Spasticity Literature Review And Clinical Observation Of Acupuncture On Spasticity

Background:Spasticity is a disorder of sensory-motor system which develops as a sequel of upper motor neuron damage and characterized by velocity-dependent increase in muscle tone and exaggerated stretch reflex.It has numerous adverse effects from functional and emotional impairment,to economic burden on patients and society plus getting a relatively high demand of time and expenses from health providing organizations.·Mechanism of spasticityThe mechanism of spasticity is not definite but is mainly through a damage of sensory-motor control inside spinal level and supra-spinal level.In spinal level,declined function of pre-synaptic and post-synaptic inhibitory pathways are proposed.While,in supra spinal mechanism,unopposed excitatory function of medial reticulo-spinal tract and vestibulo-spinal tract or the impaired inhibitory function of dorsal reticulo-spinal tract could result in variable forms of spasticity.It has also been suggested that the development of spasticity is not only a part of the motor recovery stage of stroke but also the influence of abnormal neuronal plasticity of the CNS.Thus,in terms of treatment plan it should be considered parallel to the improvement of motor recovery.·Assessment of spasticitySpasticity assessment is a difficult task due to the complex nature of the disease and its diverse influences.So far,there is no comprehensive method of measure for all aspects of spasticity.Existing methods are different in evaluating the presence and severity of spasticity or its effects on functional activities.Non-instrumental methods of assessment are cheap and easier to apply in clinical settings,so they are more used worldwide like Ashworth scale and Tardieu scale and their modified versions,spasm frequency scale,Barthel index and so on.Instrumental assessment methods,like biomechanical and electro-physiological measures,are more reliable,but not cheap and friendly which are still kept for research purposes.·Treatment of spasticityIn order to treat spasticity,pharmacological and non-pharmacological treatments have been developed overtime,because spasticity is hardly responsive to verities of treatments.Oral intake medications such as Baclofen,Tizanidine,Diazepam and Gabapentin are among centrally acting drugs to suppress spasticity,while,Dantrolene and Cannabidiol compounds act peripherally.Other pharmacological treatments are either injecting Botulinum toxin to deactivate nerve terminals(in less extent phenol injection)or intrathecal injection of Baclofen which has more specification and less general side effects.Non-pharmacological therapies consist of physiotherapy and rehabilitation exercises,Orthotics and casts,neuro-robotics,thermotherapy,repetitive Transcutaneous Electric Nerve Stimulation(rTENS),Neuromuscular Electrical Stimulation(NMES),Extra corporeal Shock Wave(ESWT),whole body and focal muscle vibrations,Non-invasive neuro-modulation(NINM),ultrasound therapy and acupuncture.The final option of treatment in severe cases and complications is surgery which has its own benefits and complications.·Acupuncture treatment in spasticityAcupuncture is a traditional method of treatment with a broad field of application in varieties of disorders and diseases.The effect of acupuncture in reducing spasticity has been shown in numerous studies.While,there is no high quality evidence for the effect of non-pharmacological approaches in treatment of spasticity,electro-acupuncture combined with conventional routine care is among the two modalities with moderate level of evidence for their effectiveness on spasticity.Mechanism of the effect of acupuncture is not totally understood but its effect in breaking the cycle of pain-spasm-pain,reducing excitability of alpha and gamma motor neurons and regulation of neurochemicals and their receptors are proposed.According to the traditional Chinese medicine(TCM)view,spasticity is the obstruction of channels and collaterals,due to the complex presence of wind-phlegm,damp-phlegm,Qi stagnation and blood stasis syndromes.The main treatment principle is then opening the channels and collaterals by resolving phlegm-dampness,extinguishing the wind and removing blood stasis by invigorating Qi and blood circulation.Due to the fact that acupuncture is an individualized intervention modality according to the patient syndrome differentiation,there is a need for developing research studies to be compatible to the complex nature of acupuncture and be able to evaluate its effect on spasticity and sensory-motor function.Objectives:The aim of this study is to observe the effect of acupuncture on spasticity cases in different clinical settings of China to get an overview of the methods of acupuncture,acupoint selections and manipulation techniques that are used in approach to spasticity treatment.Methods:Setting and patients:15 patients with confirmed diagnosis of upper motor neuron syndrome and sequel of spasticity from Dongzhimen Hospital affiliated to Beijing University of Chinese Medicine(BUCM),Beijing TCM Hospital and Beijing Guangji TCM Hospital were selected to be observed during the time range of 25/2/2019 till 16/6/2019.Interventions:The acupuncture treatment approach of each patient was recorded according to the method and point selection.Outcome measurements:Their assessment was based on the subjective test of spasm frequency scale(the number of spastic attack per day)and their self-estimation of improvement.Results:In 14 out 15 patients there was an improvement in general conditions like accompanying symptoms and daily activities,while 12 patients had a decline in reported score of spasm frequency scale.Due to the heterogeneity of the cases in terms of the duration and the start time of intervention and also different treatment protocols,we can only present the methods of acupuncture,points selections and manipulation techniques.Points selections were based on different traditional views but in general,there was major similarities between their selection in order to treat the root of the disease or the symptoms.Points that were most commonly selected for the treatment of the root condition were GB34 Yanglingquan,LI4 Hegu,ST36 Zusanli,GB20 Fengchi,GV20 Baihui,GV24 Shenting,CV4 Guanyuan,CV6 Qihai,CV12 Zhongwan,LR3 Taichong,ST40 Fenglong,GB39 Xuanzhong,BL18 Ganshu,BL20 Pishu,BL23 Shenshu.Points that were used more commonly for upper and lower spastic condition for additional effect were LI15 Jianyu,LI11 Quchi,LI10 Shousanli,TB5 Waiguan,PC6 Neiguan,LU5 Chize,EX-EU9 Baxie,SP9 Yinlingquan,SP6 Sanyinjiao,ST41 Jiexie,ST32 Futu,BL62 Shenmai,BL56 Chengjin,BL57 Chengshan.Methods of acupuncture that are observed include conventional body acupuncture and scalp acupuncture.While,methods of needling manipulations and techniques were reinforcing and reducing manipulation,waggling needling(Hui Ci)technique,penetrating needling,fire needling and myofascial acupuncture technique.Conclusions:Observation of the considerable value for the effect of acupuncture in recent literature in comparison to other treatment modalities for spasticity,plus the advantage of being safe with no major complication,makes acupuncture a promising method of spasticity treatment in near future.Finding the more effective method of acupuncture,point formula and needling technique and even best combination of them that produce synergistic effect,would be the major suggestion for the future studies.