An updated meta-analysis of the efficacy and safety of acupuncture treatment for cerebral infarction

Acupuncture and its role in the treatment of ischemic stroke: A review

Acupuncture is a traditional Chinese medicine therapy that is treatment by placing a needle or pressure in a specific position on the patient's skin. Although used in the treatment of various diseases, acupuncture is effective in the treatment of ischemic stroke (IS), and has made some progress in the mechanism of action of the treatment of this disease. IS is difficult to treat, and there is a high rate of disability. Drug therapy is usually the first line of treatment, but adjuvant therapy has outstanding efficacy in promoting the rehabilitation of the disease and preventing sequelae. Among them, acupuncture is getting more and more attention as a more popular treatment method. Therefore, this study excavates the high-quality randomized controlled trials and meta-analysis of acupuncture for IS in recent years to further summarize the efficacy of acupuncture for IS. In this review, we provide an overview of the current understanding of acupuncture and IS, and the current studies investigating the effectiveness of acupuncture in the treatment of IS.

A bibliometric analysis of acupuncture for cerebral infarction from 1993 to 2023

Objective

This research aims to explore the trends and knowledge domain of acupuncture for cerebral infarction through bibliometrics.

Methods

Publications related to acupuncture for cerebral infarction were retrieved from the Web of Science core collection database from 1993 to December 31, 2023. A domain knowledge graph was then constructed using VOSviewer, CiteSpace, GraphPad Prism, and Scimago Graphica.

Results

The cumulative publication trend shows a steady increase over the years, with China being the most productive country. Notably, Europe exhibits significant close collaboration. Institutional cooperation is primarily observed among Chinese universities specializing in traditional Chinese medicine. Tao Jing is the most prolific author, with his highest number of publications is in "Stroke" journal, and Acupuncture Electro Therapeutics Research is the significant journal. Zhang SH is the most cited author, and Si QM is a prominent author in this field. Rehabilitation treatment after cerebral infarction emerges as a prevalent research focus, with nerve regeneration being a keyword. Long EZ's 1989 paper, published in the journal Stroke, holds significant importance. The prominent papers are Donnan et al. and Wu et al., which covers the following topics: "population-based study," "Baihui Acupoint," "memory deficits," "neurotrophic factor," and "randomized trial."

Conclusion

This bibliometric analysis of acupuncture for cerebral infarction offers insights into the Web of Science database, delineates a knowledge map of countries, authors, institutions, cited authors, keywords, cited references in the field of acupuncture for cerebral infarction, which has a momentous guiding significance for quickly and accurately positioning the key information in the field.

Bibliometric analysis: Hot spots and frontiers in acupuncture treatment of cerebral infarction

OBJECTIVE

CiteSpace6.1.R2 is used to analyze the research status of acupuncture in the treatment of cerebral infarction, and to find relevant hot spots and frontiers.

METHODS

The researchers searched the Web of Science Core Collection database. The search date is from the establishment of the database to August 31, 2023. The search terms and expressions are: ("Cerebral Infarction" OR "Ischemic stroke") AND ("Acupuncture" OR "fire needle"). The researchers used CiteSpace software to draw a knowledge map to explore the hot spots and frontiers of acupuncture in treating cerebral infarction.

RESULTS

We screened 414 articles in the Web of Science Core Collection database. China is the country with the largest number of publications, with a total of 343 papers published. China's institutions cooperate most closely, and cooperation between countries is less and more scattered. The author with the highest number of published articles is Chen L, with a total of 31 published articles. The research focus mainly revolves around the mechanism of acupuncture treatment of cerebral infarction and electroacupuncture treatment of cerebral infarction. Among them, acupuncture treatment of cerebral infarction is the most.

CONCLUSION

According to CiteSpace's analysis results, China is at the forefront of this research field, while other countries have less research in this field and little cooperation among countries. At present, the mainstream aspect of research is the mechanism of acupuncture treatment of cerebral infarction electroacupuncture and acupuncture points. Therefore, in future research, we should pay more attention to the treatment of cerebral infarction mechanism of acupuncture, problems with the type of acupuncture used, and acupuncture points.

Understanding the mechanism of acupuncture in acute cerebral infraction through a proteomic analysis: protocol for a prospective randomized controlled trial

Background

Acute cerebral infarction (ACI), being the predominant form of stroke, presents challenges in terms of the limited effectiveness of various treatments in improving the neurological function. Although acupuncture shows promise in addressing ACI, the availability of high-quality evidence regarding its efficacy, safety, and underlying mechanism remains insufficient. In this study, we design a multicenter, prospective, single-blind, randomized controlled trial with the aim of evaluating the efficacy and safety of acupuncture for ACI, making an attempt to unveil the molecular mechanisms by proteomic.

Methods

A total of 132 patients involving four hospitals will be randomized at a 1:1:1 ratio in the acupuncture group, control group, and sham acupuncture group. All the patients will receive basic treatment, and the patients in the acupuncture and sham acupuncture groups will also receive either acupuncture or sham acupuncture treatment, respectively, at six sessions each week for a 2 weeks period, followed by 3 months of follow-up. The primary outcome will be the change in the National Institute of Health Stroke Scale (NIHSS) scores after treatment. The secondary outcomes will include the Fugl-Meyer Assessment (FMA) scale scores and the Barthel Index (BI). Adverse events that occur during the trial will be documented. To discover differentially expressed proteins (DEPs) and their roles between the ACI subjects and healthy controls, we will also perform 4D-DIA quantitative proteomics analysis, and the DEPs will be confirmed by enzyme-linked immunosorbent assay (ELISA). This study was approved by the institutional review board of the First Teaching Hospital of Tianjin University of Traditional Chinese Medicine (TYLL2023043). Written informed consent from patients is required. This trial is registered in the Chinese Clinical Trial Registry (ChiCTR2300079204). Trial results will be published in a peer-reviewed academic journal.

Discussion

The results of this study will determine the preliminary efficacy and safety of acupuncture in ACI patients and whether the mechanism of this form of non-pharmacologic stimulation is mediated by a novel therapeutic target for neurorehabilitation through our proteomic analysis.

Clinical trial registration

https://www.chictr.org.cn, identifier ChiCTR2300079204.

Assessment of corticospinal tract remodeling based on diffusion tensor imaging in the treatment of motor dysfunction after ischemic stroke by acupuncture: A meta-analysis

BACKGROUND

To investigate the efficacy of acupuncture in improving motor dysfunction after ischemic stroke (IS) and to investigate the effect of acupuncture on corticospinal tract (CST) remodeling using diffusion tensor imaging.

METHODS

Published literature on the effect of acupuncture on CST remodeling after IS using diffusion tensor imaging in the form of randomized controlled trials (RCTs) were systematically retrieved and screened from Cochrane Library, Web of Science, PubMed, Embase, CNKI, CBM, VIP, and Wanfang databases from inception to December 2022. The methodological quality of the included studies was critically and independently evaluated by 2 reviewers using the Cochrane Risk of Bias Assessment Tool for RCTs. The correlated data were extracted using the pre-designed form, and all analyses were performed using Reviewer Manager version 5.4.

RESULTS

Eleven eligible RCTs involving 459 patients were eventually included. The combined evidence results showed that the acupuncture group significantly improved patients' National Institute of Health stroke scale, Fugl-Meyer Assessment Scale, and Barthel index compared with conventional medical treatment. The acupuncture group significantly promoted remodeling of the CST, as reflected by an increase in fractional anisotropy (FA) throughout the CST [MD = 0.04, 95% CI (0.02, 0.07), P = .001], and in addition, subgroup analysis showed that the acupuncture group significantly improved FA in the infarct area compared with conventional medical treatment at around 4 weeks [MD = 0.04, 95% CI (0.02, 0.06), P = .0002] and FA of the affected cerebral peduncle [MD = 0.03, 95% CI (0.00, 0.07), P = .02]. Also, compared with conventional medical treatment, the acupuncture group significantly increased average diffusion coefficient of the affected cerebral peduncle [MD = -0.21, 95% CI (-0.28, -0.13), P < .00001].

CONCLUSION

The results of the meta-analysis suggest that acupuncture therapy can improve the clinical manifestations of motor dysfunction in patients after IS and advance a possibly beneficial effect on CST remodeling. However, due to the number and quality of eligible studies, these findings need to be further validated in more standardized, rigorous, high-quality clinical trials.

Effect of acupuncture with donepezil based on syndrome differentiation on cognitive function in patients with mild-to-moderate Alzheimer’s disease: a study protocol for a multicenter randomized controlled trial

Background

There has been a rapid increase in the worldwide prevalence of Alzheimer’s disease (AD). Previous studies have shown that acupuncture can improve neurological and cognitive function; however, the utility of applying acupuncture in patients with AD remains unclear. This study protocol describes a clinical trial for evaluating the efficacy and safety of acupuncture based on syndrome differentiation with donepezil hydrochloride on cognitive function in patients with AD.

Methods/design

This multicenter randomized controlled trial commenced on February 1, 2019, at the Shanghai Longhua Hospital of TCM, Shanghai Huashan Hospital of Fudan University, and Shanghai Mental Health Center, and will conclude on June 30, 2022. The study will recruit 184 patients randomly divided into an acupuncture group or a control group at a 1:1 ratio. All participants will receive donepezil hydrochloride (5 mg/day), and those in the acupuncture group will receive acupuncture based on syndrome differentiation with donepezil for 12 weeks. The primary outcome will be the post-treatment change in the Alzheimer’s Disease Assessment Scale-cognition score at 12 weeks. The secondary outcomes will be the efficacy scores of the Minimum Mental State Examination, Alzheimer’s Disease Cooperative Research Activity-Daily Life, and Quality of Life-Alzheimer’s Disease. All assessments will be performed at baseline, after treatment (week 12), and at follow-up (weeks 24 and 36).

Discussion

This trial may provide high-quality evidence for the efficacy of acupuncture in the treatment of AD. The results of this study will be published in peer-reviewed journals.

Trial registration

ClinicalTrials.govNCT03810794. Registered on 17 January 2019.

The Efficacy and Safety of Ischemic Stroke Therapies: An Umbrella Review

Background: Ischemic stroke is a leading cause of morbidity and mortality in neurological diseases. Numerous studies have evaluated the efficacy and safety of ischemic stroke therapies, but clinical data were largely inconsistent. Therefore, it is necessary to summarize and analyze the published clinical research data in the field.

Objective: We aimed to perform an umbrella review to evaluate the efficacy and safety of ischemic stroke therapies.

Methods: We conducted a search for meta-analyses and systematic reviews on PubMed, the Cochrane Library, and the Web of Science to address this issue. We examined neurological function deficit and cognitive function scores, quality of life, and activities of daily living as efficacy endpoints and the incidence of adverse events as safety profiles.

Results: Forty-three eligible studies including 377 studies were included in the umbrella review. The results showed that thrombolytic therapy (tPA; alteplase, tenecteplase, and desmoteplase), mechanical thrombectomy (MTE), edaravone with tPA, stem cell-based therapies, stent retrievers, acupuncture with Western medicines, autologous bone marrow stromal cells, antiplatelet agents (aspirin, clopidogrel, and tirofiban), statins, and Western medicines with blood-activating and stasis-dispelling herbs (NaoShuanTong capsule, Ginkgo biloba, Tongqiao Huoxue Decoction, Xuesaitong injection) can improve the neurological deficits and activities of daily living, and the adverse effects were mild for the treatment of ischemic stroke. Moreover, ligustrazine, safflower yellow, statins, albumin, colchicine, MLC601, salvianolic acids, and DL-3-n-butylphthalide showed serious adverse events, intracranial hemorrhage, or mortality in ischemic stroke patients.

Conclusion: Our study demonstrated that tPA, edaravone and tPA, tPA and MTE, acupuncture and Western medicines, and blood-activating and stasis-dispelling herbs with Western medicines are the optimum neurological function and activities of daily living medication for patients with ischemic stroke.

Systematic Review Registration: https://inplasy.com/, identifier [INPLASY202250145].

Efficacy of Ligustrazine Injection as Adjunctive Therapy in Treating Acute Cerebral Infarction: A Systematic Review and Meta-Analysis

Background: Ligustrazine injection has been widely used as adjunctive therapy in the treatment of acute cerebral infarction (ACI) during the past decades in China, but its clinical efficacy is not yet well confirmed. This study aims to evaluate the efficacy of ligustrazine injection as adjunctive therapy for ACI. Methods: Databases including China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (VIP), PubMed, Medline, Google Scholar, Chinese Biomedical Literature Database, Cochrane Library, Embase, Sino-Med, Wanfang Database, and Chinese Science Citation Database were systematically searched for the published randomized controlled trials (RCTs) on ligustrazine injection in the treatment of ACI until November 2020. Meta-analysis was performed on the primary outcome measure (i.e., clinical effective rate) and the secondary outcome measure [i.e., neurological deficit score (NDS), fibrinogen, low shear blood viscosity (LBV), and high shear blood viscosity (HBV)]. The quality of the included RCTs was assessed according to the M scoring system (the refined Jadad scale). Sensitivity analysis and subgroup analysis were conducted according to the methodological quality, years of publication, and sample size. Results: Nineteen RCTs, containing 2022 patients, were included in this study. Meta-analysis indicated that ligustrazine injection combined with Western medicine could achieve a better effect in the treatment of ACI than using Western medicine alone in terms of clinical effective rate (RR = 1.24; 95% CI, 1.19-1.29), NDS (MD = -3.88; 95%CI, -4.51 to -3.61), fibrinogen (MD = -0.59; 95% CI, -0.76 to -0.42), LBV (MD = -2.11; 95% CI, -3.16 to -1.06), and HBV (MD = -0.88; 95% CI, -1.20 to -0.55). Conclusions: This research indicated that ligustrazine injection as adjunctive therapy seemed to be more effective than using western medicine alone in treating ACI. However, more evidence is required to confirm the efficacy of ligustrazine injection due to the low methodological quality of the included RCTs.

Therapeutic effects of acupuncture on sensory ataxia after a cerebral hemorrhage: A case report

INTRODUCTION

Sensory ataxia is a dysfunction of dynamic balance due to impairment of sensory input into the control of movement. The sequelae of stroke, such as hemiplegia, somatosensory impairment, and impaired balance may cause significant disability and may affect patients' quality of life. In addition to rehabilitation programs, acupuncture therapy has been applied to stroke patients and is recommended as a complementary therapy in stroke rehabilitation.

PATIENT CONCERNS

A 70-year-old male had a sudden onset of conscious loss. The brain computed tomography showed intracerebral hemorrhage with subdural hemorrhage and subarachnoid hemorrhage.

DIAGNOSIS

Intracerebral hemorrhagic stroke was diagnosed.

INTERVENTIONS

He received craniotomy with hematoma evacuation immediately and waked up 3 weeks with bilateral hemiparesis (right side weaker than left), impaired position sensation and tactile perception in the right lower limb. He then began to receive rehabilitation therapy and had significant improvement in muscle strength and static balance, but no improvement in tactile perception of position sense in the right lower limbs and reached plateau. Then he received acupuncture therapies to Yongquan (KI1), Tongtien (BL7) and Houxi (SI3).

OUTCOMES

The patient's walking ability recovered after receiving rehabilitation programs for 3 years, but the impairment in proprioception and dynamic balance persisted. The perception and dynamic balance had significantly improved after patient received acupuncture therapy, especially the acupuncture point of Yongquan (KI1).

CONCLUSION

The clinical effect of acupuncture in combination with conventional rehabilitation therapy for neurological impairment recovery, improving activity of daily living performance and improving post-stroke imbalance was explored. We hope that this report can facilitate further well controlled quantitative objective studies on a big size of samples.

Effects of acupuncture on cardiovascular risks in patients with hypertension: a Korean cohort study

OBJECTIVES

The aim of this study was to investigate the effects of acupuncture on major adverse cardiovascular events (MACE), myocardial infarction, stroke and death in hypertensive patients taking anti-hypertensives.

METHODS

Using the Korean National Health Insurance Service-National Sample Cohort (NHIS-NSC) database, this study identified 59,370 patients taking anti-hypertensives who had been diagnosed with hypertension between 2003 and 2006. They were divided into acupuncture and non-acupuncture groups. The follow-up period ended with the diagnosis of myocardial infarction, stroke or death. After propensity score matching (PSM), there were 18,011 patients each in the non-acupuncture and acupuncture groups. We calculated the incidence rate, hazard ratio (HR) and 95% confidence interval (CI) for MACE, myocardial infarction, stroke and death in patients with hypertension using a stratified Cox proportional hazard model. In addition, secondary outcome analyses for stroke and cardiovascular mortality were performed.

RESULTS

After PSM, the HRs for MACE (0.83, 95% CI 0.80-0.86), all-cause mortality (0.73, 95% CI 0.70-0.76) and myocardial infarction (0.85, 95% CI 0.79-0.92) were significantly lower in the acupuncture group than in the non-acupuncture group. Moreover, the HRs for stroke-related mortality, hemorrhage stroke-related mortality, ischemic stroke-related mortality, ischemic heart disease-related mortality and circulatory system disease-related mortality were significantly lower in the acupuncture group than in the non-acupuncture group.

CONCLUSION

This observational study with long-term follow-up extends the evidence base in support of the effectiveness of acupuncture for the management of hypertension and potentially reduce the burden of cardiovascular disease.

Synergistic Effects of Scalp Acupuncture and Repetitive Transcranial Magnetic Stimulation on Cerebral Infarction: A Randomized Controlled Pilot Trial

This study investigated the synergistic effects of scalp acupuncture (SA) and repetitive transcranial magnetic stimulation (rTMS), known to be effective for cerebral infarction. This outcome-assessor-blinded, randomized controlled clinical trial included a per-protocol analysis to compare the efficacy of SA and electromagnetic convergence stimulation (SAEM-CS) and single or no stimulation. The trial was conducted with 42 cerebral infarction patients (control group, 12; SA group, 11; rTMS group, 8; SAEM-CS group, 11). All patient groups underwent two sessions of CSRT per day. SA, rTMS, and SAEM-CS were conducted once per day, 5 days per week, for 3 weeks. The primary outcome was evaluated using the Fugl–Mayer assessment (FMA). FMA Upper Extremity, FMA total, MBI, and FIM scores significantly increased in the rTMS group compared with the control group. Additionally, FMA Upper Extremity, FMA total, MBI and FIM scores significantly increased in the rTMS group compared with the SAEM-CS group. However, there were no significant changes in the SA or SAEM-CS groups. In conclusion, low-frequency rTMS in the contralesional hemisphere may have long-term therapeutic effects on upper extremity motor function recovery and improvements in activities of daily living. SAEM-CS did not show positive synergistic effects of SA and rTMS.

A Guideline for Randomized Controlled Trials of Acupuncture

Guidelines for clinical trials of acupuncture are scarce, particularly in their guidance on choosing an adequate control in an acupuncture trial. This guideline was developed to address the research methodology for clinical research in acupuncture which contains the essential elements to be considered in the design, preparation and reporting of an acupuncture RCT. Particularly, investigators focused on the control design because of the unique feature of acupuncture. As one size does not fit all, one single design cannot answer all research questions. Therefore, we recommend that the clinical questions be answered in different stages of trials by choosing the appropriate control or comparator. This concept is adapted from classical drug trials developed by the Food and Drug Administration (FDA) of USA in which trials are staged in four phages in order to address different research questions. From the points listed above, this guideline offers the specific recommendations in an acupuncture RCT.

Subacute stroke physical rehabilitation evidence in activities of daily living outcomes: A systematic review of meta-analyses of randomized controlled trials

BACKGROUND

Stroke is a leading cause of disabilities worldwide. One of the key disciplines in stroke rehabilitation is physical therapy which is primarily aimed at restoring and maintaining activities of daily living (ADL). Several meta-analyses have found different interventions improving functional capacity and reducing disability.

OBJECTIVES

To systematically evaluate existing evidence, from published systematic reviews of meta-analyses, of subacute physical rehabilitation interventions in (ADLs) for stroke patients.

METHODS

Umbrella review on meta-analyses of RCTs ADLs in MEDLINE, Web of Science, Scopus, Cochrane, and Google Scholar up to April 2018. Two reviewers independently applied inclusion criteria to select potential systematic reviews of meta-analyses of randomized controlled trials (RCTs) of physical rehabilitation interventions (during subacute phase) reporting results in ADLs. Two reviewers independently extracted name of the 1st author, year of publication, physical intervention, outcome(s), total number of participants, and number of studies from each eligible meta-analysis. The number of subjects (intervention and control), ADL outcome, and effect sizes were extracted from each study.

RESULTS

Fifty-five meta-analyses on 21 subacute rehabilitation interventions presented in 30 different publications involving a total of 314 RCTs for 13,787 subjects were identified. Standardized mean differences (SMDs), 95% confidence intervals (fixed and random effects models), 95% prediction intervals, and statistical heterogeneity (I and Q test) were calculated. Virtual reality, constraint-induced movement, augmented exercises therapy, and transcranial direct current stimulation interventions resulted statistically significant (P < .05) with moderate improvements (0.5 ≤ SMD ≤ 0.8) and no heterogeneity (I = 0%). Moxibustion, Tai Chi, and acupuncture presented best improvements (SMD > 0.8) but with considerable heterogeneity (I2 > 75%). Only acupuncture reached "suggestive" level of evidence.

CONCLUSION

Despite the range of interventions available for stroke rehabilitation in subacute phase, there is lack of high-quality evidence in meta-analyses, highlighting the need of further research reporting ADL outcomes.

Pharmacopuncture for Cervicogenic Dizziness

Objectives

Pharmacopuncture is a treatment that medicinal fluid including herbal extract is injected in body under qi/flavor theory and meridian theories. There are a number of studies investigating the efficacy of pharmacopuncture for cervicogenic dizziness but its usage differs in each study. This study aimed to review previous studies of pharmacopuncture treatment for cervicogenic dizziness to navigate the direction of improvement.

Methods

Literature review was conducted on studies aimed at pharmacopuncture for cervicogenic dizziness. The randomized controlled studies which assessed the efficacy of pharmacopuncture on cervicogenic dizziness were selected. The studies were searched in Pubmed, RISS, OASIS and CNKI. After selecting eligible studies, the authors read the articles and summarized the points those are necessary in pharmacopuncture treatment for cervicogenic dizziness.

Results

Twenty seven studies and 2,709 participants were included. The diverse solutions were used and the most popular were Salvia miltiorrhiza, Angelica gigas, a compound in Gastrodia elata, Panax notoginseng saponins. Some studies investigated the efficacy of conventional medical compounds (lidocaine, vitamin B, dexamethasone) injected in acupoints. Adopting acupoints and combining with body acupuncture have shown the tendency to enhance the cure rate. Pharmacopuncture could improve the efficacy of conventional treatment for cervicogenic dizziness.

Conclusion

As the solution and injection method varies, principles of pharmacopuncture for dizziness should be investigated.

Acupuncture Alleviates Levodopa-Induced Dyskinesia via Melanin-Concentrating Hormone in Pitx3-Deficient aphakia and 6-Hydroxydopamine-Lesioned Mice

Although L-3,4-dihydroxyphenylalanine (L-DOPA) is currently the most effective medication for treating Parkinson's disease (PD) motor symptoms, its prolonged administration causes several adverse effects, including dyskinesia. To identify the mechanisms underlying the effects of acupuncture on L-DOPA-induced dyskinesia (LID), antidyskinetic effects of acupuncture were investigated in two mouse models of PD. Acupuncture stimulation at GB34 alleviated abnormal involuntary movements (AIMs) in Pitx3-deficient aphakia mice (ak/ak) following L-DOPA administration and these effects were reproduced in 6-hydroxydopamine (6-OHDA)-lesioned mice with LID. A transcriptome analysis of the hypothalamus revealed pro-melanin-concentrating hormone (Pmch) gene was highly expressed in acupuncture-treated mouse from ak/ak model of LID as well as 6-OHDA model of LID. Acupuncture combined with the administration of MCH receptor antagonist did not have any beneficial effects on dyskinesia in L-DOPA-injected ak/ak mice, but the intranasal administration of MCH attenuated LID to the same degree as acupuncture in both ak/ak and 6-OHDA mice with LID. A gene expression profile with a hierarchical clustering analysis of the dyskinesia-induced ak/ak mouse brain revealed an association between the mechanisms underlying acupuncture and MCH. Additionally, altered striatal responses to L-DOPA injection were observed after prolonged acupuncture and MCH treatments, which suggests that these treatment modalities influenced the compensatory mechanisms of LID. In summary, present study demonstrated that acupuncture decreased LID via hypothalamic MCH using L-DOPA-administered ak/ak and 6-OHDA mouse models and that MCH administration resulted in novel antidyskinetic effects in these models. Thus, acupuncture and MCH might be valuable therapeutic candidates for PD patients suffering from LID.

Overview of Treatment Guidelines and Clinical Practical Guidelines That Recommend the Use of Acupuncture: A Bibliometric Analysis

INTRODUCTION

As positive evidence emerges for the use of an intervention to treat a health problem, the intervention gradually becomes incorporated into treatment guidelines (TGs) or clinical practice guidelines (CPGs) that are related to that health problem. To assess whether this general hypothesis can apply to acupuncture, 96 health problems were identified for which positive conclusions in systematic reviews and meta-analyses regarding the effectiveness of acupuncture have been made and then searched for TGs or CPGs that have recommended the use of acupuncture.

METHODS

Through August 31, 2017, searches were performed in relevant medical databases and Google using "treatment guideline," "clinical practice guideline," and the names of the 96 medical conditions as search terms. A "snow-balling" search approach was adopted. All positive recommendations were added into the registry.

RESULTS

A total of 1311 publications were found that recommended using acupuncture published between 1991 and 2017. The number per year reached 50 in 2005 and 100 in 2009. In addition, 2189 positive recommendations were found for the use of acupuncture. Of these, 1486 were related to 107 pain indications and 703 were related to 97 nonpain indications. These recommendations were made by a wide range of groups, such as government health institutions, national guideline, and medical specialty groups. The recommendations came from around the world but were especially abundant in North America, Europe, and Australasia.

DISCUSSION AND CONCLUSION

Considerably more recommendations were found for the use of acupuncture than are known within the acupuncture or medical communities. A trend by year was also found; a rise in the number of positive statements about acupuncture was typically followed by a rise in the number of recommendations of acupuncture. Thus, the recommendations followed the emergent evidence for acupuncture. Better implementation plans need to be developed for the CPG/TG recommendations about acupuncture to be more effective/efficient.

Meta-Analysis for Clinical Evaluation of Xingnaojing Injection for the Treatment of Cerebral Infarction

Objective: Xingnaojing injection (XNJ) is derived from An-Gong-Niu-Huang pill, a well-known traditional Chinese patent medicine, which is widely used for stroke. To evaluate the therapeutic effect of XNJ on cerebral infarction, an extensive meta-analysis was used.

Methods: Six major electronic databases including the Chinese Biomedical Database (CBM), Wanfang, the VIP medicine information system (VMIS) and the China National Knowledge Infrastructure (CNKI), PubMed, Embase, and the Cochrane Library were examined to retrieve randomized controlled trials designed to evaluate the clinical efficacy of XNJ in treating CI before November 26, 2016.

Results: There were 53 randomized controlled trials with 4915 participants in this study. The results reflected that compared with the conventional therapy (CT) alone, XNJ could significantly improve the overall response rate (OR = 3.56, 95% CI [2.94, 4.32], P < 0.00001), and clinical symptom (including increasing activities of daily living (ADL, MD = 10.23, 95% CI [9.47, 10.99], P < 0.00001), and reduce infarction size (MD = -1.83, 95% CI [-2.49, -1.16], P < 0.00001)). However, there was no significant difference between the XNJ treatment and conventional therapy in Glasgow Coma Scale (GCS, P = 0.32). Neurological deficit score demonstrated that XNJ could significantly reduce the score in two different evaluation criterions as National Institutes of Health Stroke Scale (NIHSS, MD = -3.44, 95% CI [-4.52, -2.36], P < 0.00001), and the Chinese Stroke Scale (CSS, MD = -5.72, 95% CI [-6.94, -4.50], P < 0.00001). Additionally, serum MMPs, including MMP-2 and MMP-9 were significantly reduced by XNJ treatment compared with conventional therapy (MD = -11.24, 95% CI [-20.83, -1.65], P = 0.02; MD = -25.08, 95% CI [-35.49, -14.67], P < 0.00001, respectively). Moreover, XNJ was able to improve hemorrheology in reducing whole blood viscosity, plasma viscosity, and hematocrit (MD = -1.44, 95% CI [-2.18, 0.70], P = 0.001; MD = -0.22, 95% CI [-0.37, -0.07], P = 0.003; MD = -3.63, 95% CI [-6.23, -1.03], P = 0.006, respectively). The therapeutic efficacy of XNJ was found associated with improving hemodynamics (increasing peak-flow rate, and average velocity) (MD = 12.66, 95% CI [10.50, 14.81], P < 0.00001; MD = 9.90, 95% CI [8.63, 11.17], P < 0.00001). XNJ was also related to reducing cholesterol and triglyceride (MD = -1.06, 95% CI [-1.21, -0.92], P < 0.00001; MD = -1.05, 95% CI [-1.12, -0.97], P < 0.00001).

Conclusion: Despite the sample size and the poor quality of the included studies of this review, the results of the research showed that XNJ might be a beneficial therapeutic method for the treatment of cerebral infarction.

Risk of dementia in patients with non-haemorrhagic stroke receiving acupuncture treatment: a nationwide matched cohort study from Taiwan's National Health Insurance Research Database

OBJECTIVE

To investigate the risk of dementia in patients with stroke who did and did not receive acupuncture treatment.

DESIGN

Retrospective cohort study.

SETTING

This study was based on Taiwan's National Health Insurance Research Database that included patients with stroke hospitalised between 1 January 2000 and 31 December 2004.

PARTICIPANTS

We identified 11 220 patients aged 50 years and older with newly diagnosed stroke hospitalisation.

PRIMARY AND SECONDARY OUTCOME MEASURES

We compared the incident dementia during the follow-up period until the end of 2009 in patients with stroke who did and did not receive acupuncture. The adjusted HRs and 95% CIs of dementia associated with acupuncture were calculated in multivariate Cox proportional hazard regressions.

RESULTS

Acupuncture treatment was associated with a decreased risk of dementia with multivariate adjustment (HR, 0.73; 95% CI 0.66 to 0.80), and the association was significant in both sexes and every age group, as well as in groups with ischaemic stroke, with fewer medical conditions and those hospitalised after stroke. Patients with stroke received acupuncture treatment, and conventional rehabilitation was associated with a significantly reduced risk of poststroke dementia (HR, 0.64; 95% CI 0.56 to 0.74).

CONCLUSIONS

This study raises the possibility that patients with non-haemorrhagic stroke who received acupuncture had a reduced risk of dementia. The results suggest the need for prospective sham-controlled and randomised trials to establish the efficacy of acupuncture in preventing dementia.

Acupuncture treatment on the motor area of the scalp for motor dysfunction in patients with ischemic stroke: study protocol for a randomized controlled trial

BACKGROUND

Scalp acupuncture has shown a remarkable treatment efficacy on motor dysfunction in patients with stroke in China, especially the motor area of Jiao's scalp acupuncture, which is the most widely used treatment. However, previous studies have summarized that the clinical curative effect of acupuncture treatment for stroke remains uncertain. Meanwhile, no randomized controlled trials on Jiao's scalp acupuncture have been performed. The aim of this study is to evaluate the efficacy and safety of Jiao's scalp acupuncture for motor dysfunction in ischemic stroke.

METHODS/DESIGN

This is an assessor- and analyst-blinded, randomized controlled trial. One hundred and eight stroke patients with motor dysfunction meeting the inclusion criteria will be allocated by a 1:1 ratio into either an acupuncture treatment group or a control group. Stroke patients in the control group will receive conventional rehabilitation treatment, whereas a combination of Jiao's scalp acupuncture and conventional rehabilitation treatment will be applied to the acupuncture group. Forty treatment sessions will be performed over an 8-week period. The Fugl-Meyer Assessment scale will be assessed as the primary outcome measure. The Modified Barthel Index, the Stroke-Specific Quality of Life, and the Stroke Syndrome of Traditional Chinese Medicine scales will be selected as secondary outcome measurements. All assessments will be conducted at baseline, week 4 (treatment 20), week 8 (treatment 40), week 12 (follow-up), and week 16 (follow-up).

DISCUSSION

This is the first trial evaluating the efficacy and safety of Jiao's scalp acupuncture for motor dysfunction in ischemic stroke. The results of this trial are expected to provide relevant evidence demonstrating that Jiao's scalp acupuncture can be used as an effective rehabilitation treatment method for improving motor dysfunction in ischemic stroke.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02871453 . Registered on 17 July 2016.

Neuroprotective effect of electroacupuncture and upregulation of hypoxia-inducible factor-1α during acute ischaemic stroke in rats

BACKGROUND

Acupuncture is a traditional method that has been widely used in various fields of medicine with therapeutic effect. However, evidence of effectiveness to support the application of electroacupuncture (EA) during the process of ischaemia is scarce.

OBJECTIVES

To investigate dynamic changes in hypoxia-inducible factor (HIF)-1α expression as well as its association with neurological status in rats subjected to acute ischaemic stroke and EA intervention.

METHODS

Forty adult male rats were randomly divided into three groups that received sham surgery (Control group, n=10) or underwent middle cerebral artery occlusion and EA (MCAO+EA group, n=15) or minimal acupuncture as a control treatment (MCAO+MA group, n=15). The rats in the MCAO+EA and MCAO+MA groups received EA or acupuncture without any electrical current, respectively, during 90 min of ischaemia. Rats in the Control group received the same surgical procedure but without MCAO. EA involved electrical stimulation of needles inserted into the quadriceps at 50 Hz frequency and 3 mA current intensity. Neurological status was evaluated on postoperative day 1, and cerebral infarction volume (IV) and HIF-1α expression 24 hours later.

RESULTS

Neurological scores were improved and cerebral IV was decreased in the MCAO+EA group compared to the MCAO+MA group (both p<0.05). Moreover, HIF-1α expression was higher in the MCAO+EA group versus the MCAO+MA group (p<0.05).

CONCLUSIONS

EA enhanced recovery of neurological function, decreased cerebral IV and increased HIF-1α expression in ischaemic rats. Further research is needed to determine whether EA is effective for stroke treatment through the stimulation of muscle contraction.

Metformin pretreatment enhanced learning and memory in cerebral forebrain ischaemia: the role of the AMPK/BDNF/P70SK signalling pathway

Context Metformin induced AMP-activated protein kinase (AMPK) and protected neurons in cerebral ischaemia. Objective This study examined pretreatment with metformin and activation of AMPK in molecular and behavioral levels associated with memory. Materials and methods Rats were pretreated with metformin (200 mg/kg) for 2 weeks and 4-vessels occlusion global cerebral ischaemia was induced. Three days after ischaemia, memory improvement was done by passive avoidance task and neurological scores were evaluated. The amount of Brain-Derived Neurotropic Factor (BDNF) and phosphorylated and total P70S6 kinase (P70S6K) were measured. Results Pretreatment with metformin (met) in the met + ischaemia/reperfusion (I/R) group reduced latency time for enter to dark chamber compared with the sham group (p < 0.001) and increased latency time compared with the I/R group (p < 0.001). Injection of Compound C (CC) (as an AMPK inhibitor) concomitant with metformin reduced latency time in I/R rats compared with the I/R + met group (p < 0.05). Neurological scores were reduced in met treated rats compared with the sham group. Pretreatment with metformin in I/R animals reduced levels of pro-BDNF compared with the I/R group (p < 0.001) but increased that compared with the sham group (p < 0.001). The level of pro-BDNF decreased in the met + CC + I/R group compared with the met + I/R group (p < 0.01). Pretreatment with metformin in I/R animals significantly increased P70S6K compared with the I/R group (p < 0.001). Conclusion Short-term memory in ischaemic rats treated with metformin increased step-through latency; sensory-motor evaluation was applied and a group of ischaemia rats that were pretreated with metformin showed high levels of BDNF, P70S6K that seemed to be due to increasing AMPK.

Acupuncture for stroke rehabilitation

BACKGROUND

Stroke is the second most common cause of death in the world and in China it has now become the main cause of death. It is also a main cause of adult disability and dependency. Acupuncture for stroke has been used in China for hundreds of years and is increasingly practiced in some Western countries. This is an update of the Cochrane review originally published in 2006 .

OBJECTIVES

To determine the efficacy and safety of acupuncture therapy in people with subacute and chronic stroke. We intended to test the following hypotheses: 1) acupuncture can reduce the risk of death or dependency in people with subacute and chronic stroke at the end of treatment and at follow-up; 2) acupuncture can improve neurological deficit and quality of life after treatment and at the end of follow-up; 3) acupuncture can reduce the number of people requiring institutional care; and 4) acupuncture is not associated with any intolerable adverse effects.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (June 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane Library 2015, Issue 7), MEDLINE (1966 to July 2015, Ovid), EMBASE (1980 to July 2015, Ovid), CINAHL (1982 to July 2015, EBSCO), and AMED (1985 to July 2015, Ovid). We also searched the following four Chinese medical databases: China Biological Medicine Database (July 2015); Chinese Science and Technique Journals Database (July 2015); China National Infrastructure (July 2015), and Wan Fang database (July 2015).

SELECTION CRITERIA

Truly randomised unconfounded clinical trials among people with ischaemic or haemorrhagic stroke, in the subacute or chronic stage, comparing acupuncture involving needling with placebo acupuncture, sham acupuncture, or no acupuncture.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed quality, extracted and cross-checked the data.

MAIN RESULTS

We included 31 trials with a total of 2257 participants in the subacute or chronic stages of stroke. The methodological quality of most of the included trials was not high. The quality of evidence for the main outcomes was low or very low based on the assessment by the system of Grades of Recommendation, Assessment, Development and Evaluation (GRADE).Two trials compared real acupuncture plus baseline treatment with sham acupuncture plus baseline treatment. There was no evidence of differences in the changes of motor function and quality of life between real acupuncture and sham acupuncture for people with stroke in the convalescent stage.Twenty-nine trials compared acupuncture plus baseline treatment versus baseline treatment alone. Compared with no acupuncture, for people with stroke in the convalescent phase, acupuncture had beneficial effects on the improvement of dependency (activity of daily living) measured by Barthel Index (nine trials, 616 participants; mean difference (MD) 9.19, 95% confidence interval (CI) 4.34 to 14.05; GRADE very low), global neurological deficiency (seven trials, 543 participants; odds ratio (OR) 3.89, 95% CI 1.78 to 8.49; GRADE low), and specific neurological impairments including motor function measured by Fugl-Meyer Assessment (four trials, 245 participants; MD 6.16, 95% CI 4.20 to 8.11; GRADE low), cognitive function measured by the Mini-Mental State Examination (five trials, 278 participants; MD 2.54, 95% CI 0.03 to 5.05; GRADE very low), depression measured by the Hamilton Depression Scale (six trials, 552 participants; MD -2.58, 95% CI -3.28 to -1.87; GRADE very low), swallowing function measured by drinking test (two trials, 200 participants; MD -1.11, 95% CI -2.08 to -0.14; GRADE very low), and pain measured by the Visual Analogue Scale (two trials, 118 participants; MD -2.88, 95% CI -3.68 to -2.09; GRADE low). Sickness caused by acupuncture and intolerance of pain at acupoints were reported in a few participants with stroke in the acupuncture groups. No data on death, the proportion of people requiring institutional care or requiring extensive family support, and all-cause mortality were available in all included trials.

AUTHORS' CONCLUSIONS

From the available evidence, acupuncture may have beneficial effects on improving dependency, global neurological deficiency, and some specific neurological impairments for people with stroke in the convalescent stage, with no obvious serious adverse events. However, most included trials were of inadequate quality and size. There is, therefore, inadequate evidence to draw any conclusions about its routine use. Rigorously designed, randomised, multi-centre, large sample trials of acupuncture for stroke are needed to further assess its effects.

Assessment of reporting quality in randomised controlled trials of acupuncture for post-stroke rehabilitation using the CONSORT statement and STRICTA guidelines

OBJECTIVES

To evaluate the completeness of reporting of randomised controlled trials (RCTs) of acupuncture for post-stroke rehabilitation in order to provide information to facilitate transparent and more complete reporting of acupuncture RCTs in this field.

METHODS

Multiple databases were searched from their inception through September 2015. Quality of reporting for included papers was assessed against a subset of criteria adapted from the Consolidated Standards for Reporting Trials (CONSORT) 2010 statement and the Standards for Reporting Interventions in Controlled Trials of Acupuncture (STRICTA) guidelines. Each item was scored 1 if it was reported, or 0 if it was not clearly stated. Descriptive statistical analysis was performed. Cohen's κ-statistics were calculated to assess agreement between the two reviewers.

RESULTS

A total of 87 RCTs were included in the full text. Based on CONSORT, good reporting was evident for items ''Randomised' in the title or abstract', 'Participants', 'Statistical methods', 'Recruitment', 'Baseline data', and 'Outcomes and estimation', with positive rates >80%. However, the quality of reporting for the items 'Trial design', 'Outcomes', 'Sample size', 'Allocation concealment', 'Implementation', 'Blinding', 'Flow chart', 'Intent-to-treat analysis', and 'Ancillary analyses' was very poor with positive rates <10%. Based on STRICTA, the items 'Number of needle insertions per subject per session', 'Responses sought', and 'Needle type' had poor reporting with positive rates <50%. Substantial agreement was observed for most items and good agreement was observed for some items.

CONCLUSIONS

The reporting quality of RCTs in acupuncture for post-stroke rehabilitation is unsatisfactory and needs improvement.

Large-conductance Ca(2+)-activated K(+) channel involvement in suppression of cerebral ischemia/reperfusion injury after electroacupuncture at Shuigou (GV26) acupoint in rats

Excess activation and expression of large-conductance Ca²⁺-activated K⁺ channels (BKCa channels) may be an important mechanism for delayed neuronal death after cerebral ischemia/reperfusion injury. Electroacupuncture can regulate BKCa channels after cerebral ischemia/reperfusion injury, but the precise mechanism remains unclear. In this study, we established a rat model of cerebral ischemia/reperfusion injury. Model rats received electroacupuncture of 1 mA and 2 Hz at Shuigou (GV26) for 10 minutes, once every 12 hours for a total of six times in 72 hours. We found that in cerebral ischemia/reperfusion injury rats, ischemic changes in the cerebral cortex were mitigated after electroacupuncture. Moreover, BKCa channel protein and mRNA expression were reduced in the cerebral cortex and neurological function noticeably improved. These changes did not occur after electroacupuncture at a non-acupoint (5 mm lateral to the left side of Shuigou). Thus, our findings indicate that electroacupuncture at Shuigou improves neurological function in rats following cerebral ischemia/reperfusion injury, and may be associated with down-regulation of BKCa channel protein and mRNA expression. Additionally, our results suggest that the Shuigou acupoint has functional specificity.

Electroacupuncture improves cognitive ability following cerebral ischemia reperfusion injury via CaM-CaMKIV-CREB signaling in the rat hippocampus

The aim of the present study was to investigate the effect of electroacupuncture (EA) on cognitive deficits, and the underlying mechanism following cerebral ischemia-reperfusion (I/R) via the calmodulin (CaM)-calmodulin-dependent protein kinase type IV (CaMKIV)-cyclic adenosine monophosphate response elements binding protein (CREB) intracellular signaling pathway in the hippocampus. In total, 45 adult female Sprague-Dawley rats were randomly divided into three groups, namely the sham group, the middle cerebral artery occlusion (MCAO) group and the MCAO + EA group. Rats in the MCAO and MCAO + EA groups were modeled for post-stroke cognitive impairment. EA was performed at the Baihui and Shenting acupuncture points for 30 min/day for one week in the MCAO + EA group. Behavioral testing was analyzed using a step-down apparatus, while 2,3,5-triphenyl tetrazolium chloride was used to detect the infarct volume and lesion size. In addition, CaM activity was assessed by cyclic nucleotide-dependent phosphodiesterase analysis, and the protein expression levels of CaM, CaMKIV, phosphorylated (p)-CaMKIV, CREB and p-CREB were analyzed by western blot analysis. The cerebral I/R injured rat model in the MCAO group was established successfully with regard to the infarct volume and neuronal lesion size, as compared with the sham group. EA was demonstrated to effectively improve the cognitive ability, as measured by the step-down apparatus test, and decrease the infarct volume when compared with the MCAO group (P<0.05). The step-down apparatus test for the EA-treated rats revealed improved learning and reduced memory impairment when compared with the MCAO group. Furthermore, CaM activity and CaM protein expression levels in the MCAO + EA group were lower compared with those in the MCAO group (P<0.05). By contrast, the protein expression levels of CaMKIV, p-CaMKIV, CREB and p-CREB were significantly reduced in the MCAO group when compared with the sham group (P<0.05), although the expression levels increased following EA treatment when compared with the MCAO group (P<0.05). Therefore, cognitive repair benefited from EA, and the main intracellular signaling pathway in the hippocampus was mediated by CaM-CaMKIV-CREB. EA effectively inhibited the expression and activity of CaM, while further enhancing the expression of CaMKIV and CREB, and their associated phosphorylated functions.

The biomechanical effect of acupuncture for poststroke cavovarus foot: study protocol for a randomized controlled pilot trial

BACKGROUND

Poststroke cavovarus foot greatly affects patients' activities of daily life and raises the risks of falls and consequent fractures. Acupuncture appears to be safe and effective in promoting motor functions and enhancing the activities of daily life among patients with poststroke cavovarus foot. The current study aims to study the biomechanical effect of acupuncture for poststroke cavovarus foot with objective outcome measurements.

METHODS/DESIGN

This is an assessor and analyst-blinded, randomized, controlled pilot study. A total of 60 eligible patients with poststroke cavovarus foot will be allocated by a 1:1 ratio into an acupuncture treatment group and a control group. Patients in the control group will receive conventional rehabilitation therapies, whereas a combination of acupuncture and conventional rehabilitation therapies will be applied in the acupuncture group. The primary outcome measures are three objective biomechanical parameters from the RSSCAN gait system: varus angle, dynamic plantar pressure distribution, and static plantar contact area. Scores of the Berg Balance Scale, the Fugl-Meyer Assessment, and the Stroke-Specific Quality of Life Scale, as well as other biomechanical parameters such as the step length and width, step time phase, and weight shifting phase will be selected as secondary outcome measurements. All assessments will be conducted at baseline, 4 weeks after the treatment course, and after a follow-up period of 3 months.

DISCUSSION

Results of the current study will provide detailed interpretations of the biomechanical effect of acupuncture for stroke rehabilitation and foundations for future larger clinical studies.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR-IPC-15006889 (8 August 2015).

The Effect of Acupuncture on the Motor Function and White Matter Microstructure in Ischemic Stroke Patients

Evidence shows that ischemic stroke can induce brain structural reorganization. Acupuncture is advised as an adjunct to mainstream rehabilitation after stroke. However, the effectiveness of acupuncture is inconsistent among previous studies. Fourteen ischemic patients were collected and divided into two groups: conventional treatment group (CG) and acupuncture treatment group (AG). The results of a Fugl-Meyer Assessment (FMA) and diffusion tensor imaging were collected before and after treatment. The AG exhibited a higher improvement in FMA than the CG. Repeated measures analysis of variance on diffusion data only found a significant main effect for scanning time point in all diffusion indices. In each group, a postpair t-test revealed that diffusion indices values were changed significantly after treatment intervention in the body of the corpus callosum and bilateral corticospinal tracts, the inferior longitudinal fasciculus, the inferior frontooccipital fasciculus, the superior longitudinal fasciculus, the forceps minor, the cingulum gyrus, and the thalamic radiation. However, there was no significant difference in the diffusion indices between the two groups. In conclusion, acupuncture had a better behavioral score than traditional medicine treatment. However, acupuncture did not significantly change WM in the AG compared to the CG as expected within one month after the intervention.

Blockade of the brachial plexus abolishes activation of specific brain regions by electroacupuncture at LI4: a functional MRI study

OBJECTIVE

Our aim was to test the hypothesis that electroacupuncture (EA) at acupuncture point LI4 activates specific brain regions by nerve stimulation that is mediatied through a pathway involving the brachial plexus.

METHODS

Twelve acupuncture naive right-handed volunteers were allocated to receive three sessions of EA at LI4 in a random different order (crossover): (1) EA alone (EA); EA after injection of local anaesthetics into the deltoid muscle (EA+LA); and (3) EA after blockade of the brachial plexus (EA+NB). During each session, participants were imaged in a 3 T MRI scanner. Brain regions showing change in blood oxygen level-dependent (BOLD) signal (activation) were identified. Subjective acupuncture sensation was quantified after functional MRI scanning was completed. Results were compared between the three sessions for each individual, and averaged.

RESULTS

Blockade of the brachial plexus inhibited acupuncture sensation during EA. EA and EA+LA activated the bilateral thalamus, basal ganglia, cerebellum and left putamen, whilst no significant activation was observed during EA+NB. The BOLD signal of the thalamus correlated significantly with acupuncture sensation score during EA.

CONCLUSIONS

Blockade of the brachial plexus completely abolishes patterns of brain activation induced by EA at LI4. The results suggest that EA activates specific brain regions through stimulation of the local nerves supplying the tissues at LI4, which transmit sensory information via the brachial plexus.

TRIAL REGISTRATION NUMBER

ChiCTR-OO-13003389.