Reference
Kong JC, Lee MS, Shin BC, Song YS, Ernst E. Acupuncture for functional recovery after stroke: a systematic review of sham-controlled randomized clinical trials. CMAJ. 2010;182(16):1723-1729.
Design
Meta-analysis of randomized controlled trials comparing the effects of acupuncture with sham acupuncture. Ten of 664 potentially relevant studies met inclusion criteria. For acute and subacute stages post-stroke, authors included 7 trials.
Results
Meta-analysis of 5 studies that accessed functionality did not show a significant difference in favor of acupuncture, with high heterogeneity. A post-hoc sensitivity analysis of 3 trials with low risk of bias did not show beneficial effects of acupuncture on activities of daily living at the end of the intervention period. For the chronic stage after stroke, 3 trials tested effects of acupuncture on function according to Modified Ashworth Scale; all failed to show favorable effects.
Interpretation
Meta-analyses of data from rigorous randomized sham-controlled trails did not show a positive effect of acupuncture as a treatment for functional recovery after stroke. Few randomized sham-controlled studies have tested the effectiveness of acupuncture during stroke rehabilitation.
Discussion
According to the authors of this study, there are several possible explanations of these findings: acupuncture may be ineffective, existing studies may have been inadequately designed, or treatment may not have been properly administered. For example, several of the trials included patients treated more than 6 months post-stroke, which may be too long after injury to expect to see significant improvements. Additionally, treatment protocols varied significantly in terms of the types of acupuncture treatments applied, whether or not electro-acupuncture was included, number and frequency of visits, and other treatment variables.
It is laudable that the authors did not use English language studies exclusively but instead did exhaustive research to include all clinically relevant trials they could find, including those from China, Japan, and Korea where acupuncture is used much more frequently than in the West for post-stroke treatment and often much closer to the stroke event than in the West, which could potentially yield more positive results.For example, over my 21-plus years as a licensed acupuncturist, I have only treated a relative handful of patients for post-stroke recovery, and all of them were at least 6 months past the dates of their strokes, significantly limiting expected treatment effectiveness.
While this meta-analysis is the most comprehensive I have reviewed, I have some concerns with the study design. In their interpretation, the authors admit that sham acupuncture is not inert and has been shown to cause physiological effects.1 The winnowing down of 664 studies to a mere 10 that compared “real” to “sham” acupuncture may have selected for criteria that excluded studies that may have shown real and positive effects.
The winnowing down of 664 studies to a mere 10 that compared "real" to "sham" acupuncture may have selected for criteria that excluded studies that may have shown real and positive effects.
It may also be indicative of selection bias. For example, 18 studies used animals, 52 were uncontrolled trials, and 172 were excluded because they did not use sham or placebo control. One hundred twenty-one studies compared 2 different types of acupuncture treatment. It is possible that some of these studies may have demonstrated more favorable effects.
For example, in 1997, researchers Hopwood and Lewith published a preliminary study of 6 patients who had suffered strokes within 3 months of acupuncture treatment.2 Each patient was treated daily for 2 weeks with electroacupuncture, with a 2-week crossover period during which the patients were treated with placebo electrotherapy. A consistent rise in motor function as assessed by the Motricity Index was observed after the electroacupuncture treatments, leading the authors to conclude that acupuncture can have salutary effects on patients recovering from stroke.
It is notable that while the study authors did not find statistical significance to the results of their analysis, specific analyses of activities of daily living showed a slight trend toward improvement favoring those treated with real acupuncture versus sham acupuncture.
While this is an exhaustive overview of studies evaluating the effects of acupuncture on post-stroke recovery and an important study in the field, clearly more research is needed, especially where patients are offered treatment as close to their stroke as possible.
