1.

Clinical Scenario/Problem definition

A) A 58 year old chinese man with underlying hypertension presented to a family
medicine clinic for follow up after a stroke 3 months ago. He had lost all power to the
upper limbs but has gradually been regaining use of the limbs. He had been attending
physiotherapy as well as taking traditional treatment; Primarily massages and
acupuncture. He had been skipping physiotherapy sessions lately because his traditional
treatments left him feeling sore, which would be exacerbated by the physiotherapy. The
man was convinced that the traditional treatments were what had restored his limbs
function. In the end, the man was advised to not go for traditional treatments if it would
interfere with his physiotherapy.
B) Is traditional Chinese treatment more effective than normal physiotherapy for
hemiplegia secondary to stroke?
P - Stroke patients suffering from hemiplegia
I - Traditional Chinese massage and acupuncture
C - Efficacy compared to normal physiotherapy treatment
O - Rehabilitation was improved at 12 weeks
2. Literature Search
A) A randomized control trial would be the best study to use, as they are good at making
sure the difference in outcome is due to the difference in treatment while minimizing
bias. A trial comparing patients who were receiving traditional treatment with those only
receiving normal treatments would be ideal.
B) I searched Pubmed with the terms: Acupuncture, massage and stroke first, but that
returned few helpful results. I then tried massage acupuncture and hemiplegia. The
only helpful studies were:
i)Therapeutic effect of acupuncture and massage for shoulder-hand syndrome in
hemiplegia patients: a clinical two-center randomized controlled trial.
ii)Clinical research on post-stroke hemiplegia treated with the optimized
rehabilitation program of integrated Chinese and western medicine
iii)A summary of clinical treatment for 58 cases of hemiplegia with electro-acupuncture
and massage.
Of which, the second seemed like the best study for my purposes.
C) Li N, Tian F, Wang C, Yu P, Zhou X, Wen Q, Qiao X, Huang L. Therapeutic effect of
acupuncture and massage for shoulder-hand syndrome in hemiplegia patients: a clinical
two-center randomized controlled trial. J Tradit Chin Med. 2012 Sep;32(3):343-9.
3) Critical appraisal
A) The most jarring problem is the small sample size, with only 120 participants across
only 2 centres. Another problem with the study was the lack of double blinding, though,
due to the nature of the treatment, it wouldnt have been feasible anyway. Some generic
confounders were sufficiently eliminated by the exclusion criteria, but several comorbid

conditions which could have altered the outcome of treatment were not excluded so long
as they were being handled by an appropriate doctor. The patients came from a wide age
range with no apparent division, or group matching, meaning age could be a confounder.
The numeric pain rating scale used is a subjective scale, with age(among other
confounders) possibly altering pain tolerance. The criteria used to evaluate shoulder-hand
syndrome(Chinese rehabilitation standards for diagnosis and treatment) is not a part of
WHO guidelines. Evaluation were done twice to reduce subjectivity from evaluators, but
that does not really eliminate the subjectivity from patients. Patients with higher stages of
disease were also excluded, meaning this study might only be valid for milder cases, if it
is valid at all. In conclusion, although the study found that while acupuncture and
massage were slightly superior to normal physiotherapy in regards to restoration of upper
limb function, it only applies to mild cases. Though the study takes some steps to
eliminate bias, it leaves a lot of possible confounders unaccounted for.
B) That this study was performed exclusively on Chinese exclusively, its low sample
size, the fact that the study was only carried out on mild cases and the various sources of
possible bias not accounted for limits its credibility severely. I wouldnt apply it in our
local setting.
C) The study claims that acupuncture and massage are better for improving upper limb
function, but not hand function in mild cases, but the poor design of the study means the
question is not satisfactorily answered.