Full title: “Acupuncture Treatment of Cognitive Impairment After Stroke: A Case Study”
Abstract
Stroke, or cerebrovascular accident, is one of the leading causes of death and disability around the world, according to the World Health Organization. As many as 70 to 80 percent of stroke survivors suffer from physical and cognitive impairments. Typical rehabilitation treatments tend to focus on motor dysfunctions to aid mobility and independent living, often overshadowing cognitive needs. Intervention for mild cognitive impairments such as memory difficulties and poor concentration includes speech and language therapy, neurofeedback therapy, transcranial direct current stimulation and medication, as well as complementary modalities such as acupuncture. Current literature shows moderate results in acupuncture treatment of cognitive impairment after stroke. This case demonstrates the effects of Zhu’s Scalp Acupuncture and daoyin for the treatment of a 65-year-old patient with memory difficulties as a result of a hemorrhagic stroke.
Introduction
Nearly 800,000 people in the U.S. suffer from stroke every year, according to the American Heart Association.1 Also known as a cerebrovascular accident, stroke is a central nervous system disease and the leading cause of disability among the elderly.1 Statistics show between 70% to 80% of stroke survivors experience complications such as motor dysfunction, cognitive impairment and sensibility dysfunction that impede their ability to live independently.2 Conventional post-stroke treatment includes physical, occupational and speech therapies in varying intensities and frequencies in either acute rehabilitation centers, skilled nursing facilities or in-home care.
Mobility and independent living exercises such as sit-to-stand, walking, stairs usage, and daily self-care activities of dressing and feeding usually dominate the rehabilitation program. Cognitive deficits including memory difficulties, poor concentration, language impairment, and executive function decline often do not receive adequate attention from healthcare providers, which in some cases, lead to post-stroke dementia in later years.3 The prevalence of cognitive deficit in stroke patients is about 40 percent, primarily with dysfunction in working memory related to daily living.4
Biomedicine
Current innovative neuropsychiatric approaches to address post-stroke cognitive impairment include neurofeedback therapy (NFT), which retrains brain waves with electroencephalography. A systematic review of NFT for stroke survivors found modest improvements in several cognitive domains including memory, mood and concentration in eight studies.5 A similar type of neural modulation is transcranial direct current stimulation (tDCS), another form of noninvasive brain stimulation via electrodes placed on a person’s scalp that has been used for Parkinson’s Disease, Alzheimer’s Disease, depression, and anxiety. Although studies show positive, statistically significant effects of tDCS therapy for mild neurocognitive disorders, the evidence is still inconclusive regarding its long-lasting and generalizable cognitive effects.6
In terms of pharmacological intervention, anti-dementia drugs such as donepezil, galantamine, and rivastigmine, which are cholinesterase inhibitors, have been used for stroke patients in clinical trials.7 The results showed some promise, but Sun and colleagues conclude that the overall efficacy of these drugs remains uncertain in terms of improving global and daily function of post-stroke cognitive impairment.7
Chinese Medicine and Acupuncture
Since antiquity, Traditional Chinese medicine’s (TCM) term for stroke is zhong feng, meaning “wind stroke,” because the disease features wind-like characteristics, which are sudden and quick to change, striking either from external or internal forces.8
With regards to cognitive impairment, the TCM understanding of the mind has to do with the kidney, heart, and spleen. In the Neijing Suwen (Yellow Emperor’s Inner Classic – Basic Questions), the brain is described as “the sea of marrow” produced by the kidneys’ essence.9 The heart is analogized as the emperor that governs over the body, which includes mental and emotional functions. “The Heart is the basis of life; it is [responsible for] changes of the spirit.”9 (p170) The Spleen is associated with thinking; as TCM scholar Elizabeth Rochat explains, “Si (思) [to think] is linked to the earth and the spleen because thought must receive all the information and elements of thinking coming from everywhere, both without and within.”10 (p140)
Commonly used TCM diagnostic patterns for post-stroke cognitive decline include kidney essence deficiency, qi and blood deficiency, liver yang hyperactive ascendance, and phlegm turbidity obstructing the orifices.11 One of the main TCM approaches to treating post-stroke cognitive impairment is acupuncture. A recent systematic review of 21 trials with a total of 1,421 patients showed positive outcomes of acupuncture treatment for cognitive impairment after stroke. Numerous studies explained the improved cognitive function that correlated acupuncture with increased cerebral blood flow. 2 Electroacupuncture, a modern modification of traditional acupuncture with low electric current conducted through two electrodes on pairs of needles, has also shown some moderate effectiveness in treating mild cognitive impairment after stroke.12
The clinical heterogeneity of acupuncture studies was high in the meta-analysis. Further studies are needed to determine the effectiveness of specific treatment protocols such as manual versus electrostimulation, points prescription with scalp and/or body emphasis, needle retention time, as well as the intervention period after stroke and how to integrate with conventional therapy.
Case Description
Case History
A 65-year-old male patient presented with mild cognitive impairment six weeks after suffering a subarachnoid hemorrhagic (SAH) stroke in March, 2017. He reported having frequent headaches, memory difficulties, mental fog, fatigue, and low energy.
His recent history includes having a permanent ventriculoperitoneal shunt (VPS) implanted inside the brain to drain excess cerebrospinal fluid to the abdomen. Some two weeks after the procedure, fluids accumulated under the scar and were pushing the wound open. The neurosurgeon then stapled the wound without anesthesia, which, according to the patient, caused excruciating pain. The VPS surgery was done to replace an external ventricular drain that was placed shortly after the onset of SAH.
Before seeking acupuncture treatment, the patient was hospitalized for about one month at three different hospitals, which included time in the intensive care unit, neurology ward, and acute rehabilitation center. During the hospitalization, family members reported the patient’s condition as having intermittent periods of alertness and somnolence. He was able to recognize and communicate with family and friends, but had trouble remembering who visited at what times. After one therapy session, the patient said, “They’re having me do a lot of prep for the performance!” although he couldn’t explain what the performance was, according to his wife. Similarly, family members said he wasn’t able to name certain objects and was frequently confused.
The stroke affected the patient’s left side, although he retained his upper limbs’ strength. The patient’s lower limbs were weakened during the extended bed rest at the hospitals. His physical therapy started with sit-to-stand exercises, learning to transfer from the bed to a chair, then progressing to walking with a walker. By the time he was discharged, he was able to walk for an hour with a cane and use stairs without support. The patient received an hour each of standard three-pronged physical, occupational, and speech therapies daily during the acute stage, followed by weekly therapy sessions in the subsequent subacute stage.
Two months prior to the stroke, the patient had an implantation of a pacemaker-defibrillator to treat a heart condition caused by a viral heart infection 18 years earlier. The patient reported that his cardiologist suspected the daily low dose (81 mg) of aspirin he had been on for almost two decades was the likely cause of the SAH.
Diagnostic Assessment
The patient showed minor balance issues, and answered verbal questions slowly with a flat affect and a low voice. He knew his name and where he was, but was unable to state the date correctly. The patient knew the name of the accompanying family member, but incorrectly stated who was older. He was able to recall what he had for breakfast right before the treatment, but not what he had for dinner the night before. He knew he had a stroke, but couldn’t remember what happened or the details at the hospital. The patient’s pulse was bilaterally deep and thready. His tongue was pale with a thin white coat and a regular body.
Based on CM patterns, the patient was diagnosed with kidney essence deficiency and qi and blood deficiency as evidenced by the memory difficulties, slow responses, diminished expression, and deep pulse. He did not show any heat signs such as red tongue, rapid, full pulse or muscle spasm that defines the other common pattern of liver yang hyperactive ascendance.
Treatment
In TCM channel theory, the Du meridian enters the brain and the sea of marrow point while all the yang meridians and the liver meridian travel to the head. The treatment principle was to nourish kidney essence and tonify qi and blood by using the style of scalp acupuncture taught by Dr. Ming Qing Zhu, a leading Chinese medicine practitioner in stroke treatment. Zhu’s Scalp Acupuncture (ZSA) involves needling points on the head along with rehabilitation exercises known as daoyin. Dr. Zhu first gained international attention when he treated a hemiplegic stroke patient during the founding congress of the World Federation of Acupuncture and Moxibustion Societies in Beijing on November 24, 1987. His technique was able to bring the wheelchair bound patient to his feet and walk without support during the demonstration. Dr. Zhu went on to promote his style of scalp acupuncture, which needles certain regions on the head, and prescribe daoyin.
The earliest known illustration of daoyin, meaning “guiding” and “pulling” was on a silk painting found from the excavation of Mawangdui Tomb, which dates back to the Han Dynasty (206 BC – 220 AD). It shows 44 different colorful figures in yoga-like stretches. The term can also be found in Jin Gui Yao Lue line 1.2, which was noted as “an ancient calisthenic method of health cultivation through exercising the sinews and bones and guiding qi throughout the body.”9 (p10)
In ZSA, the emphasis on the concurrent application of daoyin, which could be either physical or mental exercises, is to engage the patient’s participation in order to accelerate the self-healing process. Patients must focus their intention on activating their innate functions instead of relying on others or devices. The specifics of daoyin, reflecting a core treatment principle in Chinese medicine, should be tailored to each individual’s condition and constantly modified according to the progression of the condition.13 For example, Dr. Zhu often encourages patients with aphasia to sing, and those with movement disorders to dance. In this case of cognitive impairment, the daoyin was focused on what sparked interest in the patient to maintain a high level of attention without depleting his energy.
During the first treatment, the patient was needled on the following points: GV 20 or vertex-perineum-foot (VPF) in ZSA terminology, lower jiao area (LJ) x 3, which starts from GV 21 and extends 1 cun posteriorly and bounded laterally by the Bl channel; upper jiao area (UJ) x 3, which starts at GV 23 and extends 1.5 cun posteriorly also laterally bounded by the Bl channel with 0.20×30 mm (36 gauge x 1.2in) and the head and face region (HF), or 1-cun square centered at GV 24 with 0.20x 0.22mm (36 gauge x 0.8in). The needles, which did not have guide tubes, were manufactured under Dr. Zhu’s supervision by Suzhou Medical Appliance Factory, China.
The insertions were oblique and the needles were manually stimulated a few times with very gentle lifting thrusting and tiny amplitude technique during the daoyin exercises. The treatment sessions were one hour long. The daoyin featured different types of physical and mental exercises beginning with breathing and mini-squats known as Super Brain Yoga, followed by special sensory stimulation of smell and touch. The patient was given three different essential oils to smell. He was then instructed to associate a word with the aroma. At the end of the session, he was asked again to smell the oils and recall the words. The patient was able to recall two out of three words with some prompting at the end of the first session. When asked again two days later, the patient was able to recall all three words without cues. Similarly, the patient was given distinctive textures and objects to feel in his hand like magnolia buds (xin yi hua) with his eyes closed. He was then to associate a word with the tactile sensation.
The physical daoyin was cut back after the second visit when the patient reported doing daily long walks and cardio exercises. Instead, the daoyin featured topics that related to the patient’s life experience, including music and concepts in Chinese medicine. The patient was reportedly an avid musician and had family members who spent their childhood in China. The objective of the daoyin was to engage the patient on an emotional level, which theoretically enables new short-term memories to be retained and retrieved with more ease. The patient came up with creative associations for TCM five phases, such as Clint Eastwood for the wood element and east, while metal of the west was associated with heavy metal pioneer guitarist, Leslie West.
During the course of 10 treatments, a variation of the aforementioned acupuncture points was combined with daoyin that resonated emotionally with the patient, such as identifying melodies and guitar playing, at which the patient was highly skilled. He was able to sing and play fluidly without hesitation, impressing those in the clinic who overheard outside the treatment room.
According to ZSA, long needle retention time extends the therapeutic effects of acupuncture. The average recommended time to keep needles on the top part of the head, bordered by the regions of HF (Du-24) and VPF (Du-20), is between 24 to 48 hours. If the patient experiences discomfort before reaching the recommended time, he was advised to remove the needles.
On the evening after the first treatment, the patient reported experiencing intense headaches after which the needles were removed by his wife. In the following treatments, the number of needles varied between three to five. Subsequently, the patient did not report any adverse events and kept the needles in overnight before removing them first thing in the morning.
Initially, the frequency of the treatments was twice a week. After three weeks, the patient took a week off to attend an annual music festival with family and friends. Upon returning, the patient was in good spirits and able to recall most of the information from previous sessions. He resumed treatment once a week for the remaining four sessions.
Outcomes and Prognosis
Besides memory difficulties, the patient’s other symptoms of headache, mental fog, fatigue and low energy resolved by the third treatment. The staples on his scalp to close the shunt incision were removed by then. At the end of the 10-treatment course, the patient showed no visible signs of cognitive impairment. He was attentive, able to learn new concepts including some Chinese characters and retain new information. The patient reported overall improved clarity of the mind that enabled him to drive and resume daily activities independently. The prognosis for continued recovery for any residual deficits was very good. Daily physical exercises, playing music and engaging in social functions were recommended without further acupuncture treatments.
Early on during the treatment course, the patient was asked to name a short-term goal he would like to achieve in his recovery. As a creative professional with many interests, the patient reported wanting to publish a book of his travel writings and photography. Six months after the last treatment, the patient self-published his first book. As of this writing, the patient has published 11 books chronicling his artwork from the past three decades and is in the process of preparing for an art show.
Discussion
The results of this case seem to confirm ZSA’s effectiveness in combining scalp acupuncture with physical and mental daoyin for the treatment of mild memory difficulties after a stroke. The patient’s active engagement and compliance in keeping the needles for extended retention time were key elements in the patient’s recovery. Daoyin, in this case, features creative approaches that piqued the patient’s interest with underlying emotional resonance.
In addition, the patient’s recovery seemed to be aided by his supportive social network as evident by various family and friends who accompanied him to the treatments. The patient reported that one of his first activities at home after hospitalization was writing thank you cards.
The patient’s experience can also be associated with the word yi, intent or meaning. The character for yi, (意)is comprised of two parts: the upper part is a note or sound while the bottom is a heart. Lingshu (Spiritual Pivot) Chapter 8 – Rooted in Spirits explains that yi originates from the heart. “If yi is intention, purpose or idea, it means that the heart is able to organize the vibration which comes to it… This is the first elaboration of thinking, the first movement toward thought and action. The heart is like the conductor of an orchestra, recognizing whether each vibration conforms to the harmony of the whole orchestra.”10 (p37)
The TCM view of the mind and body seem to correlate with the field of brain plasticity research. According to neuroplasticity theories, the brain has the adaptive ability to regenerate neuronal connections in the case of injuries that result in cognitive impairment. What spurs neurogenesis is stimulating cognitive training with novel and challenging experiences along with physical exercise that ultimately promotes good health.14
One of the limitations of this case was the lack of cognitive function measurements. Commonly used assessment tools such as the Mini-Mental State Examination (MMSE) were likely conducted at the acute stage during hospitalization. The patient was unable to provide information regarding his initial assessment saying, “I just remember having to answer a lot of questions.”
Another major component of CM treatment of stroke sequelae that was not included in this case was herbal formulas. Since the patient was on multiple medications for his heart condition, the treatment plan did not include herbal remedies. In addition, further research is needed to investigate the optimal course of ZSA treatment for different locations of brain lesions, levels of cognitive impairment and stages of stroke recovery.
Conclusion
ZSA, which features scalp needling in tandem with physical and/or mental daoyin exercises, has shown to be effective treatment of cognitive impairment such as memory difficulties after stroke. Compared with other neuropsychiatric interventions, acupuncture with diverse mental training provides a minimally invasive and cost-effective treatment option.
References
1. Benjamin Emelia J., Blaha Michael J., Chiuve Stephanie E., et al. Heart Disease and Stroke Statistics—2017 Update: A Report From the American Heart Association. Circulation. 2017;135(10):e146-e603. doi:10.1161/CIR.0000000000000485
2. Liu F, Li Z-M, Jiang Y-J, Chen L-D. A Meta-Analysis of Acupuncture Use in the Treatment of Cognitive Impairment After Stroke. J Altern Complement Med. 2014;20(7):535-544. doi:10.1089/acm.2013.0364
3. Tang EYH, Price C, Stephan BCM, Robinson L, Exley C. Gaps in care for patients with memory deficits after stroke: views of healthcare providers. BMC Health Services Research. 2017;17(1). doi:10.1186/s12913-017-2569-5
4. Doppelmayr, M., Nosko, H., Pecherstorfer, T., & Fink, A. (2007) An attempt to increase cognitive performance after stroke with neurofeedback. Biofeedback. 35(4), 126-130.
5. Renton T, Tibbles A, Topolovec-Vranic J. Neurofeedback as a form of cognitive rehabilitation therapy following stroke: A systematic review. PLoS One. 2017;12(5). doi:10.1371/journal.pone.0177290
6. Cappon D, Jahanshahi M, Bisiacchi P. Value and Efficacy of Transcranial Direct Current Stimulation in the Cognitive Rehabilitation: A Critical Review Since 2000. Front Neurosci. 2016;10. doi:10.3389/fnins.2016.00157
7. Sun J-H, Tan L, Yu J-T. Post-stroke cognitive impairment: epidemiology, mechanisms and management. Ann Transl Med. 2014;2(8). doi:10.3978/j.issn.2305-5839.2014.08.05
8. Liu G. Foundations Of Theory For Ancient Chinese Medicine: Shang Han Lun And Contemporary Medical Texts.; 2015.
9. Wiseman N, Wilms S. Jin Gui Yao Lue: Essential Prescriptions of the Golden Cabinet. Brookline: Paradigm Publications; 2013.
10. Larre C, Rochat de La Vallée E. The Seven Emotions. Cambridge: Monkey Press; 2017.
11. Tang N-Y, Liu C-H, Liu H-J, et al. Chinese Medicine Patterns in Patients with Post-Stroke Dementia. J Tradit Complement Med. 2012;2(2):123-128.
12. Chou P, Chu H, Lin J-G. Effects of electroacupuncture treatment on impaired cognition and quality of life in Taiwanese stroke patients. Journal of Alternative And Complementary Medicine (New York, NY). 2009;15(10):1067-1073.
13. Zhu M, Siu M. Zhu’s Scalp Acupuncture Medical Practice Series − Foundation Volume. Beijing: People’s Medical Publishing Co.; 2015. (in Chinese)
14. Doidge N. Brain’s Way Of Healing. New York: Penguin Group; 2015.
