Impact of task-oriented training based on acupuncture rehabilitation on upper extremity function and quality of life of patients with early stroke

Abstract

BACKGROUND

Eighty percent of stroke patients develop upper limb dysfunction, especially hand dysfunction, which has a very slow recovery, resulting in economic burden to families and society.

AIM

To investigate the impact of task-oriented training based on acupuncture therapy on upper extremity function in patients with early stroke.

METHODS

Patients with early stroke hemiplegia who visited our hospital between January 2021 and October 2022 were divided into a control group and an observation group, each with 50 cases. The control group underwent head acupuncture plus routine upper limb rehabilitation training (acupuncture therapy). In addition to acupuncture and rehabilitation, the observation group underwent upper limb task-oriented training (30 min). Each group underwent treatment 5 d/wk for 4 wk. Upper extremity function was assessed in both groups using the Fugl-Meyer Assessment-Upper Extremity (FMA-UE), Wolf Motor Function Rating Scale (WMFT), modified Barthel Index (MBI), and Canadian Occupational Performance Measure (COPM). Quality of life was evaluated using the Short-Form 36-Item Health Survey (SF-36). Clinical efficacy of the interventions was also evaluated.

RESULTS

Before intervention, no significant differences were observed in the FMA-UE, MBI, and WMFT scores between the two groups (P > 0.05). After intervention, the FMA-UE, WMFT, MBI, COPM-Functional Mobility and Satisfaction, and SF-36 scores increased in both groups (P < 0.05), with even higher scores in the observation group (P < 0.05). The observation group also obtained a higher total effective rate than the control group (P < 0.05).

CONCLUSION

Task-oriented training based on acupuncture rehabilitation significantly enhanced upper extremity mobility, quality of life, and clinical efficacy in patients with early stroke.

Key Words: Stroke, Acupuncture rehabilitation, Task-oriented training, Upper extremity training

Core Tip: Stroke is a debilitating disease associated with high morbidity, mortality, and disability. Eighty percent of patients develop upper limb dysfunction. Effective treatment of upper limb function in patients with early stroke will help reduce the medical and economic burden on families and society. This study compared routine upper limb rehabilitation training alone vs routine upper limb rehabilitation training plus upper limb task-oriented training in terms of upper limb function (assessed using the Fugl–Meyer Assessment-Upper Extremity, Wolf Motor Function Rating Scale, modified Barthel Index, and Canadian Occupational Performance Measure Functional Mobility and Satisfaction), quality of life (Short-Form 36 Item Health Survey), and clinical efficacy. The results confirm that task-oriented training based on acupuncture–rehabilitation resulted in superior improvements on the three assessments.

INTRODUCTION

Stroke, including ischemic and hemorrhagic stroke, is an acute cerebrovascular disease and one of the most fatal conditions characterized by high morbidity, mortality, and disability. In China, approximately 2 million new patients suffer a stroke every year. The mortality rate of stroke has been declining with medical technological advancements and developments in the medical system. The disability rate from stroke has increased. Approximately 80% of patients with stroke have upper extremity dysfunction, especially hand dysfunction, the recovery from which is very slow, thereby directly delaying the integration of patients into the family and society, and imposing a huge social and economic burden. Many treatment methods have been proposed for post-stroke upper extremity dysfunction. One of which is task-oriented training, a training mode based on motor control and learning that can be used in acute, subacute, and chronic stroke and has been recommended by a high level of evidence in stroke treatment guidelines in the United States and Canada[1,2]. The Kang method of acupuncture[3] combines head point acupuncture and modern rehabilitation technology to perform various rehabilitation training exercises during the extensive duration of head point acupuncture. This study investigated the effects of task-oriented training based on the Kang acupuncture method on upper extremity movement and hand function in early stroke patients, and provided a clinical basis for enhancing the effect of rehabilitation training.

MATERIALS AND METHODS

General information

This study selected 100 patients with stable vital signs at the acute stage of stroke and no progression within 48 h who were hospitalized at the Department of Neurology of Jixi Jimine Hospital between January 2021 and October 2022. The inclusion criteria were the following: meeting the diagnostic criteria for stroke proposed in the 2019 Diagnostic Points of Various Major Cerebrovascular Diseases in China[4]: First onset; the lesion site was confirmed by head computed tomography or magnetic resonance imaging; stable condition, including vital signs, and no progression in signs and symptoms; Mental State Examination Scale score ≥ 24 points; National Institutes of Health Stroke Scale ≥ 10 points; Brunnstrom stage III or above; no hearing comprehension disorder; and ability to cooperate with treatment. The exclusion criteria were as follows: Severe cardio-renal, respiratory, and other internal diseases; bad general condition, such as malignancy; speech, hearing, and other disabilities; mental illness; and inability to cooperate with rehabilitation treatment due to previous skeletal and muscular lesions. The patients included underwent either routine acupuncture treatment (control group, n = 50) or task-oriented acupuncture treatment (observation group, n = 50). No significant inter-group differences in general data were observed between the two groups (P > 0.05; Table 1).

Table 1 Comparison of general information.

Group	Case	Sex (male/female)	Age (yr)	Course of illness (d)	Hemiplegic side: Left right	Lesion nature (cade): Cerebral infarction cerebral hemorrhage
Control group	50	31/19	61.10 ± 8.65	6.16 ± 1.68	29 21	32 18
Observation group	5	30/20	61.28 ± 9.72	6.42 ± 2.03	26 24	30 20

Methods

All patients were treated with conventional neurological drugs for stroke and were divided into two groups with different upper extremity rehabilitation treatment plans.

Control group

The patients underwent conventional acupuncture therapy. Upper extremity functional rehabilitation training included: (1) Good limb placement, Bobath technology, Rood technology, proprioceptive neuromuscular facilitation technology, upper extremity joint motion training, muscle strength training, dressing, washing, toilet training, and other routine activities of daily life[5]. The patients were rehabilitated for 30 min per session at 5 sessions per week for 4 wk; (2) Functional electrical stimulation therapy. Over 4 wk of treatment (5 sessions a week), patients were rehabilitated for 20 min per session; and (3) Acupuncture treatment: at the same time as rehabilitation training, head point cluster acupuncture and long-stay acupuncture method were performed. Method of point selection: The head needle was based on Yu’s method of head acupoint partitioning. The main acupoint was selected from the top and top front areas, and the matching acupoint was increased or decreased according to clinical symptoms.

Operation method: The patient was asked to sit. The doctor then selected a 0.30 mm × 40 mm Zhongyan Tahe acupuncture needle, used an alcohol swab to perform routine disinfection on the skin of the points on the head, and pierced 3–5 needles in the two identified areas, with the tip of the needle at a 30° angle, at a depth of 10–15 mm, until the needles reached the subcap aponeurosis. The needle retention time was 6–8 h. Acupuncture was also performed once daily, 5 d a week over 4 wk of treatment. Upper body acupuncture: The patient was asked to take the supine position. The Jianyu, Quchi, Hand Sanli, Waiguan, Hegu, Wailaogong, and Zhongzhu points were selected as the main points. Points were added or removed to match the disease. After routine disinfection at local acupoints with alcohol swabs, 0.30 mm × 40 mm Zhongyan Taihe acupuncture needles were inserted into the skin of the acupoints at a direct piercing depth of 15–30 mm. The needle retention time was 30 min. Patients were treated once a day for 5 d a week over a 4-wk treatment course. If dizziness, pallor, sweating, irritability, painful tingling, and localized allergic reactions occur during acupuncture treatment, acupuncture should be stopped immediately.

Observation group

The observation group underwent task-oriented training in addition to conventional acupuncture therapy. In the morning, routine acupuncture training was administered. In the afternoon, the upper extremity task-oriented training was conducted, and the training duration was the same as that of acupuncture training. The task-oriented training procedure was as follows: (1) The therapist assists the patient’s upper extremity and asks the patient to touch the opposite shoulder, mouth, forehead, etc.; (2) The therapist holds an object in his hand and moves it in any direction, requiring the patient to touch the object with the affected limb; (3) Beanbag throwing exercise: The therapist throws the beanbag to the patient and asks the patient to use the healthy hand to assist the affected hand in catch the beanbag; (4) The patient is asked to push building blocks, plastic cups, and other items in all directions using the affected side to reach a set target point; (5) Moving items: The affected hand moves an item on the table from one spot to another; (6) The patient is asked to practice cutting nails, opening mailboxes, holding pens, holding umbrellas, etc.; (7) A box is placed on a table. The patient is asked to use the affected hand in opening the box and putting items on the table into the box; (8) The patient is asked to turn a key in the lock; and (9) Further personalized upper extremity training is adopted according to the activities and tasks that the patient wants to perform. Corresponding tasks are designed by analyzing the ability of the patient to perform them. Patients are assisted in adapting to daily life and their immediate environment. During upper extremity task-oriented training, the weight and distance of objects being pushed, gripped, or rotated are gradually increased to increase the strength and stability of shoulder joint flexor and extensor muscles, abductor muscles, internal and external rotators, elbow extensor muscles, wrist muscles, and finger extensor muscles. During treatment, excessive shoulder hunching and trunk tilt that occurs to compensate for inadequate shoulder flexion or abduction are corrected. Task-oriented training was conducted for 30 minutes each session for 5 sessions a week for 4 wk.

Observation indicators and evaluation criteria

Therapeutic effects of the rehabilitation regimens were evaluated before and 4 wk after intervention using the Fugl–Meyer Rating Scale (FMA-UE), Wolf Motor Function Rating Scale (WMFT), and modified Barthel Index (MBI). In the FMA-UE scale assessing the upper extremity, each item has a score range of 0–2, with a maximum possible total of 66 points. A higher score indicates better upper extremity function. The WMFT has a maximum possible total of 75 points, which includes assessments of 15 upper extremity functional actions, with each scored 0–5 points. The WMFT score is proportional to the level of upper extremity function. The MBI evaluates the ability for daily living. Ten items are scored 0–15 points each, with a maximum possible total score of 100 points. A higher score indicates greater ability for daily living[6-8]. The score range for the Canadian Occupational Performance Measure (COPM) Functional Mobility and Satisfaction is 1–10 points, with higher scores indicating better performance or greater satisfaction[9]. The highest possible score for the Short-Form 36-Item Health Survey (SF-36) is 100 points. A higher score indicates a better quality of life[10].

Clinical efficacy

The Brunnstrom stage[11] of upper extremity separation movement was evaluated, which can be classified into stages I (sluggish stage), II (spasticity stage), III (combined movement stage), IV (partial separation movement stage), V (separation movement stage), or VI (roughly normal movement stage). The FMA-UE scale also assessed the clinical efficacy. Obvious effect: Brunnstrom stage VI or V, FMA-UE ≥ 40; Effective: Brunnstrom stage VI, FMA-UE ≥ 35; Invalid: Brunnstrom stage III, FMA-UE < 35; Total effective rate = (apparent + effective) number of cases/total number of cases × 100%.

Statistical methods

SPSS 28.0 was used for data analysis. Continuous variables with normal distribution are expressed as mean ± SD, and paired t-test was used for between-group comparisons. Count data are expressed as number (percentage). Differences were considered statistically significant at P < 0.05.

RESULTS

Comparison of upper extremity motor function before and after treatment

Before treatment, no significant differences were observed between the control and observation groups in FMA-UE scores (P > 0.05). Both groups demonstrated varying degrees of improvement after 4 wk of treatment (P < 0.05), with more prominent improvements observed in the observation group (P < 0.05; Table 2).

Table 2 Comparison of Fugl–Meyer Assessment-Upper Extremity scores before and after treatment.

Group	Case (n)	Before treatment	After treatment	t value	P value
Control group	50	28.60 ± 3.17	36.92 ± 2.77a	13.96	< 0.05
Observation group	50	29.26 ± 3.07	40.54 ± 2.89a,b	19.39	< 0.05
F		1.0655	1.0045
P value		> 0.05	< 0.05

^aP < 0.05 vs before treatment.

^bP < 0.05 vs control group.

Comparison of WMFT scores

The two groups also showed no significant differences in pretreatment WMFT scores (P > 0.05). After 4 wk of treatment, both control and observation groups showed increased WMFT scores (P < 0.05), with significantly higher scores in the observation group than in the control group (P < 0.05; Table 3).

Table 3 Comparison of Wolf Motor Function Rating Scale scores before and after treatment.

Group	Case (n)	Before treatment	After treatment	t value	P value
Control group	50	31.54 ± 2.91	46.14 ± 3.04a	24.52	< 0.05
Observation group	50	31.08 ± 2.92	53.10 ± 2.68a,b	39.32	< 0.05
F		0.997	0.7764
P value		> 0.05	< 0.05

^aP < 0.05 vs before treatment.

^bP < 0.05 vs control group.

Comparison of MBI values

The pretreatment MBI values did not vary significantly between control and observation groups (P > 0.05). After treatment, the MBI scores in both groups improved significantly (P < 0.05), especially in the observation group (P < 0.05; Table 4).

Table 4 Comparison of modified Barthel Index values before and after treatment.

Group	Case (n)	Before treatment	After treatment	t value	P value
Control group	50	41.10 ± 7.01	68.60 ± 7.28a	19.21 21.17	< 0.05
Observation group	50	40.30 ± 5.83	72.10 ± 8.86a,b		< 0.05
F		1.44	1.48
P value		> 0.05	< 0.05

^aP < 0.05 vs before treatment.

^bP < 0.05 vs control group.

COPM comparison

No significant between-group differences were observed in COPM scores before treatment (P > 0.05). Both groups demonstrated improvements in COPM scores after treatment (P < 0.05). The posttreatment performance activity score and satisfaction were significantly higher in the observation group than in the control group (P < 0.05) (Tables 5 and 6).

Table 5 Comparison of Canadian Occupational Performance Measure scores before and after treatment.

Group	Case (n)	Before treatment	After treatment	t value	P value
Control group	50	3.04 ± 0.64	4.32 ± 0.53a	10.92 10.44	< 0.05
Observation group	50	3.11 ± 0.78	4.91 ± 0.94a,b		< 0.05
F		0.60	0.32
P value		> 0.05	< 0.05

^aP < 0.05 vs before treatment.

^bP < 0.05 vs control group.

Table 6 Comparison of Canadian Occupational Performance Measure – Functional Mobility and Satisfaction before and after treatment.

Group	Case (n)	Before treatment	After treatment	t value	P value
Control group	50	2.70 ± 0.74	4.92 ± 0.61a	16.44	< 0.05
Observation group	50	2.73 ± 0.79	6.44 ± 1.21a,b	16.69	< 0.05
F		0.87	0.32
P value		> 0.05	< 0.05

^aP < 0.05 vs before treatment.

^bP < 0.05 vs control group.

Comparison of SF-36

No significant differences in pretreatment SF-36 scores was found between the control and observation groups (P > 0.05). The scores in both groups improved significantly after treatment, (P < 0.01), with a more significant improvement demonstrated in the observation group (P < 0.01; Table 7).

Table 7 Comparison of Short-Form 36-Item Health Survey scores before and after treatment.

Group	Case (n)	Before treatment	After treatment	t value	P value
Control group	50 50	46.37 ± 3.04	69.10 ± 10.72a	−14.91 −54.67	< 0.01
Observation group		47.48 ± 4.15	87.58 ± 3.46a,b		< 0.01
F		1.53	11.61
P value		> 0.05	< 0.01

^aP < 0.01 vs before treatment.

^bP < 0.01 vs control group.

Comparison of clinical efficacy

The observation group showed an obviously higher total efficacy rate than the control group after 4 wk of treatment (P < 0.05; Table 8).

Table 8 Comparison of clinical efficacy, cases (%).

Group	Case (n)	Significant effect	Effective	Invalid	Total effectiveness
Control group	50	14	28	8	84
Observation group	50	35	12	3	94a

^aP < 0.05 vs control group.

DISCUSSION

In recent years, with the introduction of the concept of neuroplasticity, functional recovery after stroke depends on the establishment of peripheral collateral circulation, nerve regeneration, and number of synapses. As demonstrated by evidence-based medicine, rehabilitation training is the most effective way of reducing stroke-induced disability and is an important component in stroke unit management. Therefore, modern rehabilitation therapy can effectively accelerate the rehabilitation process after stroke and reduce limb dysfunction in affected patients[12]. Upper extremity motor dysfunction is very common in patients with hemiplegia at the early stage of stroke. The fine and complex movements of the upper extremity make the recovery of upper extremity motor function more difficult than that of the lower extremity. Therefore, effective methods of improving upper extremity motor function can significantly improve the ability of patients with early stroke hemiplegia to engage in daily living activities.

During rehabilitation training, if the patient is only asked to perform flexion and extension without specific goals, the brain will lose the input and integration of information and the movements become mere mechanical joint activities. Therefore, familiarization with the COPM[7] enables the therapist to truly understand the rehabilitation needs of the patient and set rehabilitation goals and customize a treatment plan based on the unique requirements of the patient. Before beginning task-oriented training, the therapist must introduce the essentials of the actions to the patient and allow the patient to set goals and integrate familiar daily life tasks into the training. Identifying a specific target task better motivates the patient to perform the gestures or movements. Mamolo et al[8] showed that patients were better able to perform the required movements when specific tasks were identified. In addition, the position, weight, size and distance of the objects used in task-oriented training are all factors that affect the completion of the actions. If the patients can choose the tasks they are interested in, they will be more engaged in the training, and the quality of task completion would be higher[8].

In COPM-oriented training, upper extremity rehabilitation training is combined with actual activities in daily life and in the living environment. Practical, non-abstract goals are set, which integrate movements and objects that patients are interested in, such as towels, scissors, paper, coins, cups and plates, etc., as training goals or tasks. Rehabilitation starts from simple exercises, which become more complex in difficulty, so that patients continue to experience success and failure feedback. During training, patients need to judge and integrate information about the tasks to be performed through vision and touch, while simultaneously employing cognition and perception of the surrounding environment. More experience-dependent plasticity changes can be induced through the effective control of movements by the cranial nerve[11-13]. Wu et al[14] proved that when rehabilitation training has specific goals, patients are more motivated to complete the required actions, and the training process and route are more direct and smooth. This is because when a specific task goal is identified, the patient obtains a clear visual input before performing the action and integrates the information feedback during and after performing the action. Furthermore, through visual and verbal feedback, patients learn the most direct and effective movements, which will facilitate the retraining of motor skills and promoting the reorganization of brain function.

Traditional Chinese medicine believes that the head is the meeting of all Yang and is an important gathering point of the body’s viscera meridians. Acupuncture points on the head can dredge the whole-body meridians, running internal and external qi and blood, harmonizing Yin and Yang, and other functions. The Kang acupuncture method is the combination of head point acupuncture and modern rehabilitation technology. Head point acupuncture is divided into seven treatment areas, namely, parietal, preparietal, frontal, occipital, suboccipital, temporal, and nymphal areas. Acupuncture is performed on the parietal and preparietal areas for the treatment of motor dysfunction after stroke. Tang et al[15] trained the gripping function in the upper extremities of rats with cerebral infarction using forced techniques. After 21 d of observation, the density of synapsin in the penumbral zone of the cerebral ischemia increased, and functional decline was delayed. Furthermore, the expression of cortical growth-associated protein 43 was promoted, which directly enhanced nerve regeneration after cerebral ischemia and accelerated nerve function reconstruction. Rehabilitation training during prolonged needle retention can mitigate spastic paralysis of upper extremities, prevent abnormal movement patterns after hemiplegia, relieve shoulder joint pain, and prevent shoulder–hand syndrome. Acupuncture therapy can restore muscle strength after paralysis, improve patients’ ability to engage in daily living activities, reduce the disability rate, and improve quality of life. Head acupuncture can significantly stimulate blood supply to the brain, induce the excitability of the motor center of the brain, improve brain plasticity and brain function reorganization, and reduce neuronal apoptosis[16].

In the observation group, the Kang acupuncture method performed based on the COPM enables patients to customize the occupational treatment plan according to their rehabilitation needs. Patients are asked to select the top five rehabilitation goals that they want to achieve and are most eager to recover. Thus, the actual functions required in daily life are integrated into the treatment goals, and a task-oriented training strategy most suited to the patient that would constantly strengthen visual and sensory input is developed[17-19]. Functional training of the shoulder, elbow, wrist, and finger of the affected side should be strengthened. The trunk should be prevented from being involved during training. Training of the upper extremity should focus on muscle strength, coordination, and wrist stability. Finally, the ability to perform daily living activities with the upper extremity should be improved[20]. Through various targeted upper extremity tasks, intensive and repetitive functional training can restore normal motor function in the upper extremity under the motor ability of diverse upper extremity tasks, prevent abnormal patterns from developing, and enable greater improvement in upper extremity and hand functions[21-23]. In this study, the observation group showed higher FMA-UE scores than the control group after 4 wk of treatment, indicating that task-oriented training based on acupuncture therapy can improve upper extremity mobility in patients with stroke. In WMFT, the observation group also showed better performance, with significant advantages in proximal upper extremity function and hand fine motor and grip strength than the control group. A more significant improvement in the MBI was observed in the observation group. In the quality of life assessment using SF-36, a comprehensive comparison was made in eight dimensions, including physiological function, social function, physical pain, and mental health[24,25]. The observation group, which underwent COPM-led training, significantly outperformed the control group. In terms of COPM performance, the results showed that a patient-led program maximized the patients’ self-potential through their subjective initiative, with the observation group outperforming the control group in both activity and satisfaction scores, indicating that a patient-led rehabilitation treatment program is outstanding in terms of therapeutic efficacy. Target training with specific tasks combined with head point cluster acupuncture and long acupuncture induced significant central-peripheral effects, promoting the recovery of upper extremity function. Intermittent acupuncture can promote the reconstruction of nerve function and the regeneration of microvessels in the ischemic area, ultimately improving upper extremity mobility.

This study has some limitations, primary of which are the small sample size and a short observation period. In the treatment administered, 4 cases in the control group and 3 in the observation group could not continue because of time, weather and other disease recurrence. Further larger-scale studies with a larger sample size are needed to clarify the long-term efficacy and evaluate the expected outcomes from different aspects.

CONCLUSION

In summary, the Kang acupuncture method supports the recovery of upper extremity function in patients with stroke, thereby improving mobility, activitie, finger flexibility, performance of functional activities involving the upper extremity, and life satisfaction.