The Science of Acupuncture

I get asked all the time… “How does acupuncture work?” Modern science is catching up with 10,000 year old acupuncture. I’ve said for years that we just don’t have the method for seeing the structures yet – just as we didn’t understand the minute complexities of the human body – or imagine MRIs! – 200 years ago. It looks like we are slowly figuring it out! Here are a handful of recent articles exploring the science of acupuncture. These are just the ones that I stumbled across. If I had to time to do an exhaustive search this would be a much longer blog post. :)

From the first article below: Oxygen pressure is higher at acupuncture points!

p6oxygen

 Acupuncture Biochemically Reduces Pain and Inflammation

Acupuncture remaps the primary somatosensory cortex of the brain

MRI Reveals Acupuncture Modulates Brain Activity

CT Scans Reveal Acupuncture Points

New Brain Study – Acupuncture Fights Depression

Acupuncture Holds Promise for Treating Inflammatory Disease

Acupuncture Beats Gabapentin for Hot Flashes in RCT

Acupuncture as effective as drugs in treating pain, trial shows

Biological Evidence for the Existence of Acupuncture Meridians inside lymphatic vessels

Curtin researchers unlock the scientific reasons why acupuncture works – C fibers (nerve branches)

But what about “all those studies” that show it’s not effective?

First of all, there are plenty of studies that prove it works. Insurance companies (even the conservative ones) now cover needles for neck and back pain, because studies have specifically proved it, although some deny claims for, say, shoulder pain, because it hasn’t specifically been studied. Makes me want to roll my eyes. Ug.

Secondly, many of the studies that “prove” it doesn’t work are deeply flawed. They have doctors doing a few recipe points they learned in a 20 – 300hr class, rather than an actual acupuncturist. Sometimes the points they choose are completely mystifying to me – not only do they leave out important ones, but there are always one or two just make no sense at all.

Thirdly, TCM differentiates the cause of disease, but lots of studies don’t. You can have a headache due to Yang rising, or Heart xu (deficiency). When a study gives the same treatment to everyone with a headache, of course it’s not effective! The western medical equivalent is putting people with viruses, bacterial infections, and allergies in one group, giving them all an antibiotic, then declaring that drugs don’t work for runny noses.

There are other problems too, like “sham” acupuncture doing “too well” so there isn’t a statistically significant difference. In one study I read back in school, they basically compared acupressure to acupuncture… then declared nothing worked since they both did. That’s just bad study design. There should have been a third control group with no treatment.
equine acupuncture

Equine acupuncture points from the Bagyuiho (Chinese horse and cow acupuncture text), 1399

And that whole placebo thing? It may play a part, as it does with every medical procedure, but it’s not the whole story. In other states (where it was legal without a vet supervising) I have successfully treated animals – there’s no placebo effect there! When a dog, lying limply on the floor and moaning, after 15 min of needles is bouncing up and down, jumping to kiss her owner’s face… that’s not a placebo. Neither is a rabbit regaining bladder and bowel control after a spinal injury. Of course those are anecdotal evidence, but they’re pretty compelling when they repeatedly happen in front of you. Googling for animal studies quickly gave me a whole new batch of data: Horses are studied most often because they have money-making “careers.”

I’ll be perfectly honest – I’m not sold on some of the more esoteric aspects of TCM (Traditional Chinese Medicine). I don’t twirl my needles in a specific direction, for example. Thousands of years ago, when it was developed, there was philosophy as well as medicine involved, and like all ancient sciences, it could use a little update. But acupuncture itself is amazing. It stimulates neuromuscular junctions, which resets neurons (nerves control muscles, which in turn pull on bones). This helps break the cycle of spasms, or activate a non-firing muscle bundle. It reduces inflammation. It distracts nerve receptors and blocks transmission of pain signals. It helps break up fascial adhesions. With older, chronic problems it creates a microtrauma and alerts the body to a “cold case,” which restarts healing. It’s tremendous for nerve repair – check out my paper on stroke recovery. I’ve seen some truly stunning results from people who were locked inside their bodies, long after Western medical science said there would be no more improvement.

“Yang rising headaches,” is just a term for a diagnosis. It’s no more mysterious than “orthostatic hypotension’” for example, if you understand the language of TCM. The articles above show that we are just starting to understand how points work anatomically. I am confident that science will catch up and we’ll have a clear understanding of this system within my lifetime.

The good news is that it doesn’t really matter whether you believe acupuncture works… because it’s medicine, not voodoo, and it will anyway. :) The science of acupuncture is still evolving, but its effectiveness is clear.

Damp (a Chinese medicine concept)

I’ve talked briefly before about Fall in the Pacific Northwest, but let’s get into some more details about how the weather here literally leads to Damp in our bodies. I was out playing in our great outdoors, and on the way back, a fellow adventurer asked me if the soggy Portland climate affected how I practiced. It was an interesting question, so I figured I’d share my response.

In Chinese medicine, you can be “invaded” by EPIs – External Pernicious Influences:  Heat, Cold, Damp, Dryness, and Wind (There are actually two types of Heat, but I’m simplifying here). Damp Heat infection examples include yeast and urinary tract infections. Damp Heat in the Gall Bladder* can cause jaundice.

Damp can also start internally. Remember that in this system we have energetic organs* with special duties. The Spleen transforms food into energy (I think they actually meant the pancreas!), and is important in fluid management. If the Spleen fails, or if there is an invasion, fluids accumulate into Damp. A classically Damp body is overweight. Other symptoms include heavy limbs, stiffness, and edema (fluid retention). Damp left unchecked can further consolidate into Phlegm. This may be literal mucus or lipomas (fatty tumors), or “invisible Phlegm” like brain fog or even depression.

Oregon is, of course, a very wet place! Whether the rain itself penetrates us, or the fact that hiking isn’t as much fun when you have to slosh through the mud… either way, living here can definitely contribute to obesity. Alcohol and dairy are the two biggest Damp culprits in our diet. Microbrew and local cheese, anyone?

Be sure to get off the couch and enjoy the sun when you can. Try not to get soaked – a light rain jacket and hat can really make a difference. Nourish your Spleen with hearty cooked vegetables. This is especially important going into Fall and Winter, but don’t neglect them in favor of a completely raw diet even in the Summer.

Acupuncture is a great way to drain Damp, clear Heat, and restore balance to your system. Please ask if you have any questions!

* Energetic organs are typically capitalized to emphasize their distinct nature from our literal, anatomical organs.

 

 

“Dry Needling” vs. Acupuncture

I had a gentleman ask me last week if I had heard of “dry needling” and if I ever did it. I was flabbergasted… Dry needling is what acupuncture is called when non-acupuncturists do it. Wait – that’s not quite right. It’s what using acupuncture needles is called when someone else does it… but that doesn’t make it acupuncture. True acupuncture requires an understanding of a complex system, while most “dry needling” courses are surprisingly brief.

When comparing acupuncturists vs other practitioners as providers of therapeutic needling, some interesting things come to light. I feel very strongly that the various types of medical providers each have their areas of expertise. A bad injury, a serious infection, and organ failure are just a few of the problems that would send me running to “Western” modern medicine. But in some cases – chronic pain, healing after an injury, neurological repair, anxiety, etc. – acupuncture is highly effective. So….Why not just have your doctor do it?

There are some advantages to doctors doing acupuncture. First, they have a more extensive knowledge of anatomy than the average acupuncturist. I was very lucky to get to work with cadavers when I was at chiropractic school – most don’t. Secondly, the procedure is more likely to be covered by health insurance.

Unfortunately, there are also some disadvantages. Doctors are usually MDs first, and have taken a seminar on acupuncture. This course is a few weekends of instruction. They learn a handful of “recipe” points that are based on symptoms. Some people doing “dry needling” are physical therapists or chiropractors. As a comparison, I have a Master’s degree from OCOM, which consisted of 3,344.5 total hours, including 996 clinical hours. I learned about the Zang Fu organs, the channels, and the 1000 points and how they interact.

Doctors usually don’t spend much time getting to know every detail of your medical history. They tend to have 10 minutes for the whole appointment, and focus purely on your “chief complaint” as we call it in medicine: the main reason you came in. Traditional Chinese Medicine (TCM) is holistic. I prefer to take an hour with my patients. We examine the entire body, not just an isolated part, and our diagnosis is dependent upon that global perspective. For example, you may have a headache due to Liver* Yang Rising, or Qi deficiency, or a Wind Invasion. Or look at it from the other direction: A single diagnosis, such as Kidney Yin Deficiency, can cause varied symptoms like menstrual irregularity, anxiety, vertigo, night sweats… you see the problem. This is why I ask all those rude questions (sorry) in a 10 page form when you come in. What your menstrual cycle is like can actually help me determine how to treat your digestive disorder.

When doctors, chiropractors, and physical therapists use dry needling, especially for internal medicine, their results are not as strong as when a TCM trained practitioner wields the needles. I see this in a lot of research studies that “prove” acupuncture “doesn’t work.” It’s roughly equivalent to testing antibiotics for a runny nose, without separating out bacterial infections from viruses and allergies, then claiming that pharmaceutical drugs aren’t effective.

In this article, a doctor writes about needling. The myofascial part is spot on, but he’s missing the energetic component. Some of the points work on areas far away from where the needle goes! LI-4 and LV-3 are beautiful examples of powerful points that don’t really make sense with the Western understanding of anatomy. If distal points like the hands, feet, scalp and ears are neglected, the treatment may be weaker than ideal. It’s something to think about when comparing someone offering dry needling vs a true acupuncturist.

People with only basic anatomy training like massage therapists, and physical therapists doing dry needling? Super bad idea – and the reason there are so many news stories about dry needling pneumothorax (collapsed lung) problems created by physical therapists. Acupuncture needles are controlled as a medical device, because they really shouldn’t be used by amateurs.

Dry needling is a bad idea, m'kay?

Dr. Andrew Weil, M.D., agrees that TCM training should be comprehensive.

*Remember that in Chinese medicine, capitalized organs are energetic concepts and should not be confused with your anatomical organs.

Yin & Yang

*Note – some parts of this discussion were previously published in the Stroke article.

Chinese Traditional Medicine (TCM) goes back to 2000 BC in its current form, and in its antiquity goes back at least 5,300 years! It’s based on energy movement throughout the body along specific paths or “channels.” Acupuncture works by manipulating energy at points where that energy flows near the surface. There are about 1000 distinct points all over the body, each with their own unique qualities. I came to acupuncture as a profession when it was the only thing that could stop my back pain after a severe car accident (I’m now completely recovered). When I first started studying I was a little skeptical – I was a hard-core scientist and figured the map of channels was an elaborate way to memorize nerves and other anatomical landmarks. The more I studied, though, the more I came to see that this is a completely different system of physiology.

After years of seeing the power of this odd system at work – on skeptical humans, on animals, on “impossible cases” – my current belief is that this is a form of energy we just can’t explain yet. If you told a 16th century doctor that you could see inside the human body without cutting it, you would be declared a witch. Now, any x-ray or ultrasound technician has that ability. NIH has been funding research into measuring energy flow along the channels. It’s only a matter of time before TCM becomes part of our accepted science of medicine.

We’ve all heard of Yin and Yang (pronounced to rhyme with Pin and Pong, by the way). They are tossed around in popular culture a lot, generally with a superficial understanding of them as two sides of a whole. I’ve even seen them likened to Superman and Clark Kent! In Chinese medicine, however, they have a very specific meaning.

Think of Yin as being the moist, nourishing, quiet, still, internal, “feminine” aspect of your being. Yang is the other side of the coin: It’s the loud, bright, moving, motivating,expanding, “masculine” side of you. See how the white Yang is rising, while the black Yin is descending? Note also that each contains a bit of the other: They are incomplete without the other half of the pair. There is a delicate balancing act between the two types of energies, and they influence each other. When Yin and Yang separate (in a raging fever, for example) the patient will die.

Yin/Yang: Each contains and is dependent on the other to create a whole.

Think of an animal, or a baby crawling on all fours. As applied to anatomy, the front and lower parts of the body are Yin. The back and upper body are considered more Yang.  On the limbs, inside surfaces are Yin and the outside aspects are Yang. Acupuncture treatments must be planned out so they contribute to balance. For example, if someone has a headache, we don’t just use local needles on the scalp. We use points on the hands and feet to distribute the input to the body. There’s a great point on the sole of the foot that will draw excess energy down, which helps a lot with Yang-rising types of headache.

 

Yin and Yang energies must work together, and should give and take throughout the day. Yin predominates at night, while Yang rules the day. Some hormonally based examples may be helpful: A woman going through menopause is Yin deficient. Her Yang, no longer held in check by her Yin, causes hot flashes, night sweats, and dryness of the skin and other bodily fluids. To ease this “change of life,” we start by using acupuncture points to clear excess heat (the symptoms). Other points act to nourish the Yin (the cause). These treatments are surprisingly powerful for stopping hot flashes.

Likewise, a man as he ages will suffer from Yang deficiency. This is readily identified in the case of erectile dysfunction and decreased libido. Other symptoms can include lower back pain and a general loss of vigor.  In this case, we use acupuncture points that activate the Yang. Some acupuncturists use moxabustion (burning mugwort, an herb in the sage family) to warm and stimulate the Yang, although most modern clinics (mine included) are now using infrared heatlamps. Using modern technology eliminates the chance of burns and makes for a wonderfully relaxing session.

Most patients feel some immediate relief when acupuncture is used to balance Yin and Yang, but longer term hormonal changes will require multiple treatments.

This is a simplified explanation, of course. Masters of Chinese medicine study for years to understand the subtle interplay of Yin, Yang, and the channels. It’s a fascinating tradition with a lot to teach us about the human body.

Piercings and Tattoos

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Tattoos and Piercings: Are there unintended effects?

(written August 2011)

I spent last weekend at the Portland Tattoo Expo, giving bodywork treatments to tired tattoo artists and attendees. What a fun experience, to be surrounded by illustrated people!

Body modification is nothing new. I’m sure the first caveman had a good time jazzing up his chassis, starting with paint and continuing on to more permanent decisions. The location, color, and motifs of these designs have been important in many ways. They have indicated status and held religious meaning. They have shown membership in a larger group, or had medicinal or protective properties. Of course in some cultures they are just creative, artistic expressions of the human spirit.

Otzi the Ice Man and his tattoos

“Otzi the Ice Man” lived 5,300 years ago. His frozen body, discovered in 1991, has revealed much about prehistoric life. I could write pages about the secrets he shared, but for now let’s focus on his tattoos. X-rays indicate he had lower back and knee pain.  The dotted and lined tattoos he bore relate to acupuncture points to treat those areas. They were hidden under clothing, so they were clearly not just decorative.

Update 1/8/13: Otzi now “lives” in a museum exhibit in northern Italy.

My first thought was a question. I wondered if the application of the tattoos was itself the treatment, or if it was a guide to show him where to apply acupressure. I’ve certainly been known to send patients home with Sharpie marks to indicate where they should press for the next few days. The process of tattooing will of course stimulate the point, and act as an effective treatment. Long term, however, the ink doesn’t continue to activate the area (as far as I know).

Piercings have a more lasting energetic impact because of the jewelry. Metal blocks energy flow. I think this is actually how acupuncture works – the surgical steel of the needle disrupts the energy flow and draws the body’s attention to the area. A tiny needle, in place for a few minutes, has a therapeutic effect. A large gauge piercing, worn permanently, can cause problems by overstimulating the area. I’ve had patients develop unexplained shoulder pain, digestive trouble, and migraines following body modification to those corresponding points on the ear. I encourage them to either remove the piercings or at least switch to glass or bone. Personally, I wear earrings out for events, but not day-to-day and I never sleep in them. I used to have a belly ring but had to remove it due to interference with my Ren channel. Not everyone is sensitive, though: Plenty of people have piercings with no ill effects. It’s up to you as an individual to weigh the impact vs. advantage.

There was a recent discussion on an acupuncturist’s discussion board where a number of providers cited patients unconsciously placing tattoos where they need treatment. For example, someone with a Spleen* deficiency having a design above her inner ankle. I haven’t seen that trend myself, but I do recall a particularly disturbed young man I met while waiting in line for a fitting room at Goodwill. He was clearly mentally ill, and very agitated. He had Shenmen (the seat of mental health) pierced on both sides, an unusual location for an earring. I asked him why he chose that site, and he said it just felt right.

Where are your piercings?

Ear acupuncture points (most of them) with Shenmen marked.

I’m not anti-body-modification. In fact, I have a ankle bracelet tattoo myself that says “VIVO VT SERVIAM” – Latin for “I live to serve.” As with all big changes to your body, however, you should undertake them with thought.

*Remember that in Chinese medicine, capitalized organs are energetic concepts and should not be confused with your anatomical organs. In this case, the Spleen transforms food into energy, while your physical spleen stores and filters blood, and plays a role in the immune system.

 

Fibromyalgia & how to beat it

The FIRST thing to know about Fibromyalgia is that it’s real.

The SECOND thing to know about Fibromyalgia is that it doesn’t have to be forever.

So many people, when they are finally diagnosed, have a bittersweet reaction. At last, they know what is wrong. They might feel vindicated, having endured the eye-rolls and boredom of family members who didn’t believe anything was really wrong. On the other hand, some patients take the diagnosis as a death sentence. They’ve heard nothing but a negative prognosis. They think they are stuck with the pain for the rest of their lives. Some people, exhausted and depressed, can even take on the disease as an identity. DO NOT do this. You are a beautiful person dealing with a temporary disease. There’s a Southern saying “If you’re going through Hell, don’t pitch a tent!” This is perfect advice. Resist the urge to wallow. Focus on the things you CAN do to make yourself better, and keep moving!

I am here to tell you that you CAN overcome Fibromyalgia. I used to have it myself. Now, as long as I am reasonable with my diet and exercise, I am symptom-free!

I see FM as a kind of physical Post-Traumatic Stress. Generally it can be traced back to a physical or emotional trauma. The body’s pain system becomes oversensitive. It reads any little insult as a major injury. To stop this over-reaction, we have to decrease inflammation, reduce stagnation, and decrease stress.

Sleep: See my article on Sleep. Letting your body restore itself overnight is very important!

Exercise: Light, frequent exercise is key to reducing pain. In severe cases, you may need to start with a 5-10 minute walk once a day. That’s fine… just gradually increase the duration. Get up and move a little every few hours instead of sitting still all day. Try to keep your activity levels about the same day to day. Doing too much or being too sedentary will hurt – listen to your body!

Nutrition: Making a few changes in your diet can drastically reduce your pain. Avoid the inflammatory nightshades (tomatoes, potatoes, eggplant, peppers, tobacco) as most people with FM tend to be sensitive to their natural alkaloids. Sugar is the other big offender. Some people are more sensitive to dairy products, commercial red meat, alcohol, and caffeine than others. It’s worth experimenting a little to find out how your body reacts. Go two weeks without the item in question, then have a big dose. See how you feel that day and especially the next. The answer is usually pretty obvious. If you’re ready/able to make big changes in your diet, you may find that eliminating starches (pasta, bread, rice, etc) can be surprisingly helpful.

Try to eliminate fried and processed foods from your diet as much as possible. Anti-inflammatory foods like dark leafy greens and good fats are important to include.

Relaxation: Being happy is important, too. Pamper yourself by allowing time to read or pursue your other hobbies. Have fun! Enjoy a funny movie, hang out with your friends, pet a cat. Pay attention to the beautiful things in your everyday life.

Good touch: The hypersensitivity of fibromyalgia means that the wrong kind of pressure, even well-intentioned, can be very painful. Deep-tissue work and hard hugs are not appropriate. Instead, I use a gentle touch. Careful medical massage, using a large contact (palm of the hand) instead of a pokey one (fingertips), is wonderful for helping disperse blood and lymphatic stagnation. If there’s a partner in your life, I can teach him or her how to work on you. I am also conservative in my needling for FM patients. I use the skinniest possible (42 gauge) and not many of them… too many can wipe out your energy.

Address the cause: Most FM seems to stem from a past trauma, either physical or emotional. Many patients report a history of abuse. Find a good therapist or some other way to address any hidden grief. Some patients find it useful to write letters to people involved in these emotional injuries. Say it all. You can even write one to yourself (current you or younger you). It doesn’t matter if the person is still part of your life or if they are still alive – it’s about expressing yourself. Afterwards, burn the letter as a symbol of letting go of those emotions.

I can’t overstate the importance of this step. You may feel like you’ve dealt with whatever trauma kicked your FM off, but stop and think. Those land mines can be buried deep. In my case, I had to dig back to my sister’s death when I was 18, as well as the obvious car accident. Once I re-addressed my grief, the majority of my symptoms melted away. Take some time to find the splinters in your soul.

Keeping your identity as separate from a disease, and focusing on the actions you can take, is important for everything herpes to HIV. Some people with long-term managed illnesses, like diabetes or fibromyalgia, actually wind up healthier because they get serious about their diet and exercise. This life is what we make of it. Go make something awesome! 

 

Common Typical TCM (Traditional Chinese Medicine) Patterns for Fibromyalgia

One person may exhibit more than one pattern.

Liver* Qi Stagnation – anxiety, emotional upset, headaches (including migraine headache), being easily angered, muscle stiffness in neck and shoulders, insomnia, waking frequently and having difficulty falling back to sleep, irritable bowel syndrome. All symptoms may be triggered by emotional stress.

Qi and Blood Deficiency – specifically spleen Qi deficiency and heart blood/liver blood deficiency, with such symptoms as chronic fatigue, exhaustion, dull headache, muscle weakness and numbness, insomnia, dream-disturbed sleep and waking up tired, palpitations and depression.

Qi Stagnation and Blood Stasis – aches and pains in the whole body, burning or gnawing pain with tingling sensations in extremities, headaches.

Kidney* Deficiency (either Yin, Yang, Qi or Essence Deficiency) – there will be impotence or lack of libido for males and infertility issues for both males and females. Other symptoms: sore lower back with restless leg syndrome, irritable bladder, dysmenorrhea, amenorrhea, premenstrual syndrome, hot flashes and night sweats.

* Please note that the Chinese organs are energetic concepts and may or may not relate to the physical organs!

Acupuncture and Chinese medicine provide relief of symptoms by balancing Yin and Yang, and adjusting the circulation of Qi and the blood. Local measures such as heat, gentle therapeutic massage, and moxibustion* in specific regions also help to reduce the pain. A regular plan, with long-term, consistent integrative treatment is necessary in patients with fibromyalgia.

* I prefer myofacial release and moxa as methods to break up stagnation rather than cupping for people with fibromyalgia. Cupping, especially if done too harshly, creates bruising / bleeding under the skin and contributes to excess inflammation.

Acupuncture and Post-Stroke Spasticity (contains Chinese medicine theory)

EDIT 1/22/15: Since I posted this I’ve gotten a lot of emails from people all over the world wanting to know if I can help them. Unfortunately, I don’t know anyone I can refer you to outside the US… outside the American Pacific Northwest I do not have much connection with other acupuncturists.  

Also, it’s impossible for me to know how many sessions your recovery would take. There are so many factors – your condition, your general vitality, your diet, how much physical therapy you do, etc. 

To find a local acupuncturist, first ask around and read a lot of reviews (Yelp, Google, even ask your neuro docs if they know of someone local). There’s a big variation in skill / talent among practitioners, and there are lots of different styles. Feel free to try a few and fire anyone who doesn’t mesh with you. Be aware that with neurological repair it may take weeks to get observable results, which can complicate your decision. Be patient.

If you can find someone locally who does medical massage (advanced techniques are much better for this than regular relaxing massage or “deep tissue”), that will be helpful. Usually the muscles and nervous system need to be re-trained so they aren’t so spastic.
I recommend self-stimulation (rub with fingertips) all over the ears and scalp, especially Du-20 and the scalp from the ears forward. Also, stimulate points LI-4, LV-3, and GB34, and BL 62 (just under the outside ankle bone). You can do that up to a few times a day. 
Use regular (2-3 times a day) exercises to try move your body – even if you can’t see it move – imagine it and try. Visualize doing a movement you know well, like a sport, playing a musical instrument, or typing. Moving – especially novel movements – will help your neural repair more than anything else. It’s ok if you are shaky or inaccurate in your motor control, you just have to keep trying things. 
Avoid processed food. Eat lots of veggies. Good quality protein (grass-fed / pastured animals) and fats (avocado, nuts, seeds) are important to support your nervous system. 
Most important – try to keep a positive outlook. I know it’s very difficult in a frustrating situation, but focusing on the good parts of your life will keep your body less stressed, and it will heal better (When you are in “fight or flight” mode your body won’t expend energy on healing / digesting as much). Meditation, breathing exercises, etc can be helpful. 

If you are doing this research on behalf of a loved one, I would also recommend you look into a caretaker support group for YOU. It can be a huge stressor. In addition to practical advice, you can really benefit from talking to someone who understands your situation.

I hope this helps you in your recovery. If I can be of further help please let me know!
*****************************

EDIT 7/1/13: A note on longer-term neurological repair: The current “common knowledge” in the Western medical world is that most nerve repair will happen within 6 months of the injury. After that, they say, you are stuck with whatever impairments you still have. I want people to know that while it’s harder to achieve progress past the 6 month mark, it’s by no means impossible! I had a patient who suffered a stroke 17 months before I saw her. When we met, she was locked into position in bed, bent, twisted and looking into the corner of the ceiling. She was unable to move her limbs or speak. When I arrived for her fourth visit in as many weeks, she was sitting up and cracking jokes. Her legs had straightened out, and she had regained enough control of her hands to eagerly anticipate knitting again! While these results are not average, they provide hope, as does this article.

NOTE: This is a transcript of a presentation geared to healthcare providers who have no experience with Chinese medicine (doctor’s office staff, etc), and focuses on recovery rather than prevention. It was written as part of my thesis project for my Master’s Degree at the Oregon College of Oriental Medicine in 2005. It was  updated with the newest demographic information in 2011 but otherwise left in its original form.

I’ve always had a personal love of the science of the human body. I was a bodybuilder and personal trainer focusing on rehabilitation and core strength for three years. Working with my clients was thrilling but I knew I needed more education. I took the full battery of medical prerequisites and went to chiropractic school. After the first year I knew their method of adjusting wasn’t a good fit for me, but I’m grateful for what I learned in the cadaver lab and in lecture classes. I took that base of knowledge to the Oregon College of Oriental Medicine where I earned a Master’s degree in Acupuncture.

According to the American Stroke Association, nearly 800,000 people each year suffer a stroke in this country (this number was 700,000 in 2004). On average, an American suffers a fatal stroke every 3-4 minutes. It’s the third-largest cause of death behind heart disease and cancer. Strokes are not always fatal, of course. They are a major cause of disability, and are responsible for an estimated 550,000 disability cases per year. For many survivors, the ordeal may be just beginning.

More than 75% of stroke patients have motor impairments, often resulting in disability, such as impaired ambulation and inability to perform activities of daily living (ADLs) (Wojner). ADLs are the basic tasks of everyday life such as eating, bathing, dressing, toileting, and transferring (Wiener). Suddenly being handicapped can cause embarrassment, frustration, and profound depression for the post-stroke patient. Caretakers and family members also experience stress, both psychological and financial. Americans will pay about $68.9 billion in 2009 (this number was $57 billion in 2005) for stroke-related medical costs and disability (American Stroke Association).

CVAs – Cerebral Vascular Accidents – come in two flavors, ischemic and hemorrhagic. The ischemic (lack of blood) type is much more common (82%) and results from a clot stopping blood flow to part of the brain. It could be a local cerebral thrombus, or an embolism from a distant clot that occluded a cerebral artery. The hemorrhagic type, as its name suggests, results from bleeding from an intracerebral artery. In either case, the patient can suffer long-term ill effects ranging from poor memory or speech problems to paralysis.

TIAs – Transient Ischemic Attacks – are mild or “mini-strokes.” They produce brief periods of damage that resolve without medical intervention, sometimes within minutes.

Unfortunately, with most CVAs there are lasting repercussions. Symptoms will vary with the location of the brain damage. If Broca’s Area is deprived of oxygen, for example, the patient will have difficulty with speech production. If the posterior brain is affected, the patient will have impaired vision. Today I will focus on treating damage of the motor area of the brain.

After recovery from a stroke, a patient can frequently have motor weakness on one or both sides of the body. Further impairing mobility and function in this patient population is spastic hypertonia. This abnormally excessive muscle tone can cause many problems, including pain, loss of free movement of a limb, and interference with the ability to walk and perform daily activities, such as bathing or dressing. It also may cause the limb to become “fixed” or frozen in an uncomfortable position (Meythaler).
There are two nerve cells that control each muscular contraction, the upper and lower motor neurons (UMN and LMN). The upper motor neuron begins in the brain and descends through the spinal cord. It synapses (meets) with the lower neuron, which goes to a muscle. The LMN creates contraction, so damage below the synapse will result in flaccid paralysis. This is the typical post-trauma paraplegic with atrophied legs. By contrast, the upper motor neuron normally inhibits contraction. When the UMN is damaged in a stroke, the muscles are never turned off: patients have perpetually spastic muscle tone. They might have their arms pulled up tight against their bodies, or legs that want to stay crossed. In cases that affect fine motor control, writing and other small tasks are compromised. You may see a similar pattern in people who have suffered head trauma. Post-stroke spasticity creates uncontrollable muscle tightness that can cause painful muscle cramps, particularly in the arm and leg.

The current allopathic toolbag for hypertonicity is quite large and still evolving. Systemic antispasticity drugs have fallen out of favor, because they are nonselective in action and may cause functional loss of normal muscles. Some doctors like to use muscle relaxants, like tolperisone – a centrally acting muscle relaxant with membrane stabilizing activity. Stamenova conducted studies that showed tolperisone to be safe and effective in reducing spasticity as measured by the Ashworth scale.

The most common type of treatment is a local blocking agent: a medication that will deliberately impair the transmission between lower motor nerves and muscles. When the nervous system sends these abnormal commands to contract, the messages are no longer transmitted to the muscle and the muscle remains relaxed (Bakheit). Botulinum toxin has been widely used with good effects and can be performed as an outpatient procedure without anesthesia.

The pharmaceutical management of spastic hypertonia following stroke has generally been confined to the use of approaches that reduce activity at the neuromuscular junction (botulinum toxin), inhibit the release of calcium from the sarcoplasmic reticulum (dantrolene sodium), or those that act centrally (baclofen, diazepam, and clonidine). Ablative procedures are performed, such as phenol injections to the motor points or nerve blocks by injection. These procedures generally require repetition and have been associated with permanent weakness, and loss of muscular control (Meythaler).

Most recently, intrathecally delivered baclofen has been established as a treatment method in acquired brain injury. A catheter is inserted into the spinal canal and a radio-transmitting device delivers medication directly into the fluids surrounding the spinal cord. Baclofen binds to presynaptic GABA-B receptors within the brain stem and other central nervous system (CNS) sites. By blocking the transmission of neural messages, it prevents muscular contraction.

Physical therapy is another commonly prescribed modality for stroke survivors. This can range from gait retraining with a parachute harness over a treadmill, to personal training with free weights or elastic bands. Occupational therapists can intervene with training of sensory-motor functions, training of cognitive functions, training of skills such as dressing, cooking a meal, or performing domestic activities, advice and instruction in the use of assistive devices, provision of splints and slings, and education of family and primary caregivers (Steultjens). Previously, doctors feared that physical exercise would exacerbate spasticity. Research has shown instead that exercise such as pedaling a bike is a beneficial intervention for achieving gains in muscular force output without worsening motor control (Brown).

Now that we have an overview of the main techniques used to treat spasticity, let’s compare their outcomes and side effects:

There are a number of studies on botox injections as an antispasmodic, with both upper and lower limbs. Success rates in reducing spasticity are impressive, but are accompanied by muscle weakness. For example, Berlin’s Dr. Hesse noted weakness in the anterior tibialis (shin muscle, which lifts the foot) after injections of the gastrocnemius calf muscle. Side effects are known to include bleeding, skin rashes, or tenderness at the injection site, as well as flu-like symptoms (Bakheit, et al). The main drawback to botox injections is the short-lived benefit: Three months of relief seems to be average (Bakheit, et al).

Unlike other drugs used to treat spasticity, tizanidine has not been shown to cause muscular weakness (Wallace). However, it has other significant drawbacks. The side effects seen with tizanidine in this study were similar to those previously reported. In both Wallace’s and Gelber’s work, the most common were sedation, dizziness, dry mouth, and hypotension. Nearly 15% of their patients withdrew from the study because of these side effects. All of these patients developed these side effects at very low doses of tizanidine.

Intrathecal Baclofen delivered by a pump can vary the amount of medication during the course of a day. It’s effective for the lower limbs and torso, but has less predictable effects for upper limbs. Intrathecal delivery causes less sedation, lethargy, and weakness than oral Baclofen, with a stronger nerve action. It requires that a surgeon or an anesthesiologist implant a small tube into the spinal cord and a pump under the abdomen skin, and is best used for patients that have severe spasticity, particularly those with a spinal cord injury or multiple sclerosis (Ivanhoe).

Although all of these types of therapies have provided relief for patients, there is still a need for alternative therapy. Acupuncture is an appropriate adjunctive therapy for those patients who want to avoid additional drugs. Many of the patients who suffer strokes tend to be taking multiple medications. Providing relief without inducing additional drug interactions is a beautiful bonus.

Acupuncture also provides a more holistic answer when compared to botox injections. Why deaden an operating nerve (the lower motor neuron) when the damaged UMN is the problem? Two wrongs do not make a right – they create further insult to the body. TCM (Traditional Chinese Medicine) focuses on healing the original injury. Needles have been used with good success in treating neurological problems and can help stimulate nerve regrowth and recovery.

There are many styles of acupuncture, including Japanese, 5 Elements, Classical, etc. but this lecture will limit itself to TCM acupuncture. Its roots are ancient: some sources indicate needles were used for healing as much as 4000 years ago. Acupuncture in its present form was practiced 2000 years ago. Much of the theory is based on empirical science – that is, trial and error! Over 40 centuries they figured out some pretty amazing things about the human body. Before I can explain them, though, it’ll be helpful to understand the framework of TCM theory.

Acupuncture deals primarily with Qi, usually translated as Energy. There are many types of Qi. Some represent functions as well as energy. For example, our Defensive Qi, (Zheng Qi) does battle with pathogens (Xie Qi). Our Prenatal Qi (affected by genetics and the prenatal environment) is sort of our potential vitality (Jing). Children with birth defects are said to be deficient in Prenatal Qi. Postnatal Qi is affected by diet and life experiences, and we can use it to supplement and fortify our vitality. Too much stress or a poor lifestyle will drain our Jing and lead to premature aging.

The most basic differentiation in Chinese Medicine is that of Yin and Yang. Yin is the darker, moister, interior, still, nourishing, more feminine half. Yang is light, dry, exterior, expanding, moving, and more masculine. As applied to anatomy, the front and lower parts of the body are Yin. The back and upper body are considered more Yang. On the lower limbs, medial is Yin (think interior) and the lateral aspects are Yang. This will be important later when we devise a treatment strategy.

Yin & Yang aspects of the body

Our Qi flows in a series of meridians, or channels. These are rivers of energy flow that travel along specific paths, and were mapped out 2000 years ago. Chinese anatomical position describes the arms as lifted straight up, so the body forms a symmetrical X. The Yang channels start high and travel downward: from fingertips to the head, and head to the toes. The Yin channels start below and rise, to carry nourishing energy upwards: they run from the toes up, and from the torso to the fingertips.

At some areas of the body, the Qi bubbles closer to the surface. In these places we can access the energy more easily. These are acupuncture points. Acupressure, simply pressing with a fingertip, is also effective at these spots. There are 365 points on the channels. Including auricular sites and extrachannel points, there are about 1000 altogether.

The 12 ordinary meridians are each linked with an energetic organ. These are the Heart, Pericardium, San Jiao, Small Intestine, Large Intestine, Lung, Kidney, Bladder, Liver, Gallbladder, Spleen, and Stomach. The organs are bundled into Yin/Yang pairs. The eight extraordinary meridians are not linked to organs. Instead, they treat on a more constitutional level. We’ll see later how these eight can be particularly useful in treating post-stroke spasticity.

The Chinese have ascribed energetic properties to the various organs. Each organ is tied to one of the five elements: Wood, Fire, Earth, Metal, and Water. The elements are associated in a complex series of cycles, so each can influence the others. The organs (and elements) are also linked to a sense, flavor, color, season, and emotion in addition to their physiological function. Some of these make obvious sense in terms of medical science, like the Heart being the master of Blood.

Other organs may seem stranger at first glance. The Liver, for example, is in charge of emotions and smooth Qi flow. Constant circulation of energy through the meridians is considered essential for health. When Liver dysfunction prevents proper energy flow, the condition is called Liver Qi Stagnation. Anger or irritation is a common side effect. This organ is linked with female reproductive health. If you think about a woman suffering from PMS, you can see that her Liver Qi isn’t moving effectively. Stagnation causes cramps, and her mood swings are legendary. This syncs with modern science if you think about the biological liver’s role in metabolizing estrogen and other hormones.

The liver’s partner is the Gallbladder. Interestingly, it is associated with decision-making and fear vs. boldness. Herein may lie the root of the phrase “Why, the GALL of that man!”

The San Jiao is analogous to the lymphatic system. It controls water and fluids throughout the body, and is important to immune function. It’s paired with the Pericardium, which protects the Heart, and controls chest and abdomen issues.

The Spleen is responsible for transforming energy from food into energy for the body, so it takes on the functions of the biological pancreas and small intestine. If the Spleen is not functioning well, it will produce Phlegm. This can be visible Phlegm – nasal discharge or coughing with sputum – or Invisible Phlegm, which manifests as mental illness or interference with cognitive processes. The Spleen’s partner is the Stomach, which is not substantially different from modern understanding of the stomach.

The Lung captures Qi from the air and is responsible for the skin system and border immunity. Its pair is the Large Intestine, which is most often used to clear heat from infection, to treat the face (where the channel ends), and to aid Qi movement in the upper body.

The Kidneys are considered the storehouse of our vitality (Jing). Our Kidney Qi declines as we age. Women in menopause are showing signs of Kidney Yin deficiency (hot flashes, vaginal dryness, etc.) while men exhibit Kidney Yang deficiency (impotence and urinary difficulties). The Bladder channel runs down the back and contains a series of points called the Shu points that address each of the organs.

Now that we have a simplified understanding of the Chinese organs, let’s examine how their dysfunction contributes to pathology. All CVAs are considered Wind-Strokes. There are four main differentiations for stroke: Liver Wind, Phlegm Fire, Blood Stasis, and Wind in the Channels.

The Liver is the Wood element. Inadequate rest, excess sexual activity, or emotional stress beleaguers Liver’s cooling Yin. When this happens, it cannot balance the Liver Yang. Now the Wood is “on fire”. Liver Yang energy will rise to the head and cause Wind, much like heat from a campfire causes an updraft. Many Chinese medical concepts are taken from observation of nature and the elements.

If a patient has worked too hard or maintained an irregular diet, the Spleen will suffer. Phlegm-Fire will congeal to cloud the brain, prevent speech, and numb the limbs.

If the Kidneys are overstressed, due to lack of rest or excessive sexual activity, they cannot nourish Marrow, which in turn cannot produce Blood. Much like a dried up river, a body with deficiency of Blood becomes a body with Blood stasis. This leads to stiffness and pain in the limbs.

A more generalized understanding of physical overwork and inadequate rest indicates weakness of all the channels. A lack of defenses means that external Wind (including environmental and microbial challenges) will penetrate and develop into internal Wind. Paralysis is a common result.

Strokes that affect consciousness or even create coma are considered to have attacked the organs (viscera) and channels, and are categorized as severe. A CVA that infiltrates only the channels (a mild Wind-stroke) will result only in unilateral paralysis, numbness, and slurred speech.

The appearance of the patient’s tongue is a valuable tool in TCM diagnostics. A purplish tongue, or distended veins on the inferior surface of the tongue, indicate blood stasis. A red tongue body indicates Fire. A stiff, deviated, or quivering tongue reveals Wind, while a sticky coating shows Phlegm. Weakness in any of the organs will show up in specific areas (Kidney at the root, Heart at the tip, etc.).

During the acute phase of the stroke, Western medical care is essential. Time lost is brain lost. TCM can’t compete with MRIs and thrombolytics, and we don’t want to! Once the patient is in a recovery phase, however, acupuncture gives excellent results in the treatment of hemiplegia and facial paralysis. Speed is key here, too. Treatment within one month is recommended. After six months, improvement will generally be slower and less substantial.

Treatment with acupuncture involves choosing points by two methods. We select points with an empirical history of treating Wind-Stroke. These include points known for Wind in general, points to aid muscular control, and points to clear stagnation and stasis. Our therapy plan should also address the channels affected by spasticity.

The eight Extraordinary channels are often used to treat deep constitutional problems. For example, Bl-62 (Master point of the Yang Qiao / Yang Moving Channel) treats muscular dysfunction impairing locomotion. This point is just inferior to the lateral malleolus. The Xi-cleft point of this same channel, ascribed with the ability to remove stagnation, is BL 59, on the lower lateral leg.

Let’s take an example of a male patient with his right forearm fixed in flexion. His arm is pressed against his side, and his hand is curled up against his chest. According to TCM diagnostics, he is afflicted with Wind in the channels. In this case, the channels affected are the Heart, Pericardium, and Lung. Each channel has a point called the Xi-cleft, which is used to dispel accumulated stagnation of Qi and Blood. These would be Lu-6, Pc-4, and Ht-6. These three points are all located on the anterior forearm. We can treat the Xi-cleft points on the affected arm, or on the opposite arm if the points are difficult to access. Wind points such as GB-20 (at the occiput), GV –20 (top of the head), GV-14 (spine, below C-7) would typically be used. LI-4 on the hand will move Qi and Blood through the upper body. St-40 on the lateral leg will disperse Phlegm.

Even within TCM, there are some differing methods of differentiation. Dr. Wu’s textbook separates “Yin Tension” from “Yang Tension” stroke, based on signs of heat or cold in the tongue and pulse. Let’s assume that our patient presents with a red tongue, slimy yellow tongue coat, and a rapid pulse. We would add LU-11, Ht-9, and PC-9. These are the points at the fingertips (extreme ends) of the affected channels.

Wong found that patients receiving electro-acupuncture left the hospital more quickly, with a significant difference in self-care and locomotion. Pei likewise found more improvement in general ADLs with acupuncture. The Swedish studies by Kjendahl found that acupuncture delivered greater improvement on a one-year follow-up.

The Gosman, Hedstrom and Johanssen studies published in Stroke found no significant differences in acupuncture vs. physical therapy in improving post- stroke ADLs, but they neglected to differentially diagnose the patients. Each received the same set of acupoints. This is a huge oversight: Specificity of treatment is essential for an effective result. Grouping everyone together is comparable to treating everyone with a runny nose with antibiotics, then concluding that medications are useless against rhinitis. Instead, we separate out the allergic, the virus-stricken, and the bacterially-infected. Chinese medicine deserves the same rigor of analysis. It’s also worth pointing out that the needles were inserted by physical therapists, not by acupuncturists. The quality of their point location and technique must be called into question.

In conclusion, post-stroke spasticity is a debilitating and frustrating hurdle for many CVA survivors. Modern Western medicine can stop nerve transmission, mute muscles, and retrain patients to help them gain control. Acupuncture can help the damaged nerves to heal, and return to normal function. If doctors and physical therapists work with acupuncturists, we can help our patients achieve a more complete recovery in a shorter period of time. Needles won’t interact with medications, so they are a great adjunct for our more elderly stroke survivors. I encourage you to reach out to Chinese practitioners and build partnerships. Ask questions. Take a look at the research I’ve quoted in my references. Refer some people, and see what happens. I look forward to working with you all!

Assessment of clinical trials

A) C. Werner, et al., Treadmill training with partial body weight support and an electromechanical gait trainer for restoration of gait in sub-acute stroke patients. Stroke, 2002; 33:2895.
1) Training: The people working with the patients were described as “physical therapists” but no additional information was given with regard to their education or experience.
2) Inclusion criteria: Non-ambulatory hemiparetic patients, 4 to 12 weeks after a first-time stroke, age less than 75, requiring firm continuous or intermittent support from at least 1 person to walk, must be able to sit unsupported at the edge of a bed and to stand for 10 seconds without assistance. Hip or knee extension deficit of less than 20 degrees, passive dorsiflexion of the ankle to a neutral position.
Exclusion criteria: Cardiac ischemia, arrhythmia, or decompensation. Resting systolic BP of 200 or more. Maximum heart rate exceeding 190 bpm minus the age of the patient. Severe impairment of cognition or communication.
3) The study was reported as randomized. Sealed envelopes were drawn to assign groups.
4) Demographics and clinical information at onset of the trial is provided and is successfully random.
5) Previous studies on post-stroke treadmill physical therapy were cited.
6) The speed and duration of the treadmill use was given in ranges only. “Physical
assistance […] was administered according to individual needs.” More detail
would be helpful in duplicating this experiment.
7) Assessment made use of the Functional Ambulatory Category (FAC), the RMA
score (gross functions and leg and trunk section), and the modified Ashworth score
testing for ankle dorsiflexion, and mean gait velocity.
8) Outcome measures were assessed by independent raters who were not involved in the therapy, and who were blind to the patient’s grouping. Interrater reliability
scores were provided.
9) Patients were aware of their grouping.
10) Six-month follow-up phone calls were placed and data was gathered on the
persistence of improvement.

B) Effects of Acupuncture Treatment on Daily Life Activities and Quality of Life A Controlled, Prospective, and Randomized Study of Acute Stroke Patients, Gosman,- Hedstrom, et al. Stroke. 1998; 29:2100-2108
1) Acupuncture was performed by 4 physiotherapists (PTs), trained together to give the same information and to use the same techniques. They were not described as having any previous acupuncture experience.
2) Inclusion criteria: Patients 40 years with an acute focal ischemic nonhemorrhagic lesion were invited to take part in the study. The stroke onset had to be less than 1 week before the randomization. Exclusion criteria: These criteria included other severe disease necessitating hospital or nursing home care; severe aphasia or unconsciousness; an earlier cerebral lesion, with a documented need of care; and treatment with a cardiac pacemaker.
3) The study was reported as randomized. Computers were used to assign groups. 4) Demographics and clinical information at onset of the trial is provided and is
successfully random.
5) No explanation was given for the points chosen.
6) The locations, stimulation, and retention of acupuncture needles were all described.
7) Assessment made use of the Barthel Index and Sunnaas Index of ADL. The NHP questionnaire, a self-instructive instrument, was given to the patient and collected on the assessment occasion by the occupational therapist.
8) Two occupational therapists (OTs), who were blinded to patient allocation after
randomization, evaluated the treatment effects on ADL, health-related quality of
life, and use of health care and social services.
9) Patients were aware of whether they received acupuncture or not. No information is available regarding the patients’ knowledge of multiple groups.
10) The assessments were performed 4 times during the first year: 3 days after
randomization and at 3 weeks, 3 months, and 12 months. The assessments were done by means of interviews and observations at the hospitals, nursing homes, and/or in the patients’ homes.

C) Acupuncture and Transcutaneous Nerve Stimulation in Stroke Rehabilitation, Barbro B. Johansson, MD, Stroke. 2001; 32: 707-713.
1) Training: “[T]he therapists received training that ensured uniformity in the treatment procedures between centers. Each therapist performed all 3 treatment modalities.” Obviously the therapists were not trained acupuncturists.
2) Inclusion criteria: Patients of all ages and both sexes were eligible if they had had an acute stroke between 5 and 10 days before randomization. Only patients with moderate or severe functional impairment at randomization were included. This was defined as a Barthel ADL Index 21 of 70 points in combination with inability to perform the Nine Hole Peg test 22 within 60 seconds (impaired fine motor function of the hand) or inability to walk 10 meters without mechanical or personal support.
Exclusion criteria: If the stroke was a recurrent one, the patient could not have been functionally impaired before the present event. Exclusion criteria were (a) previous neurological, psychiatric, or other disorder making it difficult to pursue the treatment or evaluations, (b) inability to comprehend information about the trial, (c) concurrent participation in another trial of interventions supposed to affect long-term neurological and functional outcome, and (d) failure to obtain informed consent.
3) With the use of closed envelopes and stratified by center, eligible patients were randomized in blocks.
4) At baseline, patients in each group were closely similar in all important prognostic variables. Table provided.
5) No explanation for the points chosen were given.
6) Needling technique was adequately described.
7) ADL function was assessed by the Barthel Index, 21 overall motor function by the Rivermead Mobility Index, 23 fine motor function by the Nine Hole Peg Test, 22 walking ability by the time needed to walk 10 meters (with or without mechanical support), and quality of life by the Nottingham Health Profile.
8) An independent observer unaware of the group to which the patient had been assigned performed all investigations and recordings except monitoring of adverse reactions during treatment. Patients and observers were instructed not to discuss the treatment sessions.
9) Patients were aware of whether they received acupuncture or not. No mention was made of the level of awareness re: multiple groups.
10) Follow-ups were conducted at 3 and 12 months.

References: 1) http://www.strokeassociation.org : The web site of the American Stroke Association.
2) Bakheit, A. MD, et al. A Randomized, Double-Blind, Placebo-Controlled, Dose-Ranging Study to Compare the Efficacy and Safety of Three Doses of Botulinum Toxin Type A (Dysport) With Placebo in Upper Limb Spasticity After Stroke, Stroke. 2000;31:2402-2406.
3) Brashear, Allison M.D. Intramuscular injection of botulinum toxin for the treatment of wrist and finger spasticity after a stroke. N Engl J Med 2002 Aug 8;347(6):395-400
4) Brown, D.A. PhD, PT; S.A. Kautz, PhD. Increased Workload Enhances Force Output During Pedaling Exercise in Persons With Poststroke Hemiplegia. Stroke. 1998;29:598-606
5) Gelber, David A. MD et al, Open-Label Dose-Titration Safety and Efficacy Study of Tizanidine Hydrochloride in the Treatment of Spasticity Associated With Chronic Stroke. Stroke. 2001; 32: 1841-1846.
6) Gosman,-Hedstrom, et al. Effects of Acupuncture Treatment on Daily Life Activities and Quality of Life A Controlled, Prospective, and Randomized Study of Acute Stroke PatientsStroke. 1998; 29:2100-2108
7) Hesse, S. et al. Ankle Muscle Activity Before and After Botulinum Toxin Therapy for Lower Limb Extensor Spasticity in Chronic Hemiparetic Patients S. From the Klinik Berlin, Department of Neurological Rehabilitation, Free University Berlin (Germany) (S.H., D.L., M.T.J., K.H.M.), and the Rehabilitation Institute, Ljubljana, Slovenia (J.K., M.G.). Correspondence to Stefan Hesse, MD, Klinik Berlin, Kladower Damm 223, 14089 Berlin, Germany.
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