Based on the latest CDC statistics, more than 795,000 Americans have strokes per year, 140,000 of which are lethal. Approximately 87 percent of all strokes are ischemic with an estimated health care and missed work cost of $34 billion annually.¹ Stroke is the leading cause of serious long-term disability.

Stroke deaths aren't randomly distributed throughout the country — the majority occur in the southeast (map below).

As practitioners, we do our absolute best for our patients' well-being. Here are some evidence-based recommendations beyond "standard" physical therapy and the common body/auricular/scalp acupuncture, blood-letting, herbs and moxibustion approaches we've learned in school.

Adjunctive Therapies within our scope of practice

Plum Blossom Needling

A study published in 2016 evaluated 60 patients with ataxia, half receiving plum blossom needling along the huatojiaji points in addition to conventional rehabilitation in the observation group, and 30 patients receiving conventional rehabilitation as the control group.

After four weeks of treatment, the total effective rate was found to be 96.7 percent in the observation group, which is quite impressive.² In a 2015 study with 80 stroke patients suffering from muscle spasticity, acupuncturists tapped acupoints Jianyu (LI 15), Jianliao (LI 14), Jianzhen (SI 9), Hegu (LI 4), Chengfu (BL 36), Zusanli (ST 36), Xiyangguan (GB 33) for a total of 15 minutes a day with a plum blossom needle in addition to Bobath (a neurodevelopmental physical therapy technique) for eight weeks.

The researchers' conclusion was "The tapping therapy with plum blossom needle at the key points combined with Bobath therapy effectively relieves hemiplegic spasticity in the patients of cerebral infarction and improves the motor function of extremity and the activity of daily life."³ Don't underestimate the power of plum blossom needling.

Essential Oils

Alpinia zerumbet has a muscle relaxant and antispasmotic effect on both cardiac and smooth muscles. A study published in 2016 evaluated its effect on skeletal muscle contraction in post-stroke spasticity, and found topical application of alpinia zerumbet as an appropriate adjunctive therapy for patients with cerebral vascular disease.⁴  An additional benefit of topically applied lotions and oils is that there's no adverse events beyond potential skin reactions.

Mirror Therapy

This is an excellent (and inexpensive) way to improve motor function in a stroke patient. Vilayanur Ramachandran, a neuroscientist, considered the grandfather of mirror therapy, developed this technique to reduce phantom limb pain in amputees.

A 2018 systematic review and meta-analysis on mirror therapy's effect on gait, balance, and lower limb function demonstrated that it is a promising adjunctive therapy for patients with leg weakness.⁵ A small study evaluating hands in hemiplegic stroke patients showed meaningful improvement in motor function and coordination following mirror therapy.⁶

There are a number of YouTube videos that explain precisely how to make the folding mirror and exercises for your patient to perform with the mirror. Having the patient supply Kidney energy in their recovery naturally leads to greater results. Jeff Nagel, an expert in the Taoist naturalist school is known to say, "That which one does for oneself  (active effort) is far more powerful than that which is done for that person," (passive effort).

Both tai chi and qigong are preventive self-cultivation practices, and are reflected as such in the scientific literature. A 2017 systematic review with meta-analysis⁷ evaluated 21 trials including 1,604 patients and found significant benefits of tai chi/qigong over no interventions for hypertension, fasting blood glucose, and body mass index (compared with exercise controls).

The authors concluded that, "Although Tai Chi and qigong show some potential, more robust studies are required to provide conclusive evidence on the efficacy and safety of Tai Chi and qigong for reducing major stroke risk factors." Both tai chi and qigong also reduce risk of falls in the geriatric population, so it's appropriate to recommend to all of our middle age and senior patient communities.

Other Adjunctive Therapies Appropriate for Referral

Hyperbaric Oxygen Therapy

A hyperbaric chamber conjures up an image of the "bends" (aka "decompression sickness") where deep-sea divers swim to the surface too quickly, causing nitrogen bubbles in their blood and tissues. Hyperbaric oxygen therapy applies 100 percent oxygen at two to three times the atmospheric pressure at sea level using a tight fitting hood or chamber.

The FDA has cleared hyperbaric oxygen therapy (HBOT) for 14 conditions (see below), stroke notably absent from the list. However, the list of indications hasn't been updated in seven years, and recent research is favorable for stroke rehabilitation. Some clinics offering HBOT will use it "off label," and treat stroke patients. HBOT is one of the few therapies that can provide significant improvement years after the stroke.

Conditions Approved by the FDA for Hyper-baric Oxygen Therapy

1. Air or gas embolism
2. Carbon monoxide (CO) poisoning, CO poisoning complicated by cyanide poisoning (neurological)
3. Clostridial myositis and myonecrosis (gas gangrene)
4. Crush injury, compartment syndrome, and other acute traumatic ischemias
5. Decompression sickness (neurological)
6. Arterial Insufficiency: Enhancement of healing in selected problem wounds (includes uses like diabetic foot wounds, hypoxic wounds, and other non-healing wounds, etc.)
7. Exceptional blood loss anemia
8. Intracranial abscess (neurological)
9. Necrotizing soft tissue infections
10. Osteomyelitis (refractory)
11. Radiation tissue damage (soft tissue and bony necrosis)
12. Skin grafts and flaps (compromised)
13. Thermal burns
14. Idiopathic sudden sensorineural hearing loss

A 2005 literature review on HBOT treatment of ischemic stroke concluded that the overall quality of the studies were poor with too many variations (length of exposure time, chamber pressurization, number of treatments, stroke severity, etc.) thus, generalizing the results is limited.⁸ A study published in 2013, however, showed very favorable results for post-stroke patients who had at least one motor dysfunction within 6-36 months of their stroke.⁹

Researchers found that the neurological functions and quality of life of patients were improved, and the SPECT scans correlated well with clinical improvement. They emphasized that HBOT can lead to positive improvements even at chronic late stages of dysfunction and that neuroplasticity can still be activated long after the initial brain damage.

The two major drawbacks to using HBOT to improve stroke recovery is that (1) it's not uncommon to have 20 to 40 sessions, and (2) because it's considered an "off-label," application, there's no insurance coverage at this time. A potential adverse effect of HBOT is middle ear barotrama, which if left untreated, can lead to edema of the middle ear, and in rare cases, rupture of the tympanic membrane with conductive hearing deficit.

Repetitive Transcranial Magnetic Stimulation

Repetitive Transcranial Magnetic Stimulation (rTMS) has been around since 1985. It's a way of activating certain areas of the brain non-invasively and is fantastic for post traumatic stress disorder (PTSD), traumatic brain injury (TBI), post concussion syndrome, depression, chronic insomnia, and autism. Still in its infancy for the treatment of stroke, a very recent study published in "Brain Science" demonstrated improvement in motor function of chronic stroke patients (average 3.2 years since stroke event).¹⁰

Another study demonstrated that rTMS was effective (in addition to sensory cueing) for improving hemi-spatial attention deficits related to unilateral neglect in stroke patients.¹¹  rTMS may be more widely available in metropolitan areas. Also, be aware that it typically requires daily treatment for two or more weeks for positive response rates, so commute time can play an important part in patient compliance for those living in rural areas.

Neurofeedback

Neurofeedback (NFB) is similar to biofeedback except instead of a simple beep, it uses real-time displays of brain activity to assist in self-regulation of brain function, usually in the form of a simple video game (that you control with your mind). It has been studied to treat brain damage due to stroke, pain, addiction, aggression, anxiety, autism, depression, schizophrenia, insomnia, epilepsy, trauma, and Tourette syndrome.

In a 2017 systematic review, 12 of the authors concluded that, "neurofeedback training can lead to a learned modulation of brain signals, with associated changes at both the neural and the behavioural level. However, more research is needed to establish how its use can be optimized in the context of stroke rehabilitation."

Stem Cell Therapy

There are a number of stem cell therapies applied to humans and stroke models (in vivo/mice/rats, etc.) that are known to improve blood brain barrier integrity, behavioral deficits and reduce the incidence of hemorrhage offering a promising future for thrombolytic ischemic stroke patients, however, stem cell approaches are still in their infancy.

Small studies on humans using Mesenchymal stem cell (MSC) transplantation have produced encouraging results¹³ but the jury is still out on stem cell therapies. On the bright side, electroacupuncture has been found to stimulate MSC production,¹⁴ without concerns of infection compared to employing a more invasive procedure.

Chiropractic/Spinal Manipulation

Similar to acupuncture, chiropractic manipulation can treat a broad variety of health conditions. In a 2016 study15 published in the journal "Brain Science," New Zealand researchers evaluated the effect of spinal manipulation of post stroke patients on upper and lower limb muscles.

They found that spinal manipulation resulted in a 54.5 percent ± 93.1 percent increase in maximum motor evoked potential (MEPmax) in a thumb abductor muscle and a 44.6 percent ± 69.6 percent increase in MEPmax for the tibialis anterior muscle, recommending chiropractic for patients who have lost tonus in their muscles due to a stroke or orthopedic surgical procedures.

Hopefully this overview has provided you some additional tools in your clinical toolbox for stroke patients. As you work with local practitioners who offer neurofeedback, hyperbaric oxygen and transcranial magnetic stimulation, you'll build professional relationships as well serving your patients more effectively.

References

1. Benjamin E, Blaha M, et al. on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2017 update: a report from the American Heart Association. Circulation. 135:e229-e445. 2017
2. Zhang L, Wang F, et al. Plum-blossom needle tapping at Jiaji(EX B 2) combined with rehabilitation for ataxia of cerebellar apoplexy: a randomized controlled trial. Zhongguo Zhen Jiu, 2016; 36(2):131-4.
3. Wang F, Zhang L, et al. Efficacy on hemiplegic spasticity treated with plum blossom needle tapping therapy at the key points and Bobath therapy: a randomized controlled trial. Zhongguo Zhen Jiu, 2015;35(8):781-4.
4. Maia M, Dantas C, et al. The Effect of Alpinia zerumbet Essential Oil on Post Stroke Muscle Spasticity. Basic Clin Pharmacol Toxicol, 2016;118: 58-62.
5. Broderick P, Horgan F et al.  Mirror therapy for improving lower limb motor function and mobility after stroke: A systematic review and meta-analysis. Gait Posture, 2018;12;63:208-220.
6. Bondoc A, Booth J, et al. Mirror Therapy and Task-Oriented Training for People With a Paretic Upper Extremity. Am J Occup Ther, 2018;72(2):7202205080p1-7202205080p8.
7. Lauche R, et al. "Efficacy of Tai Chi and Qigong for the Prevention of Stroke and Stroke Risk Factors: A Systematic Review with Meta-Analysis." Ed. Yung-Hsiang Chen. Medicine, 2017; 96.45:e8517.
8. Carson S, McDonagh M, et al. Hyperbaric oxygen therapy for stroke: a systematic review of the evidence. Clinical Rehabilitation, 2005;19(8):819–833.
9. Efrati S, Fishlev G, et al. Hyperbaric Oxygen Induces Late Neuroplasticity in Post Stroke Patients - Randomized, Prospective Trial. Minnerup J, ed. PLoS ONE, 2013;8(1):e53716.
10. da Silva R, de Souza A, et al. Effects of Excitatory Repetitive Transcranial Magnetic Stimulation of the P3 Point in Chronic Stroke Patients—Case Reports. Brain Sci, 2018;(8)78.
11. Zhang R, Liu S, et al. Treatment of Unilateral Neglect using Repetitive Transcranial Magnetic Stimulation (rTMS) and Sensory Cueing (SC) in Stroke Patients. Sichuan Da Xue Xue Bao Yi Xue Ban, 2017;48(2):309-313.
12. Wang T, Mantini D, Gillebert CR. The potential of real-time fMRI neurofeedback for stroke rehabilitation: a systematic review. Cortex, 2017.
13. Bang O, Lee J, et al. Autologous mesenchymal stem cell transplantation in stroke patients. Ann Neurol, 2005;57: 874-882.
14. Salazar T, et al. "Electroacupuncture Promotes CNS-Dependent Release of Mesenchymal Stem Cells." Stem cells (Dayton, Ohio), 2017 35.5:1303–1315.
15. Haavik H, et al. "Impact of Spinal Manipulation on Cortical Drive to Upper and Lower Limb Muscles." Ed. Bernadette Murphy. Brain Sciences, 2017; 7.1:2.