Cerebrogenic spasticity is an increase in muscle tone or spasticity of the paralyzed limb that occurs when the lesion damages any part of the cortex, basal ganglia, brain cadre and its downstream motor pathways. The spasticity caused by cerebrovascular disease is equivalent to stroke spasticity in traditional Chinese medicine, in which the increased muscle tone of the limb is spastic, accompanied by pain, numbness, stiffness, and joint contracture deformity, which affects the functional activities of the limb. It has been reported that the disability rate of stroke can be as high as 86.5%, while about 65% of the paralyzed limbs have increased muscle tone or spasticity, which seriously affects the functional activities and quality of life of patients. From September 2009 to September 2010, the author used acupuncture acupoints of antagonistic muscle groups in the clinical treatment of spastic paralysis of stroke and achieved satisfactory results, which are reported as follows.
I. Clinical data
General data: 60 cases in this group were patients with stroke hemiplegia with spasticity in the Department of Acupuncture and Moxibustion, Wuhan First Hospital, and were divided into 30 cases in the acupuncture antagonist muscle group (treatment group) and 30 cases in the acupuncture active muscle group (control group) by the single-blind method according to the random number table, see Table 1. the differences were not statistically significant (P>0.05) and comparable between the two groups in terms of gender, age and duration of disease by statistical treatment.
2. Selection criteria.
It was drawn up according to the Guidelines for Prevention and Treatment of Cerebrovascular Diseases in China [1] developed by the Chinese Medical Association Neurological Society, Department of Disease Control, Ministry of Health in 2004.
2.1 Diagnostic criteria for cerebral infarction
(1) Most of the cases have acute onset at rest, while cardiogenic cerebral infarction is more common in dynamic onset, and some cases may have transient ischemic attack before onset;
(2) The disease peaks within a few hours or days, and some patients may have progressive worsening or fluctuating symptoms;
(3) The clinical manifestations are determined by the size and location of the infarct.
The main symptoms and signs are focal neurological deficits, such as hemiparesis, hemianesthesia, aphasia, ataxia, etc. Some patients may have whole-brain symptoms such as headache, vomiting, coma, etc;
(4) Imaging: X-ray computed tomography or magnetic resonance imaging suggests the corresponding lesions.
2.2 Diagnostic criteria for cerebral hemorrhage
(1)Acute onset of the disease mostly under dynamic;
(2) Sudden onset of focal neurological deficits, often accompanied by headache and vomiting, may be accompanied by increased blood pressure, impaired consciousness and signs of meningeal irritation;
(3) Blood tests: elevated white blood cells and elevated blood glucose may be present.
(4) Imaging: CT or MRI suggesting corresponding lesions.
2.3 Inclusion criteria
(1) Patients who meet the diagnostic criteria;
(2) The duration of the disease was from 15 days to 6 months after the onset of stroke recovery;
(3) Hypertonia, hyperreflexia, and even joint clonus in the hemiplegic limb, i.e., belonging to Brunnstrom II, III, and IV stages; (4) 35 years ≤ age ≤ 75 years;
(5) Those who agreed and signed the informed consent form.
2.4 Exclusion criteria
(1) Those who are confused or have language comprehension disorder and cannot express their opinions correctly;
(2) Patients with large cerebral infarction (more than 2/3 of the volume of the hemisphere);
(3) Patients with traumatic brain injury, brain tumor and encephalitis complicated by cerebral infarction;
(4) Patients with fever, severe diabetes mellitus; patients with serious complications such as heart, liver and kidney failure (i.e. ALT > 1.5 times the normal value and Cr > the upper limit of the normal value)
(5) Patients suffering from rheumatoid, gout, amputation, congenital disability, etc. resulting in impaired limb movement
(6)Those who suffer from mental illness and cannot cooperate with treatment
(7) In the process of clinical observation, patients who apply drugs that affect clinical observation due to changes in their condition or interrupt clinical observation for other reasons.
Second, the treatment method
1.Acupuncture points.
1.1 Acupuncture antagonist muscle group: acupuncture points: for flexor spasm of upper limb, acupuncture points for shoulder s, Quchi, Hand Sanli, Waiguan and Hegu; for extensor spasm of lower limb, acupuncture points for Guizhong, Blood Sea, Sanyinjiao, Zhaohai and Taixi. Acupuncture depth: to reach the muscle layer as the degree, not too deep to the bone, and not too shallow to the subcutaneous.
1.2 Acupuncture of the active muscle group: Acupuncture of the active muscle group
Upper extremity: Ji Quan, Shou Ze, Shou Ze, Neiguan; Lower extremity: Fu Hare, Yang Ling Quan, Xie Xi, Shen Yi. Needle depth: to reach the muscle layer, not too deep to the bone, and not too shallow to the subcutaneous.
2. Operation method.
Disinfect the acupuncture points with 75% alcohol, and apply different types of flat needles according to the acupuncture points. After acupuncture,
Both groups used strong stimulation needle method: twisting angle greater than 180 degrees, lifting depth greater than 12.5px, both groups once a day, every 6d rest 1d, 3 weeks for a course of treatment.
Third, the efficacy criteria and treatment effect
1. Assessment methods (all assessments were performed by the same person).
1.1 Spasticity was assessed by the modified Ashworth scale;
IV. Discussion
Chinese medicine has long recognized spastic paralysis after stroke, and believes that spasticity is located in the brain, involving the liver and the meridians. It is believed that the occurrence of spasm is closely related to the liver and the tendons, and the lack of liver blood and tendons is the pathogenesis of the disease. From the theory of yin and yang, constriction and contraction are yin, while relaxation and extension are yang, and a surplus of yin and a deficiency of yang will result in constriction and relaxation. Jing Yue Quan Shu” in the cloud: “partial dead detention impotence and so on, the original by the Yin deficiency …… blood non-gas can not, gas non-blood does not change. Where there is no qi in the blood, the disease is slow and relaxed. No blood in the gas, then the disease for the cramps and constrictions …… Therefore, the tendons slow, when blamed for the lack of gas. The tendons are anxious, when blamed for the absence of blood.” In terms of treatment, emphasize the importance of unblocking the meridians, restoring the flow of Qi and blood, and relieving the tendons to relieve the urgency in the treatment of spasms. For example, the “Spiritual Pivot – Official Needle” says: “Restore the stab, straight stab the side, lift it, before and after the restoration of tendon urgency, to cure tendon paralysis.” “Guan stab, straight stab left and right to the end of the tendons, to take tendon paralysis.” The Treatise on Typhoid says: “The shin is still slightly constricted, heavy with peony and licorice soup er is shin extension.”
Spasticity is a resistance to passive movement of the limb, caused by a decrease in inhibition of the upward and downward conduction pathways and nodal ends, resulting in increased activation of the muscle to the tensor reflex. Increased muscle tone and spasticity are more common in paralyzed limbs caused by central nervous system disorders. A certain level of muscle tone is necessary to maintain body position and limb movement. However, excessive muscle tone affects the movement of the limb. At the same time, spasticity often causes pain, reduces joint movement, affects the ability to walk and maintain posture, and increases the incidence of heterotopic ossification and fractures, thus seriously interfering with patient care and rehabilitation exercises, and affecting their ability to perform activities of daily living and rehabilitation outcomes, so it is increasingly important to find effective measures to improve spasticity. During spasticity, the tone of the dominant muscle group (active muscle group) has appeared and gradually increased to hyperactivity and developed into spasticity, but the tone of the non-dominant muscle group (antagonist muscle group) is still weak or even absent. Therefore, how to excite the antagonist muscle group, increase the excitability of the α motor neurons and γ motor neurons of the antagonist muscle group, while inhibiting the tone of the active muscle and decreasing the excitability of the α motor neurons and γ motor neurons of the active muscle group is the focus of treatment for this disease.
According to neurophysiology, deep acupuncture with milli-needle on the hemiplegic side of the antispastic muscle (antagonist muscle) muscle abdominal points, through the proprioceptive nerve to start the tension reflex to cause the corresponding antagonist muscle contraction, the spastic side of the hyper-tension reduced, to achieve the purpose of spasticity inhibition. Therefore, our acupuncture points are located on the flexor muscles of the lower limbs, and by stimulating the acupuncture points on the antagonist muscles, we can inhibit the increase in tension of the extensor muscles of the lower limbs and relieve the spasm. It helps the patient to pass the muscle spasm as soon as possible and promotes the emergence of detachment movement.
The relevant data show that any painful stimulus can cause the flexor and extensor muscles to retract in response, showing the spasm of the flexor and extensor muscles. Especially in the state of active reflexes and higher spasticity, stimulation of certain acupoints in distal sites will undoubtedly aggravate the spasticity pattern of hemiplegic patients. For example, acupoints such as foot Sanli, Sanyinjiao, and Xiexi can cause foot inversion and toe flexion spasm, and acupuncture of Quchi can cause elbow flexion and wrist flexion spasm. On the other hand, distal acupuncture points are not consistent with human neurodevelopmental patterns. The present study showed that acupuncture of the antagonist muscle can improve the ability to perform activities of daily living and reduce the disability rate, which is an effective treatment for post-stroke spastic hemiplegia and can be promoted to clinical application.