Efficacy of keishibukuryogan, a traditional Japanese herbal medicine, in treating cold sensation and numbness after stroke: clinical improvement and skin temperature normalization in 22 stroke patients

Effects of an inpatient physical rehabilitation program on body temperature distribution and functionality in individuals with stroke sequel

PURPOSE

About 60% of patients who had a stroke present sensory deficit, especially sensation of cold in the affected limb. Although unpleasant, this sensation has been little explored. The aim of this study was to assess the distribution of body temperature before and after a rehabilitation program and its association with functionality in individuals with stroke sequels.

MATERIALS AND METHODS

This experimental study included 18 patients whose thermal images were captured by an infrared sensor for analysis in 8 regions of interest. Volunteers also underwent functionality tests before and after participating in an inpatient rehabilitation program.

RESULTS

One third of the participants perceived temperature difference between limbs, tough mean discomfort was low (<2 on a scale of 1-10). After the program, patients presented better agility (p < 0,001), less movement impairment (p < 0,001), and better balance (p = 0,03). They exhibited slightly lower skin surface temperature in the affected hemisphere, and this persisted after the intervention. Nevertheless, this did not affect functional performance, as there was no difference in functionality among patients with or without the sensation of cold in the affected side.

CONCLUSION

The inpatient rehabilitation program did not alter the observed superficial temperature difference between body hemispheres but improved physical function of patients.

Traditional Use, Phytochemistry, Pharmacology, Toxicology and Clinical Applications of Persicae Semen: A Review

Persicae Semen (Taoren), the seed of mature peaches consumed as both food and medicine, is native to the temperate regions of China, distributed in the provinces of North and East China, and currently cultivated worldwide. The primary components of Persicae Semen include volatile oil, protein, amino acids, amygdalin, and prunasin, all of which have pharmacological properties, such as anti-inflammatory, antioxidant, and immune regulatory effects, and are clinically used in the treatment of gynecological, cardiovascular, cerebrovascular, orthopedic, and digestive system diseases. This review provides a comprehensive perspective on the resource status, ethnopharmacology, phytochemistry, pharmacology, and toxicology, as well as the trend of Persicae Semen patent, global distribution, and clinical applications. This review will help facilitate the development and utilization of Persicae Semen in clinical settings.

Live-Imaging Analysis of Target Vessels and Nitric Oxide Production Associated with Gosha-Jinki-Gan and Keishi-Bukuryo-Gan: Two Herbal Preparations with Clinically Proven Blood Flow-Improving Effects but with Different Traditional Clinical Indicative Patterns

Gosha-jinki-gan (GJG) and Keishi-bukuryo-gan (KBG) are Kampo traditional herbal prescriptions used for different clinical patterns (sho) that improve blood flow. The pharmacological basis of the therapeutic choice remains unclear, although the clinical reliance of this pattern-based therapy is widely proven. We aimed to investigate their effects on microcirculation and nitric oxide (NO) kinetics using a live-imaging system to provide evidence for this. Live-imaging was performed in murine subcutaneous vessels and rat mesentery. In the subcutaneous vessels, we analyzed the effects of both drugs on the vessel diameter, blood flow velocity, and volume in the arteries, arterioles, and capillaries. In the rat mesentery, we induced the “oketsu” blood stasis using a stack of thin vinylidene chloride films and examined the effect on NO production using a fluorescent diaminofluorescein-2 diacetate. Following dissolution in hot water, 300 mg/kg of both drugs were administered intragastrically via a transesophageal catheter. Live-imaging analysis of subcutaneous blood flow revealed the different effects of GJG and KBG on their target vessels and effect onset. GJG targeted the capillaries and progressively increased the blood flow velocity and rate at 30–120 min after administration. No vasodilation or increased blood flow in the arteries and arterioles occurred. In contrast, KBG increased the diameter of the arterioles and arteries at 30–90 min after administration, and increased blood flow velocity and rate in arteries and arterioles. In a model of oketsu blood stasis in the mesenteric arteries, KBG increased the NO production from the vascular endothelial cells with dilatation of the arteriolar diameter. GJG improved blood flow mainly in the capillaries. Endothelial NO production decreased after GJG administration. The empirical treatment choice between GJG and KBG is based on the difference in target vessels and NO action and provides a pharmacological basis for therapy based on traditional medicine.

The Multiple Pharmacologic Functions and Mechanisms of Action of Guizhi Fuling Formulation

Objectives

Guizhi Fuling Formulation (GZFL), a traditional Chinese medical formulation, consists of Cinnamomi Ramulus, Paeoniae Radix Alba (or Paeoniae Radix Rubra), Moutan Cortex, Persicae Semen, and Poria, with multiple therapeutic functions such as sedation, antitumor activity, anti-inflammation, and neuroprotection. However, its clinical applications remain relatively fragmented, and the underlying mechanisms of GZFL in different diseases are still not very certain. Further research and summary in both application and mechanisms remain to be needed for human health and the best use of GZFL. Therefore, we summarized the multiple pharmacologic effects and possible mechanisms of action of GZFL according to recent 17 years of research.

Methods

We retrieved four English and two Chinese databases using these keywords (the formulation name or its synonyms) and searched articles written in English from January 2006 up to February 2022. Key Findings. GZFL exhibits multiple pharmacologic advantages in gynecologic diseases and other expanding diseases such as cancer, blood, and vascular disease, renal failure, inflammation, and brain injury. Possibly due to its diverse bioactive components and pharmacologic activities, GZFL could target the multiple signaling pathways involved in regulating blood circulation, inflammatory and immune factors, proliferation, apoptosis, and so on.

Conclusion

This review suggests that GZFL displays promising therapeutic effects for many kinds of diseases, which have been beyond the scope of the original prescription for gynecologic diseases. In this way, we wish to provide a reference and recommendation for further preclinic and clinic studies.

A Review on the Mechanism and Application of Keishibukuryogan

The concept of "blood stasis" - called yū xiě in Chinese, Oketsu in Japanese - is one of the unique pathophysiology of traditional medicine that originated in China and inherited in Korea and Japan. This concept is related to the multiple aspects of hemodynamic disorders brought on by quantitative and qualitative changes. It theorizes that the quantitative changes of "blood stasis" are related to peripheral circulatory insufficiency. When chronic qualitative changes of "blood stasis" produce stagnant blood that turns into a pathological product, it could cause inflammation and lead to organic changes. Trauma induced hematomas, that are considered to be a quantitative change of blood, are also a form of blood stasis. The basic medicine research on Keishibukuryogan (KBG)-a Japanese name in Traditional Japanese Medicine (Kampo) for one of the most common anti- "blood stasis" prescriptions, also known as gui-zhi-fu-ling-wan (GFW) in Chinese in Traditional Chinese Medicine (TCM)-indicated that the initiation of quantitative changes was closely related to loss of redox balances on endothelial function induced by oxidative stress. The following qualitative changes were related to coagulopathy, hyper viscosity; anti-platelet aggregation, lipid metabolism; a regulation of systemic leptin level and/or lipid metabolism, inflammatory factor; cyclooxygenase-1,2 (COX-1, 2), interleukin-6, 8 tumor necrosis factor-α, macrophage infiltration, hyperplasia, tissue fibrosis and sclerosis caused by transforming growth factor-β1 and fibronectin, the dysfunction of regulated cell deaths, such as, apoptosis, autophagy, ferroptosis and ovarian hormone imbalance. Clinically, KBG was often used for diseases related to Obstetrics and Gynecology, Endocrine Metabolism, Rheumatology and Dermatology. In this review, we give an overview of the mechanism and its current clinical application of KBG through a summary of the basic and clinical research and discuss future perspective.

Kampo Formulae for the Treatment of Neuropathic Pain ∼ Especially the Mechanism of Action of Yokukansan ∼

Kampo medicine has been practiced as traditional medicine (TM) in Japan. Kampo medicine uses Kampo formulae that are composed of multiple crude drugs to make Kampo formulae. In Japan, Kampo formulae are commonly used instead of or combined with Western medicines. If drug therapy that follows the guidelines for neuropathic pain does not work or cannot be taken due to side effects, various Kampo formulae are considered as the next line of treatment. Since Kampo formulae are composed of two or more kinds of natural crude drugs, and their extracts contain many ingredients with pharmacological effects, one Kampo formula usually has multiple effects. Therefore, when selecting a formula, we consider symptoms other than pain. This review outlines the Kampo formulae that are frequently used for pain treatment and their crude drugs and the basic usage of each component. In recent years, Yokukansan (YKS) has become one of the most used Kampo formulae for pain treatment with an increasing body of baseline research available. We outline the known and possible mechanisms by which YKS exerts its pharmacologic benefits as an example of Kampo formulae's potency and holistic healing properties.

Body temperature and esthesia in individuals with stroke

Patients with sequelae of stroke commonly report somatosensory losses. It is believed that body temperature may be associated with tactile sensibility and sensorimotor recovery of these patients. Demonstrate the associations among tactile sensibility, cutaneous temperature, subjective temperature perception, and sensorimotor recovery of patients with stroke sequelae. 86 patients with stroke sequelae were included. Patients had standardized regions of interest (ROIs) assessed with infrared thermography (FLIR T650SC) and monofilaments esthesiometry, and global motor recovery was evaluated with Fugl-Meyer Assessment (FMA). The presence of self-reported perception of temperature difference was used to divide the participants into two groups of 43 patients, and correlation tests were applied to establish correlations among variables. There is no clinically relevant association between tactile sensibility and cutaneous temperature of the foot, regardless of the subjective sensation of temperature changes. Sensorimotor recovery evaluated by FMA is associated with the difference of sensibility between both sides of the body (p < 0.001), as well as with the difference of tactile sensibility (p < 0.001). A clinically significant association between the difference of cutaneous temperature and tactile sensibility was not found, regardless of the presence or absence of subjective perception of such temperature difference. However, sensorimotor recovery is correlated with cutaneous temperature differences and tactile sensibility.

Identification of herbal components as TRPA1 agonists and TRPM8 antagonists

Transient receptor potential (TRP) channels are non-selective cation channels that are implicated in analgesia, bowel motility, wound healing, thermoregulation, vasodilation and voiding dysfunction. Many natural products have been reported to affect the activity of TRP channels. We hypothesize that numerous traditional herbal medicines (THMs) might exert their pharmacological activity through modulating the activity of TRP channels. The present study aimed to evaluate the effects of flavonoid aglycones and their glycosides, which are the main components of many THMs, on the TRP channel subtypes. A Ca²⁺ influx assay was performed using recombinant human TRPA1, TRPV1, TRPV4 and TRPM8 cell lines. Our findings showed that flavonoid aglycones and glycycoumarin activated TRPA1. In particular, isoflavone and chalcone compounds displayed potent TRPA1 agonistic activity. Furthermore, flavone aglycones showed concomitant potent TRPM8 inhibiting activity. Indeed, flavone, isoflavone aglycones, non-prenylated chalcones and glycycoumarin were found to be TRPM8 inhibitors. Hence, flavonoid aglycones metabolized by lactase-phlorizin hydrolase and β-glucosidase in the small intestine or gut microbiota of the large intestine could generate TRPA1 agonists and TRPM8 antagonists.

Effect of transcranial direct current stimulation (tDCS) delivered via dorsolateral prefrontal cortex on central post-stroke pain and depression: a case report

Background: Transcranial direct current stimulation (tDCS) is effective in the management of patients with central post-stroke pain (CPSP) and post-stroke depression (PSD) individually. However, it is not known if tDCS delivered via dorsolateral prefrontal cortex (DLPFC) can be used to ameliorate both symptoms.Objective: The purpose of this case report was to share the effectiveness of using tDCS of the DLPFC with short inter-session intervals to reduce central pain and depression in a stroke survivor. Case Description: A 45-year-old patient presented with CPSP and depression following a stroke. The CPSP and depression were diagnosed using the Douleur Neuropathique 4 Questionnaire (DN4Q) and the Beck Depression Index (BDI) respectively. The pain score was 10 on a visual analogue scale (VAS) and it was a hemi-body burning sensation, with a score of 7 on DN4Q, and the depression score was 25 on the BDI. The patient received anodal tDCS to the left DLPFC using two different application protocols. Initially, a stimulation session of 2 milliamperes (mA) intensity for 20 minutes was given every working day for 2 weeks. After 3 weeks, she then received 7 daily sessions of periodic stimulations of 2 mA intensity for 13 minutes each with 20 minutes inter-session intervals for 1 week. The patient was followed up for 6 months post-intervention. Outcomes: Immediately following the last session of the initial protocol of stimulation, the BDI score reduced from 25 to 7 and the pain became abolished. However, the symptoms relapsed at 3 weeks post-intervention to the initial BDI score of 25, VAS score of 10 and DN4Q score of 7. Following the application of the second protocol of stimulation, the BDI score improved to 18 at three weeks and later to 7 at six months post-intervention while the pain (both VAS and DN4Q) became completely abolished.Conclusions: Further research is needed to determine if a series of periodic tDCS with short-intersession intervals applied to the DLPFC may be more effective than a single tDCS with long inter-session intervals, in decreasing pain and inducing long-term improvement in mood in people with stroke.

Cutaneous temperature sensitivity alteration in subjects with chronic stroke sequelae - pharmacological perspectives

BACKGROUND

Stroke can result in body temperature sensitivity changes. This study analyzed abnormal temperature perception of patients with stroke and the use of vasoactive drugs.

METHODS

A cross-sectional retrospective study was carried out consisting of 100 patients (55.6±12.9 years old), from both genres, with either hemorrhagic or ischemic stroke, with unilateral hemiplegia or hemiparesis. Subjects had axillary temperature and different temperature sensitivities of the limbs measured using a visual analog scale (VAS). Information on the use of medical drugs was collected in clinical records.

RESULTS

In total, 64 patients reported body temperature alterations, and 62 patients stated they feel cold in the affected side. They reported 6.12±2.44 cm alteration for the upper limb and 6.72±2.44 cm for the lower limb in the VAS. Some 86 different drugs were identified in the 85 medical records available. There was a prevalence of a group of drugs formed by the β-blockers, dopamine agonists, dopamine reuptake Inhibitors, tricyclic antidepressants (TCAs) and another group formed by the selective serotonin reuptake inhibitors.

CONCLUSIONS

Most of the subjects reported a sensation of cold in the affected limbs. The β-blockers, dopamine agonists, dopamine reuptake inhibitors, and TCAs seem to be related to this sensation, however, due to the number of uncontrolled variables that may be related to these drugs and the possible role of nitric oxide, it was not possible to establish precise relations regarding the use of a specific group of drugs and the cold sensation in the affected limbs, as reported by the patients.

Evaluation of body temperature in individuals with stroke

BACKGROUND

A stroke can cause alterations in thermal sensitivity.

OBJECTIVE

to verify the conditions of body temperature in hemiplegic patients after stroke as compared to healthy individuals, as well as establish relations between thermal sensitivity and gender, age, Body Mass Index (BMI), plegic side, time after stroke, reports of thermal alterations and the motricity of patients with stroke sequelae.

METHODS

This cross-sectional study included 100 patients (55.6±13 years) with ischemic or hemorrhagic stroke sequelae with unilateral hemiparesis and thirty healthy subjects (55±12.9 years). Individuals with nervous peripheral lesions, diabetes, peripheral vascular diseases or tumors were not included in this study. The volunteers underwent axillary temperature evaluations with the use of a cutaneous thermometer and evaluations of cutaneous temperature of hands and feet as measured by infrared thermography captured by an infrared sensor (ThermaCAMTM SC 500-FLIR Systems). The mean temperature (°C) was analyzed with the SigmaStat 3.5 statistical package.

RESULTS

The results have shown that healthy individuals have similar temperatures on either side of the body. The hemiplegic subjects presented a lower temperature on the plegic side and compared to the healthy subjects, both feet of the hemiparetic individuals were colder. The results have also shown that age, body mass index, and the time after stroke have no influence on the alterations in temperature. Regarding the paretic side, individuals with hemiplegia on the right side (right foot) had a lower temperature than those affected on the left side. Motricity was not related to any difference in temperature between the limbs and the reports of temperature differences had no relation with the actual differences found in the study.

CONCLUSIONS

Healthy individuals have temperature symmetry between between sides of the body, while individuals with stroke sequelae present lower temperature in the paretic side, especially on their feet.

Oral Administration of the Japanese Traditional Medicine Keishibukuryogan-ka-yokuinin Decreases Reactive Oxygen Metabolites in Rat Plasma: Identification of Chemical Constituents Contributing to Antioxidant Activity

Insufficient detoxification and/or overproduction of reactive oxygen species (ROS) induce cellular and tissue damage, and generated reactive oxygen metabolites become exacerbating factors of dermatitis. Keishibukuryogan-ka-yokuinin (KBGY) is a traditional Japanese medicine prescribed to treat dermatitis such as acne vulgaris. Our aim was to verify the antioxidant properties of KBGY, and identify its active constituents by blood pharmacokinetic techniques. Chemical constituents were quantified in extracts of KBGY, crude components, and the plasma of rats treated with a single oral administration of KBGY. Twenty-three KBGY compounds were detected in plasma, including gallic acid, prunasin, paeoniflorin, and azelaic acid, which have been reported to be effective for inflammation. KBGY decreased level of the diacron-reactive oxygen metabolites (d-ROMs) in plasma. ROS-scavenging and lipid hydroperoxide (LPO) generation assays revealed that gallic acid, 3-O-methylgallic acid, (+)-catechin, and lariciresinol possess strong antioxidant activities. Gallic acid was active at a similar concentration to the maximum plasma concentration, therefore, our findings indicate that gallic acid is an important active constituent contributing to the antioxidant effects of KBGY. KBGY and its active constituents may improve redox imbalances induced by oxidative stress as an optional treatment for skin diseases.

Examination of clinical efficacy of keishibukuryogan on non-specific complaints associated with varicose veins of the lower extremity

The subjective symptoms of varicose veins of the lower extremity often include malaise, numbness, coldness, pain, and pruritus of the lower extremity, and relieving these complaints is important in managing the quality of life of patients. We have examined the clinical efficacy of keishibukuryogan, a Kampo prescription for improving oketsu (impaired microcirculation, congestion), on non-specific complaints associated with varicose veins of the lower extremity. Keishibukuryogan was administered to 30 patients with non-specific complaints associated with varicose veins of the lower extremity for 12 weeks, resulting in improvements in the scores of subjective symptoms, severity of varicose veins, and oketsu as well as an increase in skin perfusion pressure. And especially the effect was remarkable in female. In addition, oketsu was shown to be involved in the subjective symptoms associated with varicose veins of the lower extremity, demonstrating efficacy of keishibukuryogan. No adverse drug reaction or abnormal laboratory result was observed in patients receiving keishibukuryogan, and the rate of general improvement and usefulness was 73.3%. It was suggested that keishibukuryogan was useful to improve the symptoms of patients with non-specific complaints associated with varicose veins of the lower extremity especially in female patients. (English translation of Jpn J Phlebol 2013; 24: 303-310).

Efficacy of kampo medicine in treating atopic dermatitis: an overview

Atopic dermatitis (AD) is a common inflammatory skin disease with recurring episodes of itching and a chronic relapsing course. Current treatment options for AD include topical agents, such as topical corticosteroids and oral antiallergic drugs. Providing effective long-term treatment is sometimes difficult due to the chronic, relapsing nature of AD; therefore, there is a need to identify better therapeutic options with minimal side effects that are well tolerated over the variable course of the disease. Traditional herbal medicine, also known as Kampo medicine in Japan, has a long history and plays a role in the prevention and treatment of various diseases, including AD. Some Kampo medicines are useful for treating inflammatory skin diseases, and there has been increased interest in using Kampo medicine to develop new therapeutic agents for AD. Standard Kampo formulas for AD are effective in removing the symptoms of “Netsu Sho,” “Ketsu-Kyo,” “Ki-Kyo,” and “O-Ketsu.” This paper discusses the efficacy of Kampo medicines in treating AD. Knowledge of the mechanisms of action of Kampo medicines will result in greater choices of pharmacotherapeutic agents for AD.

Effectiveness of keishibukuryogan on chronic-stage lichenification associated with atopic dermatitis

Atopic dermatitis (AD) is a common inflammatory skin disease with recurring episodes of itching and a chronic relapsing course. Keishibukuryogan (KBG) is a traditional herbal medicine, composed of five kinds of medical plants and has been administered to patients with blood stagnation in Japan. This study investigated the effect of KBG on the disease activity in AD (n = 45) patients. AD patients were administered KBG for 4 to 6 weeks in addition to their prescribed medications. The results showed that the SCORAD index and VAS score were significantly decreased after the administration of KBG (P < 0.01). KBG also decreased the serum LDH level significantly (P < 0.01). The global assessment of the clinical response in SCORAD index showed that 88.5% of the patients with moderate improvement to excellent response (n = 26) had a high lichenification score (lichenification score ≥2 in SCORAD). On the other hand, only 42.1% of the patients with no improvement to mild improvement (n = 19) had a high lichenification score. Furthermore, long-term administration of KBG for 9-67 weeks showed a marked improvement in patients with a high lichenification score. Therefore, KBG was found to be effective against AD, particularly in cases presenting with lichenified lesions.

Alternative Therapies for Stroke Treatment in Asia

Patients seek alternative therapies for stroke in Asia due to dissatisfaction with poststroke recovery. Most alternative therapies are of unproven benefit in rehabilitation. Well-conducted trials are needed to better define the role of alternative therapies in the process of poststroke recovery; the CHInese Medicine Neuroaid Efficacy on Stroke recovery is ongoing. However, further studies, better health education and rehabilitation services and centers are also required.

The traditional Japanese formula keishibukuryogan inhibits the production of inflammatory cytokines by dermal endothelial cells

Keishibukuryogan (KBG) is one of the traditional herbal formulations widely administered to patients with blood stagnation for improving blood circulation; currently, it is the most frequently prescribed medicine in Japan. KBG has been reported to improve conjunctional microcirculation. The aim of this study was to evaluate the role of KBG and paeoniflorin, a bioactive compound of KBG, in inhibiting the production of inflammatory cytokines using human dermal microvessel endothelial cells (HDMECs). The authors observed that lipopolysaccharide (LPS; 1 μg/mL) stimulated the secretion of proinflammatory cytokines in HDMECs. KBG treatment (10 mg/mL) significantly suppressed the mRNA levels of migration inhibitory factor (MIF), interleukin (IL)-6, IL-8, and tumor necrosis factor (TNF)-α in LPS-stimulated cultured HDMECs. Similarly, paeoniflorin significantly suppressed the mRNA levels of these cytokines in LPS-stimulated cultured HDMECs. ELISA showed that KBG and paeoniflorin suppressed the production of MIF, IL-6, IL-8, and TNF-α in LPS-stimulated HDMECs. Moreover, KBG and paeoniflorin decreased the expression of cyclooxygenase-2 and inducible nitric oxide synthase (iNOS) in these cells. These results suggest that KBG may be useful for improving microvascular inflammation in patients with skin diseases.