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J Tradit Chin Med 2018 June 15; 38(3): 452-456
ISSN 0255-2922
© 2018 JTCM. All rights reserved.

RESEARCH ARTICLE
TOPIC

Scalp-cluster acupuncture with electrical stimulation can improve
motor and living ability in convalescent patients with post-stroke
hemiplegia

Wang Xiaohong, Zhang Qi, Cui Baojuan, Sun Junhua, Ye Lan, Huang Laigang, Wang Daoqing
aa
RESULTS: Following 4 weeks treatment, all the patients exhibited significant improvements in aspects of motor ability, living ability, and the severity of neurological deficits. The experimental group
(SC + ES) scored higher on the Fugl-Meyer assessment scale (68 ± 12) and the modified Barthel Index (49 ± 9) than the control (SC) group (50 ± 13,
36 ± 13, respectively).

Wang Xiaohong, Department of Geriatric Medicine, the
Second Hospital of Shandong University, Jinan 250031,
China
Zhang Qi, Cui Baojuan, Huang Laigang, Wang Daoqing,
Department of Rehabilitation Medicine, the Second Hospital of Shandong University, Jinan 250031, China
Ye Lan, Sun Junhua, Cancer Center, the Second Hospital of
Shandong University, Jinan 250031, China
Supported by Grants from the Natural Science Foundation
of Shandong Province (No. ZR2011HL019, ZR2014HL060)
Correspondence to: Prof. Wang Daoqing, Department of
Rehabilitation Medicine, the Second Hospital of Shandong

University, Jinan 250031, China.
Telephone: +86-531-85875491
Accepted: July 12, 2017

CONCLUSION: When patients with post-stroke
hemiplegia are treated using SC acupuncture with
ES, motor and living ability can improve more than
if they were treated with SC acupuncture alone.
© 2018 JTCM. All rights reserved.
Keywords: Stroke; Rehabilitation; Hemiplegia; Electrical stimulation; Scalp cluster acupuncture

Abstract
OBJECTIVE: To determine whether patients with
post-stroke hemiplegia could benefit from
long-term treatment with scalp cluster (SC) acupuncture combined with electrical stimulation (ES)
and to evaluate the feasibility of this treatment to
improve motor and living abilities.

INTRODUCTION
Cerebral stroke is common across the globe and leads
to a wide range of disabilities.1 Hemiplegia is one of
the most common complications following stroke. It
often causes motor impairment, which is a major reason for reduced activities of daily life and socialization.2
Various physical therapies have been used in patients
with post-stroke hemiplegia to improve their motor
ability and daily living. However, the outcomes for
some patients with hemiplegia are not satisfactory.
Acupuncture has been used to treat several chronic diseases, including chronic pain,3 weight management,4
functional dyspepsia,5 and especially hemiplegia.6-9 Reports show that acupuncture can improve post-stroke
depression,10 and that scalp-cluster (SC) acupuncture is

more effective than traditional scalp acupuncture in

METHODS: Twenty patients were enrolled and divided into two groups: SC acupuncture and SC acupuncture with ES (SC and SC + ES, respectively). All
participants also received rehabilitation training.
All participants were blindly evaluated using the
Fugl-Meyer assessment scale for motor ability, the
modified Barthel Index for living ability, and a scale
for the degree of neurological deficits. Outcome
was assessed at three points before randomized
grouping, at the beginning or treatment, and after
4 weeks of treatment.
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treating patients with post-stroke hemiplegia.11,12 However, this method requires keeping needles in patients'
scalp acupoints repeatedly over several months. Additionally, it can result in complications such as skin edema and pain, which might force some patients to discontinue treatment.
Electrical acupuncture is an improved method that
stimulates acupoints by passing a certain frequency
electrical current through needles. Compared with the
traditional needle-twirling method, stimulation frequency in electrical acupuncture is higher, which results in stronger stimulation of the acupoints. In theory, electrical acupuncture might be more effective than
traditional acupuncture, which would shorten the duration of treatment and decrease complications that result from long-term acupuncture. To our knowledge,
there have not been any similar studies that examined
the effect of SC acupuncture combined electrical stimulation in treatment of convalescent patients with
post-stroke hemiplegia.

Here, the aim of this study was to determine whether
SC acupuncture combined with ES is more effective
than SC acupuncture alone in the treatment of patients with post-stroke hemiplegia.

(a) unconsciousness; (b) medically unstable; (c) uncontrolled seizures (> 1 per week for the last 2 months); (d)
severely impaired communication or cognition; (e) other confounding neurological conditions affecting the rehabilitation training; (f ) other medical issues affecting
the rehabilitation training or acupuncture therapy.
The study was conducted at the rehabilitation department of an urban general hospital in China and approved by the ethics committee of the Second Hospital
of Shandong University. The research was conducted
in accordance with the Declaration of the World Medical Association. All participants were informed about
the study and signed the informed consent to agree
that their data could be used for research purposes. All
participants were numbered sequentially according to
the order of enrollment and then divided into the control (SC) and experimental (SC + ES) groups using a
randomized digital table.
Interventions
All participants received rehabilitation training. Those
randomized to the control group received SC acupuncture and those entering the experimental group received SC acupuncture combined with ES.
Selection of the therapeutic acupoints followed the following principles. According to the method developed
by Yu Zhishun, the surface of the scalp was divided into seven sections: (a) parietal area: the line from Baihui
(GV 20) to Qianding (GV 21) and the bilateral parallel lines 1 and 2 inches to either side; (b) anterior parietal area: the line from Qianding (GV 21) to Xinhui
(GV 22) and the bilateral parallel lines 1 and 2 inches
to either side; (c) frontal area: the line from Xinhui
(GV 22) to Shenting (GV 24) and the bilateral parallel
lines 1 and 2 inches to either side; (d) occipital area:
the line from Qiangjian (GV 18) to Naohu (GV 17)
and the bilateral parallel lines 1 inch to either side; (e)
suboccipital area: the lines from Naohu (GV 17) to
Fengfu (GV 16) and from Yuzhen (BL 9) to Tianzhu
(BL 10); (f ) nuchal area: the line from Fengfu (GV 16)

to Fengchi (GB 20), including five acupoints; (g) temporal area: one point 0.5 inches inferior to Touwei (ST
8), the point 0.5 inches anterior and inferior to the parietal nodule, and the line between these two points.
Major acupoints, including the parietal area and the anterior parietal area were used in all patients. Additionally, adjunct acupoints were selected as follows: (a) for patients with language disorders, we selected the temporal or nuchal area; (b) for patients with visual impairment, we selected the occipital area; (c) for patients
with mental impairments, we selected the frontal area;
(d) for patients with dysphagia, we selected the nuchal
area. Two traditional Chinese medical practitioners
were asked to verify the choice and location of the selected acupoints at the beginning of each treatment.
Acupuncture therapy was given 5 times a week for
4 weeks using sterilized needles (0.40 mm × 50 mm).
Three to five needles were used in each area. Needles

METHODS
Participants
This was a blinded randomized controlled trial (RCT)
that aimed to determine whether SC acupuncture combined with electrical stimulation (ES) was more effective than SC acupuncture alone in treating post-stroke
hemiplegia. All patients were diagnosed with cerebral
stroke according with the diagnostic criteria for hemorrhagic stroke in "Diagnostic Essentials of Cerebrovascular Diseases" revised by the Chinese Fourth Conference
on Cerebrovascular Disease of the Chinese Medical Association in 1995.13 Patients with post-stroke hemiplegia, hospitalized in the department of rehabilitation at
the Second Hospital of Shandong University from January 2013 to December 2015, were enrolled with the
following inclusion criteria: (a) the diagnosis of stroke
was confirmed by CT or MRI of the head; (b) the diagnosis met the criteria outlined in "stroke syndrome diagnostic criteria (Trial)", established in 1994 by the
acute encephalopathy research group of the State Administration of Traditional Chinese Medicine of the P.
R.C;14 (c) timing was ≥ 2 weeks and ≤ 3 months after
stroke, and hemiplegia presented on their affected
sides; (d) they were at the stable stage of the disease
and with clear consciousness; (e) the severity of neurological deficits was at least 10. These scores were determined according to "The scoring criteria of degree of
clinical neurological deficits for patients with cerebral
stroke (1995)" established in 1995 by the Chinese
Fourth Conference on Cerebrovascular Disease of the
Chinese Medical Association.15 Exclusion criteria were:

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were angled 15 degrees to the skin and inserted 40 mm
into the acupoint, reaching below the galea aponeurotica. Needles remained this way for 6 h per day. In the
control group, the needles were twirled every 2 h. In experimental group, the needles in the parietal and anterior parietal areas were connected to the electric acupuncture apparatus (Huatuo® SDZ-II, Suzhou medical supplies factory Co., LTD, Suzhou, China), which stayed
energized during the whole treatment. The stimulation
parameters were: dilatational waves at a frequency of
(10 ± 3)-(50 ± 10) times/min and a current intensity of
0.6-1.0 mA.

used to quantitatively evaluate the severity of neurological deficits. According to the diagnostic criteria of
the Chinese Fourth Conference on Cerebrovascular
Disease in 1995,15 the degree of neurological deficits
were divided into three levels as follows: mild (0-15
points), moderate (16-30 points) and severe (31-45
points).
Adverse events
All patients were required to report any adverse events
during acupuncture treatment. If any were reported
the doctor interviewed the patient and evaluated the validity of the adverse event. If necessary, the doctor
stopped the procedure and treated the adverse event
immediately. The evaluator recorded the date and seriousness of the event and analyzed the relationship between the event and the treatment. The evaluator also
recorded other possible causes in addition to the treatment. The ethics committee was then tasked with deciding whether or not to remove this patient from the

study.

Rehabilitation training
Patients with post-stroke hemiplegia generally require
additional rehabilitation therapy to during their recovery. Due to ethical considerations, rehabilitation therapy following the Bobath concept was administered
to all patients throughout the entire study, including
correction of poor posture, active and passive movement of joints in the extremities while lying down,
training of hand function, turning and movement on
the bed, training of sitting balance, and others. Rehabilitation therapy lasted 30-45 min, once per day, 5 d
per week.

Statistical analysis
The results are presented as mean ± standard deviation
( xˉ ± s). The χ2 test and Student-t test were used to determine whether differences were statistically significant. A P-value less than 0.05 was considered significant. All statistical tests are two tailed. Statistical analysis was performed using SPSS 19.0 (IBM Corp. Released 2010. IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY, USA)

Outcomes
All participants underwent 3 blinded assessments: The
Fugl-Meyer assessment scale for motor ability, the modified Barthel Index for living ability, and a scale that
quantified the degree of neurological deficit. Outcome
assessment was completed before randomization, at the
beginning of treatment, and after the 4-week treatment
period.

RESULTS

Fugl-Meyer assessment scale
This scale comprises four interdependent parts: motor
function in the extremities, range of motion in the
joint (including pain score), balance, and sensation.
The maximum score is 226. In this study, we used the

scale for motor function in the extremities (max 100
points) to evaluate motor ability. Motor ability was divided into the following five levels: 100 was normal,
96-99 was mild motor disorder, 85-95 was moderate
disorder, 50-84 was apparent disorder, and < 50 was a
severe disorder.

Patient characteristics (Trial profile)
Twenty patients enrolled in this study (n = 10 per
group). Twenty patients were enrolled. Five patients
were excluded due to serious complications before the
experiment. Clinical characteristics did not differ between the two groups (Table 1). There were no reported adverse events in the study.
Changes in motor ability
The Fugl-Meyer assessment scale showed no difference
between groups at the beginning of treatment. Following 4 weeks of treatment, scores increased significantly
in both groups. Further, the SC + ES group scored
even higher than the SC group, indicating that motor
ability of experimental group improved more than that
of the control group (Table 2).

Modified barthel index
This scale comprises 10 topics, with each topic ranging
from 0 to 15 points. The maximum score is 100 points
and higher scores indicate better living ability. Living
ability was divided into four levels: > 60, 60-40, 40-20,
and < 20.

Changes in living ability
The modified Barthel Index indicated that living ability clearly improved in both groups following 4 weeks
of treatment. As with motor ability, living ability improved more in the experimental group than in the
control group (Table 3).

Neurological deficit scale
A neurological deficit scale that included unconsciousness, staring, facial paralysis, myodynamia of extremities and hands, and poor walking ability, was generally
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trol group. This means that the ES can increase the efficacy of SC acupuncture. In terms of daily living ability,
the average modified Barthel Index revealed that the experimental group (49.00) had a greater living ability
than the control group (36.00). Importantly, SC + ES
can be considered a safe procedure because no adverse
events were reported by the patients of this clinical investigation, and none withdrew from this study.
However, this trial provides no evidence that SC acupuncture combined ES results in a greater decrease in
severity of neurological deficits than single SC acupuncture. One reason might be that neurological deficits require a relative long time to improve, and our observation period of only 4 weeks might not have been adequate for detecting a difference between the treatments. Another possible reason is that the sample size
was too small to confirm whether differences between
the two groups were significant. In future studies, we
will enroll more patients and design a longer observation time to more conclusively determine any differences in the efficacies of the two treatment methods in
terms of improvement in neurological deficits of hemiplegic patients.

Changes of the severity of neurological deficits
After 4 weeks of treatment, neurological deficits became less severe in both groups. However, the amount
of improvement did not significantly differ between the
experimental group and the control group (Table 4).
Adverse events
No adverse events were observed in any patient during

the experiments.

DISCUSSION
Here, we aimed to determine whether SC acupuncture
plus ES could improve the condition of people with
hemiplegic syndrome. Our findings show that the treatment improved daily living and motor abilities significantly more than traditional scalp acupuncture. Following 4 weeks of treatment, the severity of motor disorder was lessened from severe to moderate in both
groups, which indicates that scalp acupuncture can improve motor ability in patients with hemiplegic. Further, mean Fugl-Meyer scores in the experimental
group averaged 18 points higher than those in the conTable 1 Group characteristics ( xˉ ± s)
Experimental group
(n = 10)

Control group
(n = 10)

P value

7

6

0.639

63.5±6.4

66.3±7.9

0.393

Time since Stroke (weeks)

6.9±2.6

7.5±2.6

0.609

Left/Right hemiplegia (n)

6/4

4/6

0.371

Item
Male (n)
Age (years)

Notes: control group received scalp-cluster acupuncture. Experimental group received scalp-cluster acupuncture combined with electrical
stimulation. Categorical variables: χ2 test. Continuous variables: Student-t test.
Table 2 Changes in motor ability for each group and between groups ( xˉ ± s)
Experimental group
(n = 10)

Control group
(n = 10)

t value

P value

Baseline

32±10

30±12

0.265

0.794

Week 4

68±12

50±13

3.171

0.005

Item

Note: control group received scalp-cluster acupuncture. Experimental group received scalp-cluster acupuncture combined with electrical
stimulation.
Table 3 Changes in living ability for each group and between groups ( xˉ ± s)
Experimental group
(n = 10)

Control group

(n = 10)

t value

P value

Baseline

21±8

21±10

0.000

1.000

Week 4

49±9

36±13

2.528

0.021

Item

Notes: control group received scalp-cluster acupuncture. Experimental group received scalp-cluster acupuncture combined with electrical
stimulation.

Table 4 Changes in the degree of neurological deficit for each group and between groups ( xˉ ± s)
Experimental group
(n = 10)

Control group
(n = 10)

t value

P value

Baseline

25±10

24±6

0.302

0.766

Week 4

12±10

14±7

－0.628

0.538

Item

Notes: control group received scalp-cluster acupuncture. Experimental group received scalp-cluster acupuncture combined with electrical
stimulation.
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Our study has some limits: (a) the sample size was too
small and it only included one center of research.
Thus, the results might not be applicable in all the cases of hemiplegia; (b) objective markers such as blood
analysis data are missing; (c) the mechanism through
which scalp acupuncture works is largely unknown.
These limitations should be considered in future research.
In conclusion, our study provided evidence that SC
acupuncture combined ES is an effective and safe treatment for patients with post-stroke hemiplegia, which
is even more effective than traditional SC acupuncture.

6

7
8

9

10

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