Post-Stroke Rehabilitation & Prevention
The TCM Approach to Stroke Rehabilitation
The occurrence of stroke was first recorded in the Nei Jing, a Chinese medical text, more than 2,000 years ago. For thousands of years, acupuncture and Chinese herbs have been used to treat the resulting dysfunction after stroke, including neurological deficits, cognitive impairments, hemiplegia, swallowing function and motor impairment. In modern China the use of acupuncture is well accepted for post-stroke rehabilitation as part of a comprehensive strategy used in conjunction with conventional stroke rehabilitation care.
In order to understand how Traditional Chinese Medicine (TCM) can help to improve outcome for stroke rehabilitation, it is useful to understand the basic principles and pathogenic factors in terms of Chinese medical theory. Conditions that are likely to produce a stroke are often a complex combination of Phlegm, internal Wind, and Heat. There is also likely to be underlying patterns of Qi, Blood and/or Yin Deficiency. Hemiplegia is often seen in the sequelae stage of Wind-Stroke, caused by retention of Liver-Wind and Phlegm in the channels. Blood stasis can also develop leading to rigidity and pain in addition to paralysis (Maciocia, 2004).
Acupuncture is seen to aid in post-stroke recovery by dilating blood vessels and helping the blood to flow, as well as by decreasing clotting and inflammation. Treatment with TCM is recommended within the first 6 months to aid in a more successful recovery for paralysis, numbness and speech disability.
In a study called Additional Effects of Acupuncture on Early Comprehensive Rehabilitation in Patients with Mild to Moderate Acute Ischemic Stroke: A Multicenter Randomized Controlled Trial (Chen et al, 2016), results indicated a significant difference (p<0.001) in NIHSS score (National Institutes of Health Stroke Scale) when measuring neurologic deficit improvements between the acupuncture group, which received both acupuncture and conventional stroke therapy, and the control group, which received conventional stroke therapy only. The NIHSS score is a strong indicator of good functional recovery in the long-term. Lower extremity, swallowing and cognitive functions also showed positive statistically significant changes in the acupuncture group, demonstrating strong evidence for post-stroke rehabilitation using acupuncture compared with conventional rehabilitation alone.
Using TCM Preventatively for Stroke
According to the Centers for Disease Control and Prevention (CDC), high blood pressure, high cholesterol, smoking, obesity and diabetes are the leading causes of stroke in the US. The National Stroke Association states that up to 80% of strokes are preventable, and this is an area where Chinese medicine can really shine and be used effectively. Although Chinese medicine has been shown to be effective in treating both acute stroke and long-term rehabilitation, the beauty of Chinese medicine is its ability to be used to prevent those conditions from occurring in the first place.
Chinese medicine practitioners are in a unique position to quickly identify pathogenic factors and conditions that could possibly lead to stroke, should they exist in a patient. As part of an acupuncture treatment, an extensively trained licensed acupuncturist will inquire about key symptoms and systems to identify imbalances within the body and arrive at an underlying TCM diagnosis. Once a diagnosis is derived, a treatment plan is implemented to address stagnation, remove obstruction, support any deficiencies and sedate any excess conditions. In addition to acupuncture, Chinese herbs are often used in conjunction to help support, strengthen and prolong the treatment plan.
Rather than focusing on a specific symptom, Chinese medicine excels by taking a holistic view of the body and addressing the underlying pathological factors that may lead to the manifestation of various symptoms. By using a macro lens to examine the complex interaction of organ systems, channel meridians and pathological substances both substantial (seen) and insubstantial (unseen), Chinese medicine can treat many seemingly unrelated conditions by identifying and correcting the root cause.
A Case Report
As a case in point, an 80 year old male patient presented in my office complaining of severe tinnitus for over one year. He described an intermittent ringing in the ears that changed in pitch from low to high, with a frequent change in quality that was described to sound like loud sirens, buzzing noises, and often a loud “wind” that sounded like a “tornado was inside his head.” The sounds were reported to significantly affect his quality of life resulting in sleep disturbances, fatigue, irritability and depression. In addition, a review of systems revealed recurrent epistaxis and frequent headaches, dizziness, the sensation of heat in his head, and bilateral hearing loss. He had also been diagnosed with hypertension and diabetes mellitus type 2 for over 15 years.
Tinnitus is a subjective sensation of hearing a sound in the absence of an external stimulus, and is a common condition that affects 5-15% of the population. Little is known about the etiology of this condition. Proposed theories range from otologic, dental, neurological, psychiatric diseases, cervical spine and metabolic disorders, or related to drug intake. Because the physiopathological mechanism is not known, can vary widely and may involve a complex interaction of systems, surgical options or pharmacological drug therapy have proven unsuccessful and the treatment of tinnitus to date has been a challenge with no known effective treatment (Doi, Tano, Schultz, Borges, & Marchiori, 2016).
After evaluating all of this patient’s symptoms and assessing from a TCM perspective, it was determined that his condition was caused by a complex combination of diagnoses including long term Liver and Kidney Yin deficiency along with a combination of Wind, Liver Fire and Phlegm flaring upwards. In Chinese medicine, the aging process depletes Liver and Kidney Yin, eventually resulting in excess heat drying up the fluids, including those of the auditory canals. Long term deficiency heat can transform into Liver Fire with Wind manifesting in the channels due to the depletion of fluids. For the patient, this excess heat can be seen with his recurrent epistaxis and the Wind rising is evident not only with his frequent headaches and dizziness, but with the patient’s own subjective description of hearing wind in his head. The diabetes mellitus presents in this patient with a corresponding Chinese medical diagnosis of Stomach Yin deficiency, which has contributed to the accumulation of Phlegm rising to combine with all other factors aforementioned to further create an imbalance that has resulted in the manifestation of severe tinnitus for this patient.
After 3 months of acupuncture and herbal medicine, the patient reported that the intensity of his tinnitus was significantly reduced from 9 to 4, out of 10. He reports that his sleep is no longer disrupted, and that the level of subjective noise is at a much more tolerable level. He also reported that the headaches, dizziness and sensation of heat in his head had subsided and were not nearly as frequent. With continued treatment, I believe there to be a favorable prognosis for recovery and management.
How is this related to stroke?
The underlying TCM diagnoses of Liver and Kidney Yin deficiency, Wind, Liver Fire and Phlegm which led to the manifestation of severe tinnitus in this patient are also the common pathogenic factors that can lead to stroke. Head symptoms such as headaches and dizziness are especially important in the elderly when accompanied by hypertension and tinnitus, as it may indicate a symptom of Liver-Wind, Phlegm or both. These symptoms are considered to be prodromal signs of Wind-Stroke (Maciocia, 2004).
By assessing this patient with a holistic, macroscopic view and aiming to correct imbalances within the body as a whole rather than focusing microscopically on the auditory system, Chinese medicine was used in this case to effectively treat a condition that otherwise has no known solution. TCM seeks to identify and treat the root cause of symptoms rather than solely treating the symptom itself, and recognizes that the same pathological states within different people can lead to the manifestation of different symptoms, whether it be tinnitus or stroke.
For this patient with severe tinnitus, all of the necessary components were present to progress to stroke. By recognizing the common pathogenic factors and correcting the imbalance before it worsens and progresses, a Chinese medicine practitioner is in a unique position to be able to identify key symptoms that may seemingly be unrelated to stroke, but are in fact caused by the same pathogenic factors according to Chinese medical theory. By catching and treating it in its earlier stages and changing the internal conditions that may lead to stroke, it may be possible to prevent its occurrence.
Stoke is the 5th leading cause of death in the US and there are 7 million stroke survivors in the US only (National Stroke Association, n.d.). The Centers for Disease Control and Prevention (CDC) states that “stroke is a leading cause of serious long-term disability,” and the associated costs including health care services, medication and missed days of work are an estimated $34 billion in the US alone.
Chinese medicine is a safe and effective solution that must be considered not only for prevention and post-stroke rehabilitation, but as an integrative healthcare solution that reduces cost in an increasingly unaffordable healthcare system.
Dr. Erin Lee, DACM, L.Ac. is a doctor of Acupuncture & Chinese Medicine, licensed acupuncturist and board certified Chinese herbalist. She obtained her Doctoral degree and Master of Science degree in Traditional Oriental Medicine from the Pacific College of Oriental Medicine in New York. Previous experience includes working with cancer patients at Mount Sinai Beth Israel Integrative Oncology Center, acute stroke and long-term rehabilitative care at NYU Lutheran Neurological & Orthopedic Rehabilitation, Housing Works (HIV/AIDS), Columbia Health Medical Center and Bronx Lebanon Hospital Center. She resides and practices in New York City.
Chen, L., Fang, J., Ma, R., Gu, X., Li, J., & Xu, S. (2016, July 18). Additional effects of acupuncture on early comprehensive rehabilitation in patients with mild to moderate acute ischemic stroke: A multicenter randomized controlled trial. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27430340
Doi, M. Y., Tano, S. S., Schultz, A. R., Borges, R., & Marchiori, L. L. (2016, April 30). Effectiveness of acupuncture therapy as treatment for tinnitus: A randomized controlled trial. Retrieved from https://www.sciencedirect.com/science/article/pii/S1808869416300660?via=ihub
Maciocia, G. (2004). Diagnosis in Chinese medicine: A comprehensive guide. Edinburgh: Churchill Livingstone.
Stroke facts. (2015, April 06). Retrieved from https://www.stroke.org/understand-stroke/what-stroke/stroke-facts
Stroke. (2017, September 06). Retrieved from https://www.cdc.gov/stroke/facts.htm