis of the Lower Limb (Yang aspect)	GB 30 Huantiao ST 31 Biguan GB 34 Yanglingquan BL 36 Chengfu Bafeng (Extras)	GB 31 also useful
Paralysis of the Lower Limb (Yin aspect)	SP 10 Xuehai SP 6 Sanyinjiao LR 2 Xingjian KI 3 Taixi Bafeng (Extras)	SP 9 if oedema present
Shoulder pain	Eyes of the Shoulder SI 11 Tianzhong LI 11 Quchi SJ 9 Sidu Baxie (Extras)	Support subluxation
Facial paralysis, deviation of the mouth	Qianzheng (Extra) ST 2 Sibai ST 4 Dicang CV 24 Chengjiang	Also used in Bell’s palsy
Deviation of the tongue and aphasia	Ear Shenmen CV 24 Chengjiang GV 15 Yamen	Speech generally HT 5 Tongli
General trunk weakness and asymmetry	GB 20 Fengchi Bailao (Extra) BL 23 Shenshu BL 25 Dachangshu	Could also open Du meridian with SI3 Houxi and BL 62 Shenmai
Internal problems including loss of appetite, constipation difficulties with urination	CV 12 Zhongwan CV 4 Guanyuan ST 25 Tianshu ST 36 Zusanli	Sp 6 Sanyinjiao also helpful
To eliminate pathogenic Wind	GB 20 Fengchi TE 17 Yifeng GB 12 Wangu	GV 20 Baihui and GV 16 Fengfu may also be used

Summary

Stroke is a major health problem in the UK and treatment and rehabilitation of stroke patients are considerable expenses to the NHS. Modern diagnostic techniques make it possible to identify which areas of the brain are damaged. However, at present there are no completely effective treatments available in the acute phase and very few therapies that have been proven to change the rate of improvement after the initial swelling in the brain tissue has resolved.

A form of therapy which could decrease the resulting disabilities is certainly worth investigating. Physiotherapists, as part of the rehabilitation team, are able to use acupuncture at appropriate times in the process but should also be able to refer to specialist clinics outside the NHS if more long-term treatment is required.

Relatively weak but cumulative evidence from the recent research literature indicates that investigation of the effect of acupuncture on both motor power and spasticity is not yet complete [56, 61, 64, 78–80]. Although the evidence for acupuncture in acute stroke remains equivocal, the borderline trends in the Cochrane review [81] indicate further work on two aspects, motor recovery and overall morbidity, with perhaps more accurate distinction between haemorrhagic and non-haemorrhagic stroke.

Since stroke is the most common cause of neurological damage affecting the elderly we should consider any modality that may help with the rehabilitation process. Patients may receive 2–3 months of physiotherapy after which they will be managing their own recovery. Lack of additional formal therapy has the potential to slow rehabilitation especially in the presence of substantial muscle weakness, atrophy, spasticity and reduced physical fitness. This may further lead to decreased activity impacting on independence and quality of life, thus becoming a major socioeconomic problem.

Case studies

Case study 6.1: level 1 case study

A 52-year-old male had a stroke 8 weeks previously. He was left with mild right-sided weakness with the leg worse than the arm. He complained of sensory changes in the arm, feeling ‘heavy’ with pain around the shoulder. There was no loss of range of movement in the arm but the patient was very anxious about what he perceived as a lack of dexterity and the change in sensation.

Initially the visual analogue scale (VAS) was measured for feeling of ‘heaviness’ 8/10 and the outcome measure Nine-Hole Peg Test was also used (for finger dexterity); time taken was 49 seconds.

Treatment

Treatment lasted only 10 minutes and only LI 15 and TE 14 (Eyes of the Shoulder) were needled to address general shoulder pain on the first occasion. Deqi achieved without manipulating needles.

Once the patient was used to the feeling of the needles, the ‘Four Gates’ (LI 4 and LR 3 bilaterally) were added for relaxation and global pain. Then, progressively, the following points were added over the first three treatments:

• LI 14 Binao for neuralgia and paresis of the upper extremity

• LI 10 Shousanli and LI 11 Quchi for motor impairments and pain in the upper limb

• GB 21 Jianjing for pain in the shoulder girdle and referred pain into the arm

• Yintang for relaxation and calming the mind

• Baxie points for changes in superficial sensation.

The sessions were gradually increased in length to 30 minutes and 12 treatments were given in total over a period of 4 weeks. Manipulation of needles was used to achieve Deqi if possible.

Results

The acupuncture treatment regime had a very positive effect on this patient. His VAS for the ‘heaviness’ he felt went from 8/10 to 3/10. The time taken to perform the Nine-Hole Peg Test improved from 49 to 23 seconds.

Part of this improvement could be attributed to natural recovery and the desensitization work carried out in additional physiotherapy sessions and in the patient’s own time, but both the patient and the therapist felt that the acupuncture had a definite beneficial effect on his arm sensation and this directly improved his dexterity.

Case study 6.2: level 2 case study

The patient was a 59-year-old woman with a left CVA thrombosis 5 years previously. She had been discharged after a period of inpatient rehabilitation.

Main complaint

There was no hand activity present. The patient was being taught weight transfer techniques. Previous treatment during the year after the stroke by a professional acupuncturist was unsuccessful. Now she was being treated by the community physiotherapist every 2 weeks, working on increased central control and mobilizing the right hand and forearm.

Aim of physiotherapy

The aim of physiotherapy was to decrease high tone in pronators and flexors and increase potential extensor ability. Acupuncture was introduced twice weekly to attempt this.

Acupuncture treatment

Points: first treatment: LI 11, LI 10, LI 4 and Baxie 15 minutes. Deqi was felt at all points.

Passive/active activity with supination, pronation and wrist and finger extensors was carried out. Nine further treatments followed and the points were not changed.

Results

After the first session there was a flicker of activity with facilitation in wrist extensors. Nothing was noted in the fingers. Some activity was seen in triceps with shoulder protraction. Subjectively, the patient reported a ‘buzzing’ feeling in her arm for 2 hours afterwards and the friend who carried out the daily stretching exercises said it was looser the following morning.

The patient continued to get a strong ‘buzzing’ response afterwards. The physiotherapist reported more potential for movement but no functional changes and further commented, ‘The improvements noted: right scapular stabilization, some mid-range shoulder medial and lateral rotation, mid-range elbow extension, supination and pronation, wrist extension and flickers of finger extension were remarkable as they had not been observed in the 4 years since her stroke despite continuous good-quality neurophysiotherapy input.’

Case study 6.3: level 3 case study

A 62-year-old French-speaking male was admitted via A&E after collapsing and losing consciousness at home. He was doubly incontinent at the time of collapse and had subsequent left-sided weakness on gaining consciousness. Since his admission he reported blurred vision, dizziness with nausea, severe headache, fatigue, reduced sensation on the left side but high levels of perceived pain throughout the left side. He quickly regained full continence. CT scan confirmed right-sided LACI and evidence of small-vessel disease.

Prior to his admission, he had been fully independent. He had just arrived in the UK from abroad the day before his collapse. Whilst abroad, he had been subjected to a 6-month period of significant physical abuse whilst in a political prison. Although he reported not having any lasting significant physical injuries as a result of this, he described feeling traumatized by it. He had some history of hypertension which was well controlled since his admission. He was a controlled diabetic, had persistent sinusitis for which he was under the care of the Ear, Nose and Throat team, and was diagnosed with hepatitis C since his admission.

At the time of assessment he described generalized, constant pain on the left side of his body with a VAS of 9/10. This pain was unchanging irrespective of position or time of day. He also described experiencing ‘intense burning’-type sensations, different to his constant pain, when touched on that side. This was considered to be allodynia since it was elicited by a normally non-painful stimulus. He was unable actively to move the left side due to pain. His other predominant symptom was constant dizziness and nausea (vertigo), worsened by all head movements and change of position. He was sitting out of bed daily and transferring through standing with the assistance of two people. He was only tolerating standing with the support of one person for a few minutes at a time and was refraining from weight-bearing through his left side due to pain.

Treatment

Acupuncture was suggested as his pain and vertigo were preventing him from attending other therapy sessions (Table 6.6).

Table 6.6 Summary of acupuncture treatment in level 3 case study

Comment

Nociceptive pain is always located in the periphery, i.e. in the nociceptors; neuropathic pain may be peripheral (involving the peripheral nervous system) or central (involving the central nervous system, as in stroke).

Pain is another common symptom following stroke, and can be either central or peripheral in origin. Peripheral nociceptive pain is caused by the stimulation of body nociceptors. Often it can be attributed to postural dysfunction exacerbated by limited mobility often following stroke, or the disrupted biomechanical alignment of joints due to the weak and/or altered tonicity of the affected muscles. Poststroke shoulder pain associated with subluxation of the joint has been reported as one of the most common sources of pain, occurring in up to 80% of survivors.

Centrally generated or central neuropathic pain results from damage to the central nervous system. Central poststroke pain (CPSP) is estimated to occur in up to 8% of patients following a stroke and can begin up to a month after the event [82]. It is thought that damage to the spinothalamic pathways is responsible for this pain. The most common treatment for CPSP is the use of amitriptyline, which is also commonly used as an antidepressant. This was prescribed early on in the patient’s management. However, it seemed to be of no benefit. Gabapentin, another neuropathic painkiller, was subsequently prescribed but made the patient very drowsy and he chose to cease taking it.

Rationale for treatment

The decision to try acupuncture for this patient was mainly driven by the fact that he was not able to comply with his rehabilitation sessions with either physiotherapy or occupational therapy, nor had he responded to the prescribed analgesia. He was becoming despondent and frustrated with his limitations. The clinical presentation of his painful symptoms associated with weakness and sensory disturbance associated with the stroke meets the diagnostic criteria of CPSP.

Initial treatment was administered to his non-stroke side due to the allodynic symptoms he was experiencing on the left. It was hoped to impact the pain of the other side via diffuse noxious inhibitory control, stimulation of the descending inhibition pathways and deactivation of the limbic system. LI 4, which is considered the most powerful analgesic point, was not chosen initially for precisely this reason. If he proved to be a strong responder, the experience might have been too overwhelming. LI 11 was chosen initially as it is indicated in the treatment of pain and hemiplegia of the arm, and is considered a tonification point. LR 3 and especially PE 6 were predominantly chosen for their indication in cases of dizziness and nausea, with SP 6 added on day 3 to accentuate this effect. As well as HT 7, both LR 3 and PE 6 are also useful in calming the mind. The addition of LI 4 was indicated on the second session as the patient had experienced no adverse effects from the first treatment. He was also suffering from nasal congestion, for which LI 4 can also be effective.

The patient was very pleased with the results of his first three sessions, with significant improvement in his vertiginous symptoms and reduced allodynia, allowing him to move more freely. His generalized pain however remained essentially unchanged so direct treatment to the left side was deemed appropriate to include. Siguan; the ‘Four Gates’ were chosen as this is thought to be useful in the treatment of more global pain. HT 7 and PE 6 were added to this combination on separate occasions to try to eradicate the vertigo which was now intermittent, yet mild. TE 5 was combined with the ‘Four Gates’ due to onset of constipation, but then replaced with ST 36. This point is a homeostatic point, restoring balance to the system, and is implicated in sinusitic Phlegm stagnation. ST 36 is also a useful point for lower-limb pain, which was now more dominant than the upper limb.

Treatment progressed well, with elimination of the vertigo, improved allodynia allowing firm touch, much-reduced upper-limb pain limited to the joints, moderately reduced lower-limb pain and improved range of movement and strength in both limbs. All of these contributed towards markedly improved function, allowing him to mobilize short distances with a walking frame and participate in his therapy sessions. Focus was then changed to treat only the left side at days 16 and 17, after which he was given a 10-day break from acupuncture treatment to focus on his mobility and functional therapies. In this time, he gained independence in his mobility unaided and his leg pain improved. However, some pain persisted in the shoulder with some self-reported stiffness and reduced range of motion. He was treated on two consecutive days with the ‘Eyes of the Shoulder’ (LI 15 and TE 14), LI 11, LI 4 and ST 38. ST 38 is commonly used to release shoulder stiffness. The following day he was discharged from hospital with full mobility, full active range of motion in the arm and leg, and with only mild strength impairment. He was still aware of some mild pain, rated as 1/10 on VAS, but his allodynia was mostly gone. Pins and needles on the sole of his left foot were still experienced on weight-bearing. Unfortunately we have not been able to follow this patient up after discharge.

It is interesting that, throughout acupuncture treatment, this patient often felt the scratch of the needle penetrating the skin, but described none of the sensations associated with Deqi after insertion. These include numbness, heaviness, aching or tingling. Some authors have suggested that the perception of Deqi is necessary for acupuncture to be effective and that the lack of this feeling in acupuncture might negate its effects. The sensations associated with Deqi are thought to be transmitted via the type II and III muscle afferents via the spinothalamic tract. Damage to the spinothalamic tract is implicated in the pathophysiology of CPSP and this might explain the lack of Deqi felt by this patient.

Conclusion

Although CPSP is one of the less common sequelae of stroke, it can be incredibly debilitating for those who experience it and is notoriously difficult to manage. Pharmaceutical management is often inadequate and can be associated with unpleasant side-effects. The outcome of this case study supports that of Yen and Chen [83], that the use of acupuncture alongside standard Western rehabilitation can be effective in the management of CPSP. Further investigation into the use of acupuncture for the management of this kind of neuropathic pain would be of great interest.

Part 2 Cerebral palsy

Introduction

Cerebral palsy is included in this section of the book because it is an acquired brain injury, although in most cases this injury occurs before or during birth.

The condition is caused by abnormalities in the parts of the brain that control muscle movements. This means that, while cerebral palsy seriously affects movement and posture, it often does not become apparent until the child reaches an age where independent movement is the norm. The majority of children with cerebral palsy are born with it, although it may not be detected for several years. A minority of children may have cerebral palsy as a result of brain damage in the first few months or years of life. Causes can be as varied as bacterial meningitis, viral encephalitis, head injury from child abuse or a road traffic accident.

Symptoms

The most common signs are difficulty when performing voluntary movements, a lack of muscle coordination, which may result from ataxia or athetosis, spasticity and exaggerated reflexes causing stiff or tight muscles or, conversely, muscle tone that is too floppy. An unusual walking pattern, walking on the toes or tending to crouch or with one foot or leg dragging is often an early sign. Speech problems may be apparent, often as a result of muscle weakness affecting respiratory control or laryngeal and soft-palate function. The articulation of the jaw may also be affected. The seriousness of this problem depends on the general degree of muscle weakness. Other communication disorders (e.g. hearing loss, language delay or disorder) may also be associated with cerebral palsy.

Prognosis

Cerebral palsy does not always cause profound disabilities. While one child with severe cerebral palsy might be unable to achieve independent mobility and need extensive, lifelong care, another with mild cerebral palsy might be only slightly awkward and require no special assistance. Supportive treatments, medications and surgery can help many individuals improve their motor skills and ability to communicate with the world.

Treatment

It is not possible to cure cerebral palsy, but treatment will often improve a child’s capabilities. Many children go on to enjoy near-normal adult lives if their disabilities are properly managed. In general, the earlier treatment begins, the better chance children have of overcoming developmental disabilities or learning new ways to accomplish the tasks that challenge them. Treatment may include physical and occupational therapy, speech therapy, drugs to control seizures, relax muscle spasms and alleviate pain; surgery to correct anatomical abnormalities or release tight muscles; braces and other orthotic devices; wheelchairs and rolling walkers; and communication aids such as computers with attached voice synthesizers.

Cerebral palsy and physiotherapy

A physiotherapist will concentrate on improving the development of the large muscles of the body, in the arms, legs and abdomen, and those concerned with posture and locomotion, the gross motor skills. Children are taught better ways to move and balance. Help will be given with the use of wheelchairs, independent standing and the safe use of stairs. Work is also done on the fun skills such as running, kicking and throwing or learning to ride a bike. Therapy usually begins in the first few years of life or soon after the diagnosis is made, and may continue for many years.

In the UK physiotherapy is likely to include Bobath techniques for correcting posture and guiding functional movement. The aim is to help children change the abnormal posture that they are forced into by weakened or shortened muscles. Therapists can help parents to understand their child’s needs. Parents are shown the most appropriate ways of positioning in order to help their child to move and how to incorporate these into the child’s daily life.

The Voita method is also used to a certain extent. This aims to release inner, innate movement reflexes by constant repetition.

Children with cerebral palsy also grow and develop, but their patterns of growth and development are delayed or arrested at a certain stage. The brain controls all movements, so that when some part of the brain is damaged, as in cerebral palsy, the control is disordered, resulting in movement problems. Each case is different and each child has to be treated according to individual need. One child may be able to move his lower limbs more easily than his upper limbs, or the other way round. This will interfere with his development. Sometimes many stages of movement development are missing altogether. If, for example, a child cannot lie on her tummy, lift her head up or support herself with her arms she will not learn to use the muscles of her neck and her back which she needs for sitting up straight or standing up. This may also interfere with the control of breathing and speech.

Physiotherapists use specific sets of exercises to work toward the prevention of musculoskeletal complications. An example of this is preventing the weakening or deterioration of muscles that can result from lack of use. Also, physiotherapy can help avoid contractures, in which muscles become fixed in a rigid, abnormal position. The focus of treatment is on enabling the child to grow and develop as normally as possible, ideally in mainstream education.

Acupuncture

The focus of acupuncture treatment will be very similar to that for stroke.

The emphasis lies mainly on the use of Yang meridians, as in the sequelae of stroke. Body points such as LI 4, LI 11, GB 34, GB 39, SP 6, TE 5 and PE 6 to open the channels, and scalp acupuncture for the upper- and lower-limb motor regions can also be used.

There has been some useful Chinese research in this field but much of it has failed to spark enthusiasm in the West due to a large number of the available trials being uncontrolled. Imposing a controlled protocol and an inert placebo intervention on a child could be seen as unethical in China, or indeed anywhere, so better protocols are needed. The following are good examples of the work undertaken but lacking rigorous controls or outcome measures.

Researchers at the Children’s Hospital, Zhejiang Medical University, in China spent over a year researching the effects of acupuncture and acupressure treatment on children suffering from infantile cerebral palsy. Seventy-five children took part in the study which involved comprehensive meridian therapy, including scalp and body acupuncture supplemented with acupressure and massage. The number of treatments each child received ranged from a minimum of 10 to a maximum of 120, the exact number being assessed according to the child’s needs.

The effect of the treatment was measured by evaluating the children’s performance of physical exercise, social adaptability and their intelligence quotient (IQ) both before and after the treatment period. The results revealed ‘a very positive improvement in the children’s physical capability and an increase of their intelligence’ [84].

A clinical study of acupuncture looking at both the Bobath approach, commonly used by physiotherapists, and acupuncture was undertaken in 2005 [85]. This involved the treatment of 90 cases of spasmodic cerebral palsy patients aged from 1 to 10 years. The patients were randomly divided into three groups, with 30 members in each group: group A (acupuncture group), group B (rehabilitation training group) and group C (acupuncture and rehabilitation training group).

Group A was treated by both scalp and body acupuncture; group B received physical therapy following the Bobath and Voita methods; and group C was treated by acupuncture and received physical therapy at the same time. All three groups took 90 days as one course of treatment. The results showed that the total effective rate of groups A and C were significantly higher than group B; the developmental quotient of both groups A and C were higher than that of group B after treatment. It appears that acupuncture can add something to the quality of life of cerebral palsy patients.

In a similar study, again with a mixture of exercise, Bobath techniques and acupuncture, Mu et al. [86] suggest that the combination of techniques can be effective. More recently a single case study [87] seemed to indicate that in the child studied a simple acupuncture intervention, regular needling of GB 34 and St 36, resulted in temporary cessation of involuntary extension contractions of the erector spinae muscle. This was not maintained between treatments. Although of limited value evidentially this case indicates that there may be a response worth full investigation in the future.

Acupressure as a single intervention has been recommended for cerebral palsy but this has little evidence base and seems to need to be undertaken regularly over a very long period [87]. Many of the acupressure points offered as useful for general mobilization of the soft tissues in cerebral palsy patients correspond clearly with trigger points known to Western medical acupuncture [88]. A form of light massage given regularly to areas of muscle with perceived physiological changes can be helpful in decreasing muscle tone; this type of massage is sometimes termed Tuina.

Successful and early prevention and/or control of contracture may prevent the need for later corrective surgery, so this often takes precedence in any physiotherapy programme. It is important to work with both the parents and the school to maximize the independence of the child and when the neurophysiology of acupuncture is better understood we may find it has a useful place in the treatment regime. At present it seems to do no harm.

Case study 6.4: level 1 case study: back pain and abnormal posture

A 54-year-old woman presented with chronic low-back pain of 7/10, radiating down the lateral aspect of her right leg as far as the knee. She reported long-standing abnormal standing posture and movement difficulties when walking secondary to cerebral palsy. She complained of poor-quality sleep which was disturbed by involuntary ‘jumping’ of her legs. She was independent in daily activities.

Treatment

This patient was referred for physiotherapy to address her posture and movement difficulties as well as her back pain. Following detailed assessment it was clear that the patient needed to complete a range of activities to improve activation of core stability muscles, to improve strength and endurance of abdominal muscles and to mobilize the lumbar spine. However the presence of pain meant that completing these activities was impossible. Therefore acupuncture was used to reduce pain to allow subsequent muscle re-education.

Pain was localized to particular points, and palpation reproduced the patient’s pain. Points which were tender on palpation were needled. This included BL 27 bilaterally as well as BL 54, GB 30, GB 31 and GB 34 on the right side. The patient responded strongly during treatment and during these early sessions some needles had to be removed after a few minutes due to localized pain, for example, GB 34. Gradually the points became less tender and other points were palpated and selected. General points for pain relief were also chosen. Points needled included extra point Shiqizhuixia (M-BW-25), LR 3, BL 60, Yintang, GV 4 and GV 20. A course of 10 acupuncture treatments was provided over a period of 6 weeks. Needles were stimulated initially for Deqi and then every 10 minutes during the 30-minute treatment.

Outcome

At the end of individual treatment sessions the patient appeared calm and less anxious. By the end of the course of treatment the back and leg pain had reduced to 0/10 and there was a marked improvement in her posture and functional ability. The patient was able to stand with a more upright posture and was able to walk greater distances. Both the patient and the physiotherapist were surprised and delighted by the degree of improvement, especially in view of the long-standing nature of the condition. In addition the patient reported a range of general benefits, including a reduction of involuntary movements of the legs, improved sleep quality, improved mood, reduced anxiety, improved self-confidence and an overall sense of enhanced well-being.

Part 3 Traumatic brain injury

Introduction

Traumatic brain injury is a form of acquired brain injury resulting from sudden trauma to the brain. This injury is commonly caused by road traffic accidents, but may also result from falls, assault, gunshot wounds and sporting injuries [89]. The brain may be damaged by accelerating, decelerating and impacting on the inside of the skull leading to bleeding, bruising and damage to nerve cells and fibres. The skull may remain intact or may be fractured [90]. Traumatic brain injury is a leading cause of death and disability worldwide, causing up to 1.5 million deaths annually. It causes severe disability for 150–200 people per million each year and is the leading cause of disability for those aged under 40 years [91]. Injuries are more common in people aged 15–24 or over 75 years [92].

Symptoms

Presenting symptoms depend upon the initial severity of injury but may include motor difficulties including paralysis, spasticity and ataxia, visual difficulties, sensory impairment, aphasia as well as difficulties with attention, perception, memory, problem-solving and judgement. Mood swings, irritability and aggression, disinhibited sexual behaviour, poor initiation and apathy may also be evident. Recognised sequelae of traumatic brain injury include the development of seizures, chronic pain, particularly headache, and disturbed function of the hypothalamopituitary axis.

Prognosis

Outcome following traumatic brain injury depends on the severity of initial damage. Improvement in acute management means that some of those with severe injuries will now survive. These individuals are likely to develop substantial disability and require long-term support. Those with less severe injuries may be left with minor or moderate residual symptoms. However some of those with apparently minor injuries may experience long-lasting difficulties which have a substantial impact on their functional ability and participation within the wider community [92].

Treatment

Initial treatment focuses on saving life and minimizing further damage to the brain. Many patients will require artificial ventilation to ensure adequate oxygenation of the brain. Other injuries, such as fractures and soft-tissue injuries, will be assessed and managed appropriately. Particular care will be taken to screen for spinal fractures. Neurosurgical intervention may be required to evacuate significant haematomas or to remove any debris resulting from penetrating injuries to the skull. After the acute phase, treatment will aim to improve the functional ability of the patient and support the patient and family to adjust to any residual difficulties. Input will be provided by a multidisciplinary team.

Traumatic brain injury and physiotherapy

Physiotherapy will begin in the acute stage and involve respiratory care. Management of the musculoskeletal system will begin from the acute stage and continue throughout the rehabilitation process. Interventions will aim to maintain range of movement, promote motor control and balance as well as to restore functional abilities. The physiotherapist will work closely alongside other members of the specialist neurorehabilitation team as well as actively involving the patient’s family.

Traumatic brain injury and acupuncture

The focus of acupuncture shares similarities with the approach to stroke and includes the use of Yang meridians in the upper and lower limbs. However, the sudden and traumatic onset of injury may result in areas of local Qi or Blood stagnation as well as the effect of shock on the Heart and Kidney, causing depletion [75]. Common TCM patterns noted in traumatic brain injury include blood stasis, hyperactivity of Liver Yang, obstruction of Phlegm, deficiency of Kidney Essence and deficiency of Qi and Blood [93].

Very little research has been conducted in this condition. A Chinese study by He et al. [94] reported the use of acupuncture in 30 cases of posttraumatic coma. Patients in the treatment group (n = 15) received acupuncture and point injection in addition to standard care. This study reported that patients in the acupuncture group showed ‘obvious’ improvement in symptoms such as aphasia, hemiplegia, facial weakness and eye movement in comparison to the control group. These are interesting results but studies with more rigorous design and outcome measurements are required. A number of case reports have noted benefits from acupuncture in traumatic brain injury. Chen used needling of Shendao (GV 11) complemented by Guanyuan (CV 4) to improve circulation through the Governor and Conception Vessels [93]. He reported greater benefits from this option for relief of spasticity than from body, scalp or ear acupuncture. Donnellan reported benefits from body acupuncture for the relief of central neuropathic pain and mood disturbance in a patient with severe traumatic brain injury and multiple fractures [95].