Acubriefs Newsletter 4th Quarter Winter 2004

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Acubriefs Newsletter Volume 5 Issue 4

 

December 2004 - 4th Quarter

View this Newsletter and New Citations with your browser at:

http://www.acubriefs.com/newsletters/newsletter_Q4a04.htm

(Because some of the following URLs are long, you may have to " cut and

paste " the entire URL into your Web browser address bar)

 

From the Editor:

Since our last newsletter there are significant developments

in acupuncture research. There were two articles with favorable results

in the Annals of Internal Medicine. The most noteworthy was the RCT

done by Berman,B.M., et al.. In their article: " Effectiveness of

Acupuncture as Adjunctive Therapy in Osteoarthritis of the Knee. " Ann

Intern Med. 2004 Dec 21;141(12):901-10. PubMed Abstract at:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dop

t=Abstract & list_uids=15611487

they came to the following conclusions: Acupuncture seems to provide

improvement in function and pain relief as an adjunctive therapy for

osteoarthritis of the knee when compared with credible sham acupuncture

and education control groups.

We are not going to formally review this study or the one

written by White,P., et al: " Acupuncture versus Placebo for the

Treatment of Chronic Mechanical Neck Pain. " Ann Intern Med. 2004 Dec

21;141(12):911-9. PubMed Abstract at:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=pubmed & dop

t=Abstract & list_uids=15611488

Suffice it to say, these articles were published in the Annals of

Internal Medicine.

 

For this newsletter Dr. Francine Rainone was kind enough to

do a clinical review of acupuncture for stroke. Please see below. I

think her review is excellent and is clinically relevant. She is an

advocate for taking steps to promote trials that establish efficacy for

acupuncture for stroke victims. She also promotes studies to evaluate

cost-effectiveness. I tend to believe that if cost-effectiveness can be

demonstrated, this is what ultimately will push the cart in having

acupuncture accepted as appropriate adjunctive care in stroke

rehabilitation. As she points out, hopefully with time we can be more

specific as to which patients are likely to benefit.

Below is a list of announcements/news items that I suspect

many readers of Acubriefs will be interested in.

- Dr. Michael Levin, a developmental biologist working in Boston, is

looking for a postdoc who has experience in both acupuncture research

and cell biology. His group studies the role of endogenous bioelectric

phenomena (ion fluxes, pH and voltage gradients, and gap junctions) in

embryonic morphogenesis and regeneration. He has a long-time interest in

acupuncture. He has recent publications in Cell and other journals. For

more info, please take a look at

http://www.drmichaellevin.org/ (publications and current research topics

are available there). People who are interested may contact Dr. Levin

directly at:

mlevin or mlevin Let Acubriefs know

if you have employment opportunities in acupuncture research and we'll

try and get the word out.

 

- Familiarize yourself with current studies being funded by the American

NIH on acupuncture. Visit CRISP (Computer Retrieval of Information on

Scientific Projects) at:

http://crisp.cit.nih.gov/crisp/crisp_query.generate_screen and do a

search with acupuncture as a keyword and I think you'll be impressed as

I was as the number of studies currently being funded.

 

- Acubriefs is pleased to welcome the Arizona Chapter of the American

Academy of Medical Acupuncture as an Institutional Affiliate. If your

chapter, group or school is interested in becoming and Institutional

Affiliate, please contact info. You can also visit us

online at http://www.acubriefs.com/ to find out more about the benefits

of institutional affiliation.

 

- Lonny Jarrett, a skilled practitioner, teacher, and author of two

books which explore the " Five Element " style of acupuncture announces

his Clinical Integration class. You can find out more about it at:

 

http://www.spiritpathpress.com/~spiritpa/classes/clinical_integration.ph

p

If you enroll in the course please let him know you heard about it

through us. He's going to give us a little kick-back if you do.

 

- Acubriefs also acknowledges the continuing support of Lhasa OMS, Inc.

http://www.lhasaoms.com/ and SEIRIN America

http://www.seirinamerica.com/ as Sponsors. Acufinder.com

http://www.acufinder.com/ has also agreed to be a sponsor.

 

- For American practitioners there are new acupuncture codes which are

being used to bill insurance companies. I suspect as reimbursement for

acupuncture accelerates more funding for acupuncture research will

ensue. If you want to review a brief discussion of these new codes

visit: http://www.acubriefs.com/acucodes/

 

- If you are looking for a source of " placebo: " acupuncture needles I've

got a source: Coastal Medical Supplies, Inc in Hanover MA.:

http://www.coastalmedicalsupplies.com/

James K. Rotchford, MD, MPH, Editor

 

Review: Acupuncture for Stroke

Francine Rainone, PhD, DO, MS, Director of Community Palliative Care,

Department of Family Medicine, Montefiore Medical Center, Bronx, NY

 

Introduction

It is now common for people to publish reviews of the literature

concerning Complementary and Alternative Medicine (CAM) for specific

conditions. In a typical review, exhaustive searches are completed and

then criteria for scientific validity are applied, resulting in the

exclusion of most of the studies. The remaining studies are subjected to

statistical analysis, and the conclusion is often that there is

insufficient evidence to recommend for or against the therapy. While

such reviews are valuable in determining whether the efficacy of a

treatment has been established, their narrow focus rarely provides help

to guide clinicians already using the therapy or researchers interested

in furthering CAM research. My intention here is to utilize most of the

literature to review the topic of acupuncture for stroke. The purpose of

the review is not to assess the evidence for efficacy so much as to

think through the issue as an acupuncturist and a researcher.

 

In the People's Republic of China, acupuncture is widely used as an

adjunctive therapy in the treatment of stroke. In the United States it

is almost never used. In general, novel therapies are investigated in

this country because they elicit physiological mechanisms that suggest

potential efficacy and/or because there is compelling clinical evidence

of their effectiveness. Numerous studies demonstrate that acupuncture

induces physiologic changes that promote healing after ischemic and

hemorrhagic brain injury, but the clinical evidence is mixed. A recent

review concluded that there is no additional benefit to administering

acupuncture as part of a comprehensive rehabilitation program following

stroke.(1) This conclusion is premature.

 

Several types of " clinical evidence: should be distinguished. The lowest

level is anecdote. Anecdotal evidence, as defined here, refers to case

reports involving ten or fewer patients whose clinical improvement is

associated with a particular intervention. Anecdotal evidence is often

the start of off-label uses of pharmaceuticals or botanicals. Anecdote

can be an important source of innovation, but necessarily runs the risk

of leading to unforeseen consequences. The next level of clinical

evidence is custom. The customary way of doing things is accepted as

useful regardless of the evidence base. Separating the customary from

the efficacious is difficult for every health care practitioner.

 

Physiologic Studies in Animals

At least seven animal studies of the effect of acupuncture following

transient brain ischemia have shown that acupuncture regulates chemical

mediators of ischemia. Much of the work has centered on nitrous oxide

(NO). Levels of NO, which is responsible for excitotoxicity, are

significantly increased during cerebral ischemia and reperfusion.

Acupuncture has been shown to regulate NO levels by several mechanisms.

In three studies in rats, 60 minutes of electroacupuncture (EA)

delivered to two points 10 minutes after occlusion of the middle

cerebral artery (MCA) inhibited overexpression of both neuronal and

inducible nitric oxide synthase messenger RNA (nNOS and iNOS mRNA).(2-4)

A subsequent study showed that the same EA regimen inhibited NO release

by 53% at 56 minutes following MCA occlusion, though it did not

normalize levels.(5) In rats with chemically induced epilepsy, EA also

inhibited nNOS and iNOS to a statistically significant degree.(6) In

addition to inhibiting the genetic precursors to expression and the

release of NO, acupuncture affects its production by another mechanism.

Glial cell line derived neuronal factor (GDNF) reduces the volume of

infarct in rat brains by inhibiting neuronal NO production and neuronal

apoptosis. EA administered immediately after MCA occlusion did not

increase peak GDNF mRNA expression in rat brains, but did delay the

decline of GDNF that occurs 12 hours after reperfusion.(7)

 

Studies also document the effects of acupuncture on regulators and

mediators of ischemia other than NO. Basic Fibroblast Growth Factor

(bFGF) protects against ischemia in both rat and cat models. EA applied

10 minutes after occlusion of the MCA in rats upregulated the expression

of bFGF-like immunoreactivity in the striatum and cortex of rat

brains.(8,9) Following transient global ischemia, acupuncture suppressed

apoptosis in the hippocampus of gerbils.(10) In this study, the acupoint

Zusanli had the most potent effect.

 

More limited data suggests a role for acupuncture in treating

hemorrhagic injury. Zusanli applied to rats with intrastriatal

hemorrhage decreased lesion size and apoptotic neuronal cell death.(8)

Studies of EA at acupoint Neiguan suggest that acupuncture exerts a

pressor effect during hemorrhagic hypotension in dogs.(9)

 

Finally, acupuncture administered to rats at Bai Hui 15 minutes before a

training trial significantly attenuated cyclohexamide-induced impairment

of passive avoidance. Efficacy paralleled duration of acupuncture: rats

treated for 60 minutes had the greatest response, and decreasing levels

of response were seen in those treated for 30 and 15 minutes. This

suggests that acupuncture could positively affect the memory storage

system, a system frequently damaged by stroke.

 

Cumulatively, these studies indicate that acupuncture has the potential

to decrease the volume of infarct and enhance recovery from ischemic

brain injury. The studies that investigated the effects of specific

acupoints provide the rudiments of a scientific rationale for point

prescriptions.

 

Physiologic studies in Humans

Four studies in humans have attempted to demonstrate physiologic

mechanisms by which acupuncture affects ischemia. In six patients with

MCA occlusion and eight healthy volunteers, single-photon emission

computed tomography (SPECT) brain perfusion images were obtained before

and after acupuncture at LI4, 10, 11, 15, 16 and TE5.

All participants exhibited increased cerebral blood flow (CBF), but in

stroke patients the increase was pronounced in the perilesional and

use-dependent areas.(10) Another study focused on the mechanisms by

which blood flow is stimulated. Endothelin (ET) is a potent

vasoconstrictor which also increases levels of the vasoconstrictor and

platelet-aggregating factor thromboxane B2 (TXB2). In contrast,

6-keto-prostaglandin-F1a (6-keto-PGF1a) is a potent vasodilator and

inhibitor of platelet aggregation. 20 healthy subjects and 20

" convalescent " stroke patients were given body acupuncture 30 minutes a

day for 10 days. The serum level of ET was significantly higher than

that of healthy subjects at baseline. After treatment it declined

significantly but did not normalize. Urine levels of TXB2 and

6-keto-PGF1a were also higher in cases at baseline. TXB2 declined

significantly (but did not normalize), but 6-keto-PGF1a levels did not

change significantly.(11) These results suggest that the net effect of

acupuncture is to increase vasodilation, which could explain the

increased CBF.

 

Two other physiologic studies in humans attempted to delineate groups of

patients for whom acupuncture would be effective. 64 healthy subjects

and 16 post-stroke patients were administered scalp acupuncture. After

treatment, those with stroke expressed Motor Evoked Potentials (MEP)

with similar waveforms and intervals to controls, but with lower

voltage, a latent period, and an after effect. In 10 cases there was

damage to the pyramidal tract and basal ganglia. For these patients,

needling scalp on the affected side did not elicit MEP on the

contralateral side, but needling the scalp on the unaffected side

elicited MEP in the ipsilateral (paralytic) hand with increased latent

period, markedly lower amplitude and a shorter interval. This suggests

that even patients with damage to the pyramidal tract may benefit from

acupuncture. Unfortunately, the extent of the damage was not

quantified.(12) Finally, in a study of 64 subjects with acute ischemic

cerebral events, 33 were given routine treatment while 31 were given EA

to body points for 20 minutes a day for 14 days, in addition to routine

treatment. 26 healthy subjects functioned as controls. Both before and

after treatment, the level of plasma somatostatin (SS) in the EA group

did not differ significantly from controls. But among those who

responded well to acupuncture, the levels of SS in serum and

cerebrospinal fluid were significantly higher than among those who did

not respond well. Similarly, the serum level of pancreatic polypeptide

did not differ significantly between groups, but within the acupuncture

group those who responded well had significantly higher levels than

those who did not.

 

This type of research, which is not relevant in a review of efficacy, is

essential to practitioners. Few if any practitioners believe that

acupuncture will be beneficial for everyone who has ever had a stroke.

Practitioners implicitly or explicitly apply selection criteria in

deciding whom to treat. One of the goals of research is to provide

clinicians with selection criteria that guide the choice of treatment

modalities to maximize benefit to patients. Chemical markers of efficacy

such as the ones explored above, if confirmed, could be among the

indicators that an individual patient would benefit from acupuncture.

 

Other indicators are suggested in the study reported by Naeser et

al.(13) Her group performed acupuncture on 10 acute and 10 chronic

stroke subjects. They correctly predicted response to acupuncture in 19

of the 20 patients based on CT scan lesion site. Those who responded

well had damage to less than half of the motor pathway areas on CT scan,

especially in the periventricular white matter area at the level of the

body of the lateral ventricle. 8 of the 20 patients had significant

improvement in motor function, including 3 of the 10 subjects treated

more than 3 months post stroke and 5 of the 10 treated less than 3

months post stroke. Most improvements were sustained for at least 4

months after the last acupuncture intervention. Unfortunately, clinical

researchers have not integrated this type of information into their

study designs.

 

Clinical Outcome Studies

In the 1990s there was an explosion of promising research on the

clinical outcomes of acupuncture and transcutaneous electric nerve

stimulation (TENS) for stroke.

 

Tekeodlu and colleagues compared the Barthel Index of Activities of

Daily Living (ADLs) in 30 post-stroke subjects who received

high-frequency TENS and 30 who received placebo TENS. (14) At entry the

intervention group was more disabled (Barthel score 30.4 +/- 22.1 versus

44.7 +/- 17) than the control group. At the end of the study the

intervention group had globally improved significantly more than the

control group. Subjects given the intervention improved in all 10

categories measured on the Barthel Index, whereas in the control group

they had improved significantly only in 5 of the 10 categories.

Specifically, the control group showed no significant improvement in

grooming, feeding, mobility, climbing stairs or bathing.

 

Sonde and colleagues compared subjects who were 6 - 12 months

post-stroke and received low-frequency TENS to subjects 6 - 12 months

post-stroke who did not receive this additional intervention.(15) They

focused on the functional motor capacity of the paretic arm. The 26

patients in the intervention group had significantly improved motor

performance on the Fugl-Meyer scale, compared to the 18 controls. There

was no improvement in ADLs. Although there was no decrease in pain or

spasticity, this was expected, as high-frequency TENS (which was not

used in this intervention) is the standard type used for pain and

spasticity. Given the lack of improvement in ADLs, it is difficult to

assess the clinical significance of the improvement that was made.

Perhaps to answer this question, a follow-up study was performed 3 years

later. Both groups had declined below baseline on the Fugl-Meyer Motor

Performance Scale and spasticity had increased in both groups, though

not significantly. On the other hand, the ADL score deteriorated

significantly in the control group, but did not change significantly in

the intervention group.(16)

 

A similar study, with even more favorable results, was conducted by Wong

and colleagues. 128 subjects within 2 weeks of stroke onset were

randomized to receive comprehensive rehabilitation with or without

electrical stimulation of acupuncture points through adhesive surface

electrodes, 5 times a week for 2 weeks. Neurological status was assessed

by Brunnstrom's stages and the Chinese version of the Functional

Independence Measure (FIM), before treatment and at discharge. The group

that received electrical stimulation had a significantly shorter

duration of hospital stay (29.1 +/- 7.9 days vs. 32.4 +/- 8.2 days), and

scored significantly better on FIM for self-care and locomotion.(17)

 

A Kjendahl et al compared the responses of subjects given six weeks of

acupuncture treatment during the subacute phase of stroke, to subjects

given the standard rehabilitation program in a rehabilitation unit.

Those who received acupuncture showed significantly more improvement in

motor function and ADLs on discharge, compared with those who did not

receive acupuncture.(18) In a one-year follow-up study (1997) they found

that although both groups continued to improve, those in the acupuncture

group improved significantly more on the Motor Assessment Scale, Sunnaas

Index of ADLs and Nottingham Health Profile. Of note, the points

selected were individualized to each patient, in accordance with

Traditional Chinese Medical Theory.

 

Another, earlier pair of studies showed equally remarkable results. K

Johansson et al conducted a trial in which 78 stroke patients with a

median age of 75 were randomized within 10 days of stroke onset to

receive either standard care or standard care plus additional sensory

stimulation, including EA. The group receiving EA had significantly

better scores on balance, mobility and ADLs.(19) In a follow-up study

by Manusson et al (1994) more than 2 years after stroke onset (mean 2.7

years, range 2.0-3.8 years) they investigated postural control in the 48

survivors of the original trial. 22 subjects from the EA group and 26

from the control group were compared with 23 age-matched healthy

subjects. Significantly more subjects in the treatment group than in the

control group maintained stance during perturbation. The values

approached the normal for age-matched healthy controls.(20) To account

for the persistence of effects so long after the intervention, they

speculate that the sensory stimulation provided by EA enhances the

functional plasticity of the brain.

 

Two studies of the effects of acupuncture on spasticity produced

contradictory results. 25 patients with chronic poststroke leg

plasticity were randomized to placebo needling (n=12) or real treatment

(n=13). At the end of 4 weeks there were no significant differences

between the two groups on the Modified Ashworth Scale (MAS). 35 stroke

patients with elbow spasticity were randomized to EA (n=15), moxibustion

(n=10) or control (n=10). The EA group received 30 minutes of

stimulation every other day at LI11, LI10, TB5 and LI4 on the paretic

side. The moxa group received direct moxa three times a day every other

day, to the same points. The control group received " routine

acupuncture " therapy for stroke. All patients also received range of

motion exercises. Significant reductions in spasticity, as measured by

MAS, were achieved in the EA group after day 5, and persisted at day 15

after the start of treatment. There were no significant changes in

either of the other groups.(21)

 

In contrast to the studies mentioned so far, three well-known clinical

trials produced negative outcomes. Gosman-Hedstrom, et al conducted a

study they state was intended specifically to examine the possible

placebo effects of acupuncture. 104 subjects were randomized to 3

groups: deep, superficial and no acupuncture treatment. Assessments were

conducted 4 times during the first year after randomization.(22) No

differences were found in changes in neurological score, Barthel or

Sunnaas ADL index scores. On the Nottingham Health Profile the no

acupuncture group had somewhat fewer mobility problems.

 

The main problem with this study is that all the statistical analyses

were performed in 2 steps. In the first step the superficial and no

acupuncture groups were compared. If no significant differences were

observed, they were combined and compared to the deep acupuncture group.

This resulted in comparing 37 patients who received deep acupuncture to

67 patients, 34 of whom received superficial acupuncture. Superficial

acupuncture may have a modest, systemic effect, and most acupuncturists

would not consider it an adequate control arm. Combining its effects

with that of the no acupuncture group may have masked a modest

improvement in those who received some kind of acupuncture, compared to

those who received no acupuncture.

 

The Swedish Collaboration on Sensory Stimulation After Stroke whose 1993

article had been important in attracting attention to acupuncture for

stroke, subsequently published a negative study. 150 subjects with

moderate or severe functional impairments were randomized 5 to 10 days

after acute stroke to 1 of 3 groups: EA, high-intensity, low-frequency

TENS, or low-intensity (subliminal) high-frequency electrostimulation.

At 3-month and 1-year follow-ups, no clinically important or

statistically significant differences were observed in motor function,

ADLs, walking ability, social activities or life satisfaction.(23)

 

As Schiflett points out in a letter to the editor, what appear to be

clinically important improvements in the acupuncture group, such as a

greater than 100% increase in walking speed, are ignored by restricting

analysis to increases in global scores in quality of life. Other

improvements are masked by using nonparametric statistics and intention

to treat analysis (which included assigning a functional score to

patients who died as a result of disease, not as a result of

acupuncture).

 

In 2002, Sze published a prospective randomized controlled trial on 106

patients in a rehabilitation unit enrolled 3 to 5 days after acute

stroke. The control group received standard modalities, including

physiotherapy, occupational and speech therapy. The intervention group

received manual body acupuncture at LI4, 10, 11, and 15, TE5, GB30 and

34, S36 and 41, with optional points CV4, 6, 10 and 12, and S24 and 26.

The treating acupuncturist was allowed to omit or add a maximum of 3

acupoints. Acupuncture was administered on the paretic side for 30

minutes per session 5 times a week for inpatients and 3 times per week

for outpatients, for 10 weeks. A mean of 35 treatments were received. No

differences in Fugl-Meyer Assessment (FMA), Barthel Index (BI) or

Functional Independence Measure (FIM) were noted at weeks 0, 5 or

10.(24)

 

The power analysis for this study indicated that 40 patients were

required for each arm to have 0.8 power to detect an effect size of 0.5.

However, the study stratified patients in each arm into two groups -

those with moderate and those with severe levels of disability. Although

53 patients were treated with acupuncture, only 31 of them had severe

stroke and 22 had moderate stroke. Neither group is large enough to

achieve the requisite power. Grouping them together makes the assumption

that acupuncture will be just as effective for moderate as for severe

stroke. No justification is given for this assumption. In addition,

despite their statement that the groups were evenly matched in baseline

characteristics, table 1 appears to show significant differences in CT

scan result, number and location of lesions. Finally, in the severe

group, scores on the BI and FMA (total), and change in median FMAM

(motor) are in fact higher in the treatment group. In the treatment

group, the FMAM (motor) median score improved from 29.7 to 51.2, while

in the control group it improved from 38.7 to 53.3. The interquartile

range in the treatment group (14.0 - 46.4) is much narrower than in the

control group (14.1 - 64.5). It is possible that in this underpowered

study, outliers in the control group skewed the results, making it

appear that improvement in the two groups was equivalent.

 

Later the same year Sze and colleagues published a meta-analysis of the

effect of acupuncture on motor recovery after stroke. The review

concluded that acupuncture had no additional effect on recovery in

patients who were given stroke rehabilitation, and that it had a

positive effect on motor recovery in patients who did not receive

rehabilitation and were treated at either an unknown interval or more

than six months after stroke onset. These conclusions were reached by

pooling data from heterogeneous trials, many of which are summarized

above. Pooling required a large number of statistical conversions, which

may have obliterated clinically important aspects of the trials. As

discussed above, restricting analysis to global measures of improvement

may mask clinically significant improvements in specific components of

the global measures.(25)

 

Lessons and Directions for Future Research

Perhaps the main lesson we can learn from the experience of trying to

prove efficacy of acupuncture for stroke is the necessity for

preliminary studies that attempt to define the set of patients for whom

acupuncture is most likely to be beneficial. Since CT scans are

routinely performed in stroke patients, a reasonable next step would be

to compare and contrast retrospectively the CT scans of those who did

and did not improve after acupuncture. An efficacy trial can be designed

subsequently. Such a trial may well show an additional benefit to

acupuncture in addition to rehabilitation. The second aspect of analysis

missing from most acupuncture research is cost effectiveness. If Sze and

colleagues turn out to be correct that acupuncture adds little to

comprehensive rehabilitation programs but is helpful in their absence,

then in areas without the resources to establish such programs

acupuncture may be a viable alternative. Just as importantly, if

acupuncture is as effective as rehabilitation programs, then it may be a

viable, lower cost alternative. Assuming that efficacy can be

demonstrated for some patients, cost effectiveness analysis, which is

largely absent from acupuncture research, will be an essential piece of

the argument that its widespread use should be adopted.

 

References:

 

1. Rabinstein AA, Sluman LM. Acupuncture in clinical neurology

[Review][120 refs] Neurologist. 2003; 9(3):137-48

 

2. Ying SX, Cheng JS, Jin ZQ, Cheng JS. Acupuncture for Stroke:

Physiologic Mechanisms Studied in Animals 1994, 1997

 

3. Zhao P. Acupuncture for Stroke: Physiologic Mechanisms Studied in

Animals 2000

 

4. Yang R, Huang ZN, Cheng JS. Acupuncture for Stroke: Physiologic

Mechanisms Studied in Animals 2000

 

5. Wei GW, et al. Acupuncture for Stroke: Physiologic Mechanisms Studied

in Animals 2000

 

6. OuYang W, et al. Acupuncture for Stroke: Physiologic Mechanisms

Studied in Animals 1999

 

7. Jan MH, Shin MC, Lee TH, et. al. Acupuncture suppresses ischemia

induced increase in c-Fos expression and apoptosis in

 

the hippocampal CA1 region in gerbils. Neuroscience Letters. 2003 Aug.

14; 347(1):5-8

 

8. Cho NH, Lee JD, Cheong BS, Choi DY, et al. Acupuncture suppresses

intrastriatal hemorrhage induced apoptotic neuronal cell death in rats.

Neuroscience Letters. 2004 May 20; 362(2):141-5

 

9. Syuu Y., Matsubara H., Hosogi S., Suga H. Pressor effect of

electroacupuncture on hemorrhagic hypotension. American Journal of

Physiology - Regulatory Integrative & Comparative Physiology.2003 Dec.;

285(6):R1446-52 (abstr)

 

10. Lee JD, Chon JS, Jeong HK, Kim HJ, Yun M. Kim DY, Kim DI, Park CI,

Yoo HS. The cerebrovascular response to traditional acupuncture after

stroke. Neuroradiology. 2003 Nov.; 45(11):780-4

 

11. Zhang S. Acupuncture for Stroke: I. Pathophysiologic Studies: Animal

and Humans 1999

 

12. Sun and Sun. Acupuncture for Stroke: I. Pathophysiologic Studies:

Animals and Humans 1998,

 

13. Nasser M, Alesander, MP, Stiassny-Eder D, et.al. Acupuncture and

Electro-Therapeutics Research 1994 Oct.-Dec.; 19(4):227-49.

 

14. Tekeodlu Y. Acupuncture for Stroke: Clinical Outcome Studies in

Humans 1998

 

15. Sonde L, et al. Acupuncture for Stroke: Clinical Outcome Trials in

Humans 1998

 

16. Sonde L, et al. Acupuncture for Stroke: Clinical Outcome Trials in

Humans 2000

 

17. Wong AMK, et al. Acupuncture for Stroke: Clinical Outcome Trials in

Humans 1999

 

18. Kjendahl A, et al. Acupuncture for Stroke: Clinical Outcome Trials

in Humans 1996

 

19. Johansson K, et al. Acupuncture for Stroke: Clinical Outcome Studies

in Humans 1993

 

20. Magnusson, et al. Acupuncture for Stroke: Clinical Outcome Studies

in Humans 1994

 

21. Fink M., Rollnik JD, Bijak M, Borstadt C, Dauper J., Guergueltcheva

V., Dengler R., Karst M. Needle acupuncture in chronic poststroke leg

spasticity. Archives of Physical Medicine & Rehabilitation 2004 Apr.;

85(4):667-72

 

22. Gosman-Hedstrom, et al. Acupuncture for Stroke: Clinical Outcome

Studies in Humans 1998

 

23. Johansson BB, Haker E, von Arbin M, et.al. Acupuncture and

Transcutaneous Nerve Stimulation in Stroke Rehabilitation: A Randomized,

Controlled Trial. Stroke 2001 March; 32(3):707-713

 

24. Sze SK, FRCP, Wong E, et.al. Does Acupuncture Improve Motor Recovery

After Stroke? A Meta-Analysis of Randomized Controlled Trials.

Acupuncture for Postroke Motor Recovery 2002; 33:2604-2619

 

25. Ibid

 

Acubriefs Newsletter has three objectives:

 

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acupuncture in English.

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of the Medical Acupuncture Research Foundation.

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