Acupuncture For Dysphagia Following Stroke
Noel C. Nowicki, MD
Allison Averill, MD
Background Acupuncture has been used to facilitate recovery of motor function following stroke. However, its use has not been verified for dysphagia, a potentially life-threatening sequela of stroke.
Objective To determine whether acupuncture, in conjunction with standard therapy, is a useful modality in post-stroke dysphagia.
Design, Setting, and Patients A total of 52 patients (mean age, 66.9 years; 34 men and 18 women) admitted to a rehabilitation hospital from August 1997-August 1999 following a stroke.
Intervention Eighteen patients received manual and electrical acupuncture with points on the LU-LI meridian for a 21/2- to 3-week period. Controls (n=34) and the acupuncture group received standard care for dysphagia.
Main Outcome Measure Using videofluoroscopic swallowing study (VFSS), change on a 5-point aspiration/penetration scale.
Results All patients began the study with a VFSS score of 5 (aspiration present). Both groups experienced a statistically significant (P<.05) improvement from baseline. At the end of the study, the acupuncture group mean (SEM) VFSS score was 2.56 (0.34) compared with 3.76 (0.28) in controls (P<.05). There were no significant differences in VFSS score by patient sex.
Conclusions Dysphagia symptoms as demonstrated on VFSS improved in patients treated with acupuncture as well as in controls. However, acupuncture patients achieved significantly greater swallowing function at study end.
Acupuncture, Stroke, Rehabilitation, Aspiration, Dysphagia, Videofluoroscopic Swallowing Study (VFSS)
Dysphagia is a potentially life-threatening sequela of stroke that affects anywhere from 28% to 52% of stroke patients.1-3 The greatest risk is aspiration of food into the lungs with subsequent pneumonia. There is limited treatment for this condition and natural recovery is essential. A significant number of patients with this condition never recover their swallowing function fully and must be fed via tube for the remainder of their lives.
Acupuncture is a recently emerging therapy in the United States for assisting in patient recovery of function following stroke.4-17 Acupuncture has been applied primarily for overall recovery of motor function of the limbs; we have not found a study that involved recovery of the swallowing function.
Inherent in the design of our study was the choice of acupuncture points that have an empirical use for problems of the nasopharynx. The same points were used on all patients without making a TCM diagnosis and individualization of points in order to make the findings reproducible. We sought to determine whether acupuncture would be a useful adjuvant treatment in standard rehabilitation following stroke.
On admission to our rehabilitation hospital, all stroke patients are observed for dysphagia by the nursing staff. If dysphagia is suspected or it is known by patient history, a speech therapist then performs a full bedside evaluation to determine the extent of the difficulty. Any patient in whom the diagnosis of dysphagia is suspected routinely undergoes a videofluoroscopic swallowing study (VFSS).
In our study, a physiatrist (A.A.) viewed all studies and rated them on a specially developed penetration/aspiration scale described below. If the diagnosis of dysphagia was confirmed on the VFSS, the patient received a course of therapy with speech and occupational therapists. All patients who underwent a VFSS and scored 5 for aspiration were invited to participate in the study. They received an explanation of the acupuncture treatment and signed an informed consent form if they agreed to participate. The institutional review board of Kessler Institute for Rehabilitation granted approval for treating and obtaining data for the subjects of this research.
From August 1997-August 1999, 18 patients completed 6 to 8 acupuncture treatments, 2 to 3 times per week, over a 21/2- to 3-week period. Five acupuncture points located on the Lung and Large Intestine meridian, including the Distinct Meridian of LU-LI, were used bilaterally: LI 4, LU 7, LU 1, LI 15, and LI 18. Needles were inserted to a depth of 1/8" to 1/4" and were stimulated manually to achieve De Qi. They were then attached to the stimulators negative LU 7, positive LI 4, long needles used to clip LU 1 and LI 15 together as the negative lead, and LI 18 as the positive lead; then remained in place for electrical stimulation at 2 Hz for 15 minutes. We used disposable steel 0.25-gauge Seirin L No. 5 needles, presterilized and individually wrapped. An electric current generated by a 9-V battery-powered stimulator (Ito Model IC1107; Tokyo, Japan) was used to stimulate all the points. All patients continued to receive standard dysphagia therapy from speech and occupational therapists, which included oral exercises and strategies to avoid aspiration.
Initially, participants were to be randomized to a treatment or placebo control condition. Pilot testing suggested that this would be inefficient due to low participation in a placebo study. Treatment was to be conducted during an inpatient rehabilitation hospital stay, with routine discharge after 21 days. This would have created difficulty in following up the wait-list controls due to transportation difficulties. There were also 4 patients receiving sham treatment in the pilot study. Due to controversy surrounding what constitutes an adequate sham treatment condition in acupuncture, the sham group was dispensedwith after the pilot testing in accordance with findings of the 1997 NIH Consensus Study on Acupuncture. With the exception of 17 patients who were randomized controls, the others are historical controls or were chosen as control subjects because of the use of warfarin, an anticoagulant. The resultant control group was 38 patients.
Videofluoroscopic Swallowing Study (VFSS)
The VFSS is conducted in the presence of the speech/language pathologist, radiologist, and attending physiatrist. Initial swallows are recorded in the lateral plane. The speech/language pathologist feeds the patient in the following sequence. Barium liquid is given in a measured bolus of 5-10 mL. At least 2 trials of each amount are administered. A single sip and/or continuous swallows of liquid from a cup may be given as appropriate. Swallows are performed in the anteroposterior plane using any consistency and/or compensatory strategy as appropriate. When the patient cannot tolerate a given consistency (thin, 1 part barium, 1 part water; thick, 2 parts barium, 1 part water; or thickened, 100% barium), appropriate compensatory strategies may be attempted. Swallows of a given consistency are terminated if the patient cannot perform the recommended compensatory strategies or cannot tolerate the given consistency using the recommended compensatory strategies.
A 5-level aspiration/penetration scale was developed for this study. A score of 5 indicates that liquid enters the trachea then passes beneath the level of the true vocal cords (aspiration); 4, inability to expel liquids spontaneously or on command (laryngeal penetration present); 3, ability to expel liquids on command but not spontaneously (laryngeal penetration present); 2, spontaneously expels liquids that have entered beneath the level of the laryngeal vestibule (transient laryngeal penetration); and 1, no penetration or aspiration. Statistical analyses assume that this scale approximates an interval scale, although all parametric analyses are confirmed with non-parametric tests. Patients' VFSS were screened by a physiatrist or speech therapist and individuals scoring a 5 on this scale (aspiration occurred) were invited to participate in the study. Patients were given a 2nd VFSS some 2 to 3 weeks later, which was viewed and scored by a physiatrist who was blinded to whether the video was of a treatment or control participant.
Figure 1. Mean Videofluoroscopic Swallowing Study (VFSS) Scores at Baseline and Study End for Acupuncture and Control Patients
Figure 2. Mean Videofluoroscopic Swallowing Study (VFSS)
Change Scores by Treatment Group and Sex
The mean end of treatment VFSS scores were significantly different
(P<.05) from baseline for both groups. The mean end of treatment VFSS score for the acupuncture group was significantly different (P<.05) from the score of the control group.
Acupuncture treatment did not differentially affect male and female
recovery of VFSS-related function.
A total of 74 patients were recruited into the study. Some did not complete a full course of rehabilitation due to medical illness or were discharged prior to a 2nd swallowing study. Only patients who had both VFSS were included. The final study sample included 52 participants: 18 in the acupuncture group and 34 in the control group. The mean (SD) age was 66.9 (10.7) years (64.4 [11.5] years in the acupuncture group and 68.1 [10.3] years in the control group). There were 20 men and 14 women in the control group and 14 men and 4 women in the acupuncture group. In the course of the study, 2 patients with brain stem strokes were treated and recovered swallowing function, but were excluded from the statistics because they were past the 6-week subacute inclusion criteria. Treatment observations of this acupuncture protocol have shown recovery of swallowing function 2 years out from the original stroke in 2 additional patients.
The mean VFSS values at the beginning and end of the treatment period for all participants is shown in Figure 1. As shown, both groups' mean VFSS values decreased over time. A 2-way repeated measures analysis of variance (ANOVA) revealed a significant treatment x time interaction for VFSS (F1,50 = 7.14; P=.01). Thus, VFSS values at the beginning and at the end of the study differed depending on whether the patient received acupuncture. Newman-Kuels multiple comparisons (a=.05) indicated that although both acupuncture and control patients had significantly lowered end of study VFSS values (mean [SEM], 2.56 [0.34] for acupuncture and 3.76 [0.28] for controls) compared with baseline (mean [SEM] for both groups, 5.0 ), the mean end of study VFSS for acupuncture-treated patients was significantly lower than that for controls (Figure 1).
To determine whether acupuncture treatment interacted with patient sex to influence recovery during the study period, VFSS scores were calculated by subtracting each patient's post-treatment VFSS value from the pretreatment VFSS value. Figure 2 presents the mean VFSS change scores for men and women in both groups. For both sexes, acupuncture-treated patients appeared to have larger changes in VFSS scores compared with the controls. A 2-way ANOVA revealed a significant overall treatment effect (F1,48 = 4.47; P<.04), indicating that patients treated with acupuncture exhibited a larger change in VFSS values (mean [SEM], 1.26 [0.27]). There was no significant sex or treatment x sex effects.
These findings indicated that patients improved in VFSS-related functions over time with or without acupuncture treatment. However, patients receiving acupuncture treatment recovered significantly more VFSS-related function by the end of the study compared with controls.
Two studies indicate that dysphagia happens more frequently in male than in female stroke patients. When dysphagia occurs it happens at an older age as a sequela of stroke.18 Also, patients who develop dysphagia with stroke have more extensive strokes requiring longer
hospitalization and fewer return home. One study suggested that the majority of patients who develop dysphagia regain the ability to swallow within 14 days. All the patients included in our study had subacute strokes, meaning we studied them 2 to 6 weeks following stroke. Our patients may have had more pronounced disabilities because milder cases would have been having outpatient therapy as opposed to intensive inpatient therapy in a rehabilitation hospital. Stronger results might have been achieved by increasing the number of acupuncture treatments as well as the number of participants.
Our findings suggest that acupuncture may be useful for the treatment of post-stroke swallowing disorders. The specificity of the results to swallowing implies that its success is not simply a generalized response to acupuncture. Further studies are warranted in this area.
Funding was provided by a grant from the NIH Office of Alternative Medicine for rehabilitation for stroke and neurological disease to Samuel Shiflett, PhD, at Kessler Institute for Rehabilitation.
We thank Joseph Helms, MD, for guidance in point selection and acupuncture training at UCLA. Statistics and graphs were prepared by Robert E. Landsman, PhD.
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Dr Noel C. Nowicki is an Internist in private practice, and at Kessler Institute for Rehabilitation in East Orange, New Jersey. He is Board-certified in Medical Acupuncture and active in the AAMA New Jersey chapter. Dr Nowicki won 2nd place in an international research study, dysphagia after stroke, funded by NIH.
Noel C. Nowicki, MD*
Kessler Institute for Rehabilitation
240 Central Ave
East Orange, NJ 07018
Phone: 973-414-8605 • Fax 973-414-8129 • E-mail: firstname.lastname@example.org
Dr Allison Averill is a Psychiatrist and Associate Medical Director of the Kessler Institute for Rehabilitation in East Orange, New Jersey. Dr Averill's concentration is on the treatment of patients with acquired brain injury and neurological injuries.
Allison Averill, MD
Associate Medical Director, Kessler Institute for Rehabilitation
Assistant Professor, UMDNJ-NJ Medical School
Department of Physical Medicine and Rehabilitation
Kessler Institute for Rehabilitation
240 Central Ave
East Orange, NJ 07018
Phone: 973-414-4773 • E-mail: email@example.com
*Correspondence and reprint requests