On the home page of Zhu’s Neuro-Acupuncture Center there is a video relaying a testimonial of how scalp acupuncture helped a patient recover from acute stroke. The use of testimonials is very common in the promotion of dubious health treatments. A personal story and endorsement is psychologically more compelling than dry data. Testimonials are completely unreliable, however, and in fact I would argue that they are ethically questionable. I would even go as far as saying that the presence of testimonials is almost a sure sign that the treatment being promoted is not legitimate.

Webpage screenshot (click picture to embiggen)

Webpage screenshot (click picture to embiggen)

What I could not find on Zhu’s website were links to published scientific researcher establishing the safety and efficacy of his treatments. You would think if they existed, he would display them prominently.

Acupuncture for stroke is a common claim, contradicting the notion that acupuncture is primarily used for the symptomatic treatment of subjective symptoms. That, in my experience, is part of the promotional strategy for many CAM treatments. They are presented as benign treatments for symptomatic treatment only, so what’s the possible harm. In reality, proponents will claim they can actually treat diseases whenever given the chance.

Treating stroke

A stroke results from an acute lack of blood supply to a portion of the brain, usually caused by a blockage in a cerebral artery, but can also be caused by overall lack of blood flow to the brain. Brain cells are metabolically very hungry, and can only go a few minutes without a steady blood supply before they start to die.

When the blockage of blood flow occurs brain cells will immediately stop functioning. Depending on how completely the blood flow is blocked, the amount of collateral flow from other arteries, and the duration of blockage, brain cells might be temporarily stunned, damaged but capable of recovery, severely damaged and likely to die, or they may be already dead. Clinically (based on patient symptoms and neurological exam) it is not possible to tell the difference, because stunned and dead brain cells look the same. They don’t function.

In fact some patient who present with a stroke actually have a transient ischemic attack (TIA), which is essentially a stroke that leaves behind no permanent damage and completely resolves within 24 hours.

Some patients with acute stroke are candidates for a drug called TPA that can break up a clot and restore flow. In the best cases, treatment with TPA can rapidly reverse the clinical signs of stroke, and so apparently restore flow before permanent damage occurs.

Therefore, when a patient presents with, for example, paralysis of one side of the body due to stroke, it is possible that they may recover very quickly, or they may recover over days as stunned brain cells recover, or over weeks as damaged but viable brain cells recover. Or, the patient may have permanent deficits due to dead brain tissue from the stroke. Modern imaging such as MRI scanning can help us predict to some extent how bad the damage is, but not completely. So in practice we mostly have to wait and see how the patient recovers.

What all this means is that, in order to study the effects of any treatment in the recovery from acute stroke, you need to perform careful double-blind placebo-controlled trials. Cherry picking for testimonials can produce seemingly-amazing stories of recovery no matter what treatment you are looking at, and therefore testimonials for stroke recovery are completely useless.

The testimonial promoted on Zhu’s homepage is just such a case. The story appears to be that of a patient with an acute stroke who recovered most of his function over several days, and then had rehab to complete his recovery. This is a very common outcome and therefore says nothing about the effects of the scalp acupuncture he received. It is therefore also deceptive (and unethical) to use this testimonial to promote a treatment that has not been scientifically validated.

Recovery long after stroke is another claim made for acupuncture, and other questionable treatments. Here the issues are a little different, because we are dealing with patients with chronic symptoms, sometimes for years. They are unlikely to make a rapid genuine neurological recovery, therefore.

However, when evaluating chronic stroke patients we need to consider both neurological recovery and functional recovery. Neurological recovery means making new connections between neurons, recruiting neural stem cells to lay down new circuits, and engaging the plasticity of the brain to have healthy areas take over for damaged areas.

Functional recovery means having improved function with stable neurological deficits. This type of recovery is often neglected by inexperienced stroke researchers (such as when non-neurologists study dubious treatments). For example, you can take someone who is weak from a stroke they had 10 years earlier and they can improve their function even without any further neurological recovery. They may be deconditioned and not fully rehabbed. Getting them exercise, mobilizing their joints, and training them to function better with their weakness can result in a significant functional improvement. There is also what stroke researchers call the “cheerleader effect.” Simply encouraging someone to try harder can have a measurable effect.

So again we see that unless a treatment is properly controlled for, it can be easy to present non-specific functional recovery as if it were a specific neurological effect of a treatment.

The literature

Are there any well-designed trials of acupuncture for stroke? Not many. There are many preliminary or poor-quality studies and some moderate quality. There is no single definitive study, however.

The most recent Cochrane systematic review of acupuncture for acute stroke is from 2005, and concludes:

Acupuncture appeared to be safe but without clear evidence of benefit. The number of patients is too small to be certain whether acupuncture is effective for treatment of acute ischaemic or haemorrhagic stroke. Larger, methodologically-sound trials are required.

The most recent Cochrane systematic review of acupuncture for chronic stroke rehab is from 2006, and concludes:

Currently there is no clear evidence on the effects of acupuncture on subacute or chronic stroke. Large, methodologically-sound trials are required.

A 2009 systematic review of acupuncture for post-stroke spasticity concluded:

A reliable conclusion can not be drawn from the present data because of the defects in methodological quality and insufficient numbers of trials, especially lack the long-term terminal outcomes, although it appears a tedency [sic] that acupuncture can improve the conditions of post-stroke spastic paralysis.

A 2012 systematic review concluded:

The evidence for the effectiveness of acupuncture for stroke was inconclusive, mainly due to poor methodological quality and small samples.

And a 2014 systematic review concluded:

The available evidence suggests that acupuncture may be effective for treating poststroke neurological impairment and dysfunction such as dysphagia, although these reported benefits should be verified in large, well-controlled studies. On the other hand, the available evidence does not clearly indicate that acupuncture can help prevent poststroke death or disability, or ameliorate other aspects of stroke recovery, such as poststroke motor dysfunction.

There is a clear consensus, agreeing with my own take on the literature, that the current evidence does not establish that acupuncture is effective for stroke, post-stroke rehab, or post-stroke symptoms such as spasticity. Most of the studies are poorly controlled, and therefore non-significant trends are of no value.

Conclusion

Acupuncture is a highly implausible treatment for stroke in any phase. While it is possible to make hand-waving speculations about possible mechanisms by which inserting a needle into the skin might reduce pain (even though a benefit has never been reliably demonstrated), there is nothing approaching a plausible mechanism for stroke recovery.

Needling the scalp or any part of the body will not restore blood flow to the brain, dissolve clots, or help neurons recover. Some acupuncturists will resort to claims based on Chi or life energy, but this is a pre-scientific belief without a shred of support from our modern scientific understanding of biology.

I do disagree with the reviewers above in that I do not think that larger well-controlled trials are necessary to conclude that acupuncture is not an effective treatment for stroke. Acupuncture is a highly implausible treatment, it has not been shown to work for any indication, and preliminary data for stroke is unimpressive. This is sufficient evidence to abandon a treatment as likely useless.

The expense and trouble of a large rigorous trial is only justified if a treatment is likely to be safe and effective based on a reasonable combination of prior plausibility and encouraging preliminary data. In this case we have neither.

One might argue that because acupuncture is already culturally embedded, definitive trials will be useful to convince proponents and the public that it does not work, if nothing else. However, history has shown this to not be the case. We already have large definitive trials showing acupuncture does not work for several indications, and this has not altered the enthusiasm for which proponents continue to support and use acupuncture. They simply ignore the negative evidence, or spin the results as somehow being positive – because placebo acupuncture works too. The entire exercise is therefore fruitless.

It should simply be acknowledged by the scientific and medical community that acupuncture is a failed hypothesis and the position of any self-respecting science-based organization should be the complete abandonment of this anachronistic treatment.

 

 

Posted by Steven Novella

Founder and currently Executive Editor of Science-Based Medicine Steven Novella, MD is an academic clinical neurologist at the Yale University School of Medicine. He is also the president and co-founder of the New England Skeptical Society, the host and producer of the popular weekly science podcast, The Skeptics’ Guide to the Universe, and the author of the NeuroLogicaBlog, a daily blog that covers news and issues in neuroscience, but also general science, scientific skepticism, philosophy of science, critical thinking, and the intersection of science with the media and society. Dr. Novella also contributes every Sunday to The Rogues Gallery, the official blog of the SGU.

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