Transcript Stroke

Acupuncture for treatment CVA And Bell
palsy
By balgis MD MSc CM-FM Sp Ak
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:
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Lesions on walls of vessels leading to brain
Occlusions of vessel lumen by thrombus or embolus
Vessel rupture
Alterations of blood quality
CV disease leads to two types of brain
abnormalities :
1. Ischemia (with or without infarct)
2. Hemorrhage
Sudden weakness, paralysis, or numbness of the face,
arm and the leg on one or both sides of the body
Loss of speech, or difficulty speaking or understanding
speech
Dimness or loss of vision, particularly in only one eye
Unexplained dizziness (especially when associated with
other neurologic symptoms) unsteadiness, or sudden falls
Sudden severe headache and/or loss of consciousness
Incidence
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Highest risk > 65 years of age
But about 1/3 (28%) are < 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
Three types :
• Global hypoperfusion – shock
• Ischemia – thrombotic and embolic
• Hemorrhagic
Risk Factors
• Arterial hypertension
• Heart disease
– Myocardial infarction or endocarditis
– Atrial fibrillation
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Elevated plasma cholesterol
Diabetes mellitus
Oral contraceptives
Smoking
Polycythemia and thrombocythemia
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
Transient Ischemic Attacks
• Last for only a few minutes, always less
than 24 hours
• All neurological deficits resolve
• Symptom of developing thrombosis
Causes:
• Thrombus formation
– Atherosclerosis
– Arteritis
– Hypertension
• Vasospasm
• Other:
– Hypotension
– Anemia
– Polycythemia
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
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
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
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
• 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
NIH Stroke Scale
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.
Acupuncture
• Qi maintains
balance in the
body.
• 16 meridians
• 360 regular
acupoints
• 40 commonly used
extra points
• Acupoints
influence the
physiology
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:
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Nausea
Dental pain
Addictions
Asthma
Osteoarthritis
Menstrual Cramps
Myofascial Pain
Carpal Tunnel Syndrome
Lower Back Pain
- Headache
-Fibromyalgia
-Tennis Elbow
-Stroke Rehab
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."
• 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,
• 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
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.
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 43:2189-2192.
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)
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.
90
80
70
60
50
Acupunc
ture
group
40
30
20
10
0
go home
Tradition
al
therapy
group
• 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 (n=40) 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.
More Doctor Believing in
Acupuncture,CM
Peran Akup pd CVA
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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
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
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.
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
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
Titik2 yg digunakan untuk membangkitkan
kesadaran
• Renzhong
• Fengchi
• Neiguan
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
Rencana terapi
1.
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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
Titik untuk Ekstremitas sup
1.
2.
3.
4.
5.
Jianyu
Quchi
Waiguan
Hegu
Houxi
Titik untuk Ekstremitas inf
1.
2.
3.
4.
5.
Biguan
Xuehai
Yanglingquan
Xianzhong
Taichong
Rencana terapi
2.
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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
Titik untuk Ekstremitas sup
1.
2.
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7.
8.
Jianyu
Jianliao
Tianjing
shousanli
Waiguan
Hegu
zhongzhu
Houxi
Titik untuk Ekstremitas inf
1.
2.
3.
4.
Nei Biguan
Xia Xuehai
Yanglingquan
Xiaxi
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
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.
Bell's Palsy
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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
Gejala pada sisi lumpuh
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Akibat kelumpuhan serabut somatomotoris n
fasialis
Dahi tidak dapat dikerutkan
Mata tidak dapat menutup (lagopthalmus)
Dalam usaha menutup mata bola mata kerap
berputar keatas ( bell’s 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
Terapi akupunktur pd bell’s palsy
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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
• Rangsangan penjaruman atau dengan
EA
• Setiap kali dirangsang 5-6 buah titik
• 3 kali perminggu
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.
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.
MEDICATIONS
•
Prednisolone, Premarin, Acyclovir,
DHEA, vitamins, minerals, and a
natural Synthroid substitute.
• 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.
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.
• 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).
PATIENT RESPONSE
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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.
• 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).
• Abstract: Background Bell’s 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 Bell’s 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 HouseBrackmann scale, and facial disability index (FDI) scores were
assessed and determined both pre- and post-treatment to
evaluate the effectiveness of the treatment methods.
• 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
(χ2=15.265, P=0.018). 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, P=0.005).
Conclusion The efficacy of acu-moxi treatment for
Bell’s palsy is verified scientifically.
• 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.
• 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 HouseBrackmann scale into 6 grades: Ⅰ, Normal;
Ⅱ, Mild dysfunction; Ⅲ, Moderate
dysfunction; Ⅳ, Moderately severe
dysfunction; Ⅴ, Severe dysfunction and Ⅵ,
Total paralysis. The House-Brackmann scale is
generally accepted as effective in evaluating
facial nerve function.
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.
• RESULTS: (1) Acupuncture was effective for the Bell's
palsy in active stage, resting stage and recovery
stage (all P<0. 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 P<0.
01). (3) There was no significant difference of the
obvious effective rate between the resting stage
group and the recovery stage group (P>0. 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.