Acupuncture for functional recovery after stroke: a systematic review of sham-controlled randomized clinical trials

Background

Acupuncture is frequently advocated as an adjunct treatment during stroke rehabilitation. The aim of this review was to assess its effectiveness in this setting.

Methods

We searched 25 databases and 12 major Korean traditional medicine journals from their inception to October 2009. We included randomized controlled trials, with no language restrictions, that compared the effects of acupuncture (with or without electrical stimulation) with sham acupuncture. We assessed the methodologic quality of the trials using the Cochrane risk-of-bias criteria and the PEDro (Physiotherapy Evidence Database) scale.

Results

Ten of 664 potentially relevant studies met our inclusion criteria. For acute and subacute stages after stroke, we included seven trials. A meta-analysis of the five studies that assessed functionality did not show a significant difference in favour of acupuncture, with high heterogeneity. A post-hoc sensitivity analysis of three 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 (n = 244; standard mean difference 0.07, 95% confidence interval CI] −0.18 to 0.32; I² = 0%) or after follow-up (n = 244; standard mean difference 0.10, 95% CI −0.15 to 0.35; I² = 0%). For the chronic stage after stroke, three trials tested effects of acupuncture on function according to the Modified Ashworth Scale; all failed to show favourable effects.

Interpretation

Our meta-analyses of data from rigorous randomized sham-controlled trials did not show a positive effect of acupuncture as a treatment for functional recovery after stroke.Acupuncture is often used as an adjunct to mainstream rehabilitation after stroke. It involves the insertion of an acupuncture needle into the skin at certain points of the body. Acupuncture is claimed to be effective for a wide range of conditions, such as pain, musculoskeletal disorders and several neurologic diseases.¹ Possible mechanisms of its effects on neurologic conditions include stimulation of neuronal cell proliferation,² facilitation of neural plasticity,³ reduction of the post-ischemic inflammatory reaction⁴ and prevention of neuronal apoptosis.⁵Before acupuncture can be recommended for routine use, we require evidence from rigorous randomized clinical trials. In acupuncture trials, it is difficult to allow blinding of the treatment allocation.⁶ A placebo must be indistinguishable from the real treatment and inert.⁶ “Sham” is used to describe any control procedure that is used to blind treatment allocation in clinical trials of acupuncture.⁶ Several sham procedures are now available, such as the use of penetrating acupuncture on nonacupuncture points, superficial puncture of the skin on acupuncture points and nonpenetration on acupuncture points with sham needle devices.⁶Several reviews assessing the effects of acupuncture for stroke have been published. However, some did not include all of the relevant articles published in Asian countries; others included interventions other than acupuncture; and several were not systematic. We conducted a systematic review to critically evaluate all of the currently available randomized sham-controlled trials of acupuncture as an adjunct to mainstream stroke rehabilitation.